Management of pain from heel stick in neonates: an analysis of research conducted in Thailand

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

A Randomized Comparative Effectiveness Study of Reflexology, Sucrose, and Other Treatments for Needle Procedures in Newborns

BACKGROUND

Approximately 10 to 14 painful procedures per day are performed in infants during the hospital stay. We aimed to determine the effect of reflexology applied to the sole during painful procedures on pain perception in newborns compared with other nonpharmacologic methods.

METHODS

Our study was planned as a randomized controlled trial in term infants being followed up in the neonatal intensive care unit and maternity ward. To reduce pain during collection of venous blood or heel lance reflexology on the soles of the foot, 24% sucrose solution, kangaroo care, and classical music listening were applied to the infants. The Neonatal Infant Pain Scale (NIPS) was used to assess newborns during acute pain.

RESULTS

A total of 300 patients were enrolled in the study. Higher pain scores and crying times were observed during heel blood collection. All analgesic methods significantly reduced NIPS scores during heel blood collection. Sucrose was the most effective method, followed by reflexology. The best method that significantly shortened the crying time was again sucrose solution followed by reflexology, kangaroo care, and classical music, during heel blood collection. However, none of the nonpharmacologic methods was effective during venous blood collection.

CONCLUSIONS

Although sucrose was the most effective method, reflexology has significant positive effects, especially on average heartbeat, reducing pain, and shortening crying times during heel blood sampling. Reflexology might be considered among the nonpharmacologic methods to be applied before routine interventions, but still, there is a need for further studies to investigate the efficiency.

Effects of maternal voice on pain and mother-Infant bonding in premature infants in Taiwan: A randomized controlled trial

PURPOSE

This study aimed to examine the effectiveness of maternal voice in alleviating premature infants' pain during the heel sticks and facilitating mother-infant bonding during hospitalization.

DESIGN AND METHODS

A randomized controlled trial with a parallel group design was conducted in which 64 premature infant-mother dyads were randomly assigned to an intervention group or a control group. Voice recordings of the mother reading a children's book were created and subsequently played for the infant during a heel stick procedure once daily for 3 consecutive days. The primary outcomes were heart rate, respiratory rate, oxygen saturation, and pain response assessed using the Neonatal Infants Pain Scale before, during, and after the procedure. The secondary outcome was mother-infant bonding evaluated using the Mother-Infant Bonding Inventory on the seventh postnatal day. Data were analyzed using generalized estimation equations.

RESULTS

The two groups did not significantly differ in length of gestation, sex, weight, or other demographic characteristics. At 1 min after the procedure, the intervention group had a lower heart rate (p < 0.001) and Neonatal Infants Pain Scale score (p < 0.001) than the control group did.

CONCLUSIONS

The maternal voice intervention slowed the heart rate and alleviated the pain response of the hospitalized premature infants.

PRACTICE IMPLICATIONS

This intervention has clinical potential to provide mothers with an opportunity to care for their infants and infants with an opportunity to be soothed during health care, thus enhancing the infant-mother connection. The clinical trial registration number is NCT04158206.

The Effect of 3 Positions Given to Preterm Infants During Heelstick Procedure on Pain and Durations of Crying and Procedure

The purpose of this randomized controlled study was to determine the effect of 3 positions given to preterm infant during heelstick procedure on the pain and durations of crying and procedure. The sample of the study consisted of 90 preterm infants (30 in each group). The heelstick procedure was video recorded. Data from the pain scores, durations of crying, and procedure were collected watching the video recordings. It was determined that the pain mean score of the infants in the control group (supine on the crib) (5.50 ± 2.13) was statistically significantly higher than that of the infants in the positions of upright (3.00 ± 2.17) and supine on the lap (3.20 ± 2.46) (P < .01), and there was no difference between the positions of upright and supine on the lap (P > .05). Giving the positions of upright or supine on the lap during heelstick is effective in reducing pain, shortening the duration of crying, and calming down the infant. Heelstick in the position of upright on the lap shortened the procedure duration and allowed the infants to be subjected to less painful procedure. It is recommended for nurses to take the preterm infants on their laps during heel lancing and give them the upright position, in particular.

Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update

Infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available that may be used for these painful procedures, including swaddling/containment, pacifier/non-nutritive sucking, rocking/holding, breastfeeding and breastmilk, skin-to-skin care, sweet tasting solutions, music therapy, sensorial saturation, and parental presence. Adoption these interventions into routine clinical practice is feasible and should be a standard of care in quality health care for infants. This review summarizes the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions.

Effects of breastfeeding and heel warming on pain levels during heel stick in neonates

AIM

To determine the effects of two different methods, breastfeeding and heel warming, during heel stick procedures on pain levels in healthy term neonates.

METHODS

This study was a prospective, randomized controlled trial. The sample of the study consisted of 150 healthy newborns who matched the case selection criteria and were brought to the nursery for the heel stick procedure. Fifty neonates were randomly assigned to each group: breastfeeding (n = 50), heel warming (n = 50), and control (n = 50), using computer-based randomization. The study data were obtained using an Information Form and the Neonatal Infant Pain Scale (NIPS).

RESULTS

The pre-procedural pain scores of the breastfeeding group (mean 4.44 SD 1.21 seconds) were lower than in the heel warming (mean 6.10 SD 1.07 seconds) and the control group (mean 6.42 SD 0.91 seconds) (P < 0.01). Both the total crying time and the first calming time of the breastfeeding group were shorter than the heel warming and control group. The first calming time of the heel warming group was shorter than in the control group.

CONCLUSIONS

Both breastfeeding and heel warming are effective in reducing the calming time during heel stick procedures. However, breastfeeding is more effective than heel warming in reducing pain during heel stick and should be preferred as the first choice.

Analgesic Effect of Maternal Human Milk Odor on Premature Neonates: A Randomized Controlled Trial

BACKGROUND

Two studies have demonstrated an analgesic effect of maternal milk odor in preterm neonates, without specifying the method of olfactory stimulation. Research aim: This study aimed to assess the analgesic effect of maternal milk odor in preterm neonates by using a standardized method of olfactory stimulation.

METHODS

This trial was prospective, randomized, controlled, double blinded, and centrally administered. The inclusion criteria for breastfed infants included being born between 30 and 36 weeks + 6 days gestational age and being less than 10 days postnatal age. There were two groups: (a) A maternal milk odor group underwent a venipuncture with a diffuser emitting their own mother's milk odor and (2) a control group underwent a venipuncture with an odorless diffuser. The primary outcome was the Premature Infant Pain Profile (PIPP) score, with secondary outcomes being the French scale of neonatal pain-Douleur Aiguë du Nouveau-né (DAN) scale-and crying duration. All neonates were given a dummy.

RESULTS

Our study included 16 neonates in the maternal milk odor group and 17 in the control group. Neonates exposed to their own mother's milk odor had a significantly lower median PIPP score during venipuncture compared with the control group (6.3 [interquartile range (IQR) = 5-10] versus 12.0 [IQR = 7-13], p = .03). There was no significant difference between the DAN scores in the two groups ( p = .06). Maternal milk odor significantly reduced crying duration after venipuncture (0 [IQR = 0-0] versus 0 [IQR = 0-18], p = .04).

CONCLUSION

Maternal milk odor has an analgesic effect on preterm neonates.

Effect of combined music and touch intervention on pain response and β-endorphin and cortisol concentrations in late preterm infants

BACKGROUND

Preterm neonates undergo many painful procedures as part of their standard care in the neonatal intensive care unit. However, pain treatment is inadequate in many of these routine procedures. In the present study, we investigated the impact and mechanism of combined music and touch intervention (CMT) on the pain response in premature infants.

METHODS

Sixty-two preterm neonates (gestational age of <37 weeks) were randomly assigned to either the experimental or control group. Infants in the experimental group underwent painful procedures with CMT, and those in the control group underwent painful procedures without CMT. Blood samples were collected from all infants at the beginning of hospitalization and 2 weeks later to assess the cortisol and β-endorphin concentrations. Differences in the levels of cortisol and β-endorphin between two groups were examined using analysis of covariance (ANCOVA).

RESULTS

In total, 3707 painful procedures were performed on 62 neonates during their hospitalization. The average number of painful procedures in the control group (n = 35.5) was higher than that in the experimental group (n = 29.0) during hospitalization, although no significant difference was reached (P > 0.05). After 2 weeks, the Premature Infant Pain Profile scores were significantly higher in the control group than experimental group (13.000 ± 0.461 vs 10.500 ± 0.850, respectively; P < 0.05). The cortisol concentration was not significantly different between the control and experimental groups either at the beginning of hospitalization (131.000 ± 18.190 vs 237.200 ± 43.860, respectively; P > 0.05) or 2 weeks later (162.400 ± 23.580 vs 184.600 ± 21.170, respectively; P > 0.05). However, the serum β-endorphin concentration was higher in the experimental group than in the control group both at the beginning of hospitalization (1.640 ± 0.390 vs 1.179 ± 0.090, respectively; P < 0.05) and 2 weeks later (2.290 ± 0.740 vs 1.390 ± 0.410, respectively; P < 0.05).

CONCLUSIONS

CMT might decrease the pain response of preterm neonates by significantly improving the β-endorphin concentration, but not the blood cortisol concentration.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14131492 . Registered on 01 Aug 2016.

Comparative Survey of Holding Positions for Reducing Vaccination Pain in Young Infants

Background. Infant holding position may reduce vaccination pain. However, the optimal position for young infants remains controversial. Objectives. To compare the effectiveness of holding infants in the supine position and the effectiveness of holding infants in upright position for relieving acute pain from vaccine injection. Methods. This prospective cohort study enrolled 6-12-week-old healthy infants. We examined infant pain responses by evaluating the following three categories: (1) crying, (2) irritability, and (3) facial expression. Results. In total, 282 infants were enrolled, with 103 and 179 held in the supine and upright positions, respectively. At 30 s after vaccination, the infants in the supine position showed a larger decrease in crying (p < 0.001), irritability (p = 0.002), and pained facial expression (p = 0.001) than did those in the upright position. However, there was no significant difference in pain response between two groups at 180 s after intervention. Conclusion. In 2-month-old infants, the supine position may reduce acute pain more effectively than does the upright position. Our findings provide a clinical strategy for relieving vaccination pain in young infants.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.  This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'.

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). 

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update.

DATA COLLECTION AND ANALYSIS

Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method.

MAIN RESULTS

Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.

Efficacy of swaddling and heel warming on pain response to heel stick in neonates: a randomised control trial

AIMS AND OBJECTIVES

To determine the efficacy of swaddling and heel warming on pain response in neonates following heel stick.

BACKGROUND

Swaddling has been suggested to reduce pain response in neonates during heel stick. Heel warming is also often performed for drawing blood easily before heel stick. However, the efficacy of both on pain response is unclear.

DESIGN

A randomised controlled study was used.

METHODS

Twenty-five neonates were randomly assigned to each of the control, swaddling and heel-warming groups. Heart rate, oxygen saturation Neonatal Infant Pain Scale and duration of crying were used to assess pain reactivity and pain recovery. A greater heart rate and Neonatal Infant Pain Scale increase, or oxygen saturation decrease, indicated higher pain reactivity. A longer duration of heart rate and oxygen saturation changes after heel stick back to baseline indicated a longer pain recovery.

RESULTS

The decrease in oxygen saturation in swaddling group was significantly greater than that in heel-warming group. The increase in the Neonatal Infant Pain Scale in control group was significantly higher than that in swaddling group. The heart rate recovery time in control group and swaddling group was significantly longer than that in heel-warming group. The oxygen saturation recovery time in control group was significantly longer than that in heel-warming group. The duration of crying in control group was significantly longer than those in swaddling group and heel-warming group.

CONCLUSION

Both swaddling and heel warming decreased the pain response of neonates during heel stick. Heel warming resulted in a lower pain response than did swaddling for neonates, particularly in terms of pain recovery.

RELEVANCE TO CLINICAL PRACTICE

Heel warming could become a routine practice to decrease the pain response of neonates during heel stick.

Nonpharmacological management of pain during common needle puncture procedures in infants: current research evidence and practical considerations

All infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available for these painful procedures, including swaddling, holding, skin-to-skin care, pacifier, sweet-tasting solutions, and breast-feeding. Adoption of nonpharmacologic pain-relieving interventions into routine clinical practice is feasible and should be a standard of care in the delivery of quality health care for infants. This review summarizes current knowledge about the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions for future research.

Effective analgesia using physical interventions for infant immunizations

BACKGROUND

To measure the analgesic effectiveness of the 5 S's (swaddling, side/stomach position, shushing, swinging, and sucking) alone and combined with sucrose, during routine immunizations at 2 and 4 months.

METHODS

We conducted a prospective, randomized, placebo-controlled trial with 2- and 4-month-old infants during well-child visits. Patients were assigned into 4 groups (2 × 2) receiving either 2 mL of water or 2 mL of 24% oral sucrose and then either standard-of-care comfort measures by parents or intervention with the 5 S's immediately postvaccination. The Modified Riley Pain Score was used to score the infants' pain at 15-second intervals for 2 minutes, then every 30 seconds up to 5 minutes postvaccination. Repeated-measures analysis of variance examined between group differences and within-subject variability of treatment effect on overall pain scores and length of crying.

RESULTS

Two hundred thirty infants were enrolled. Results revealed significantly different mean pain scores between study groups with the exception of the 5S's and 5S's with sucrose groups. These 2 groups had lower similar mean scores over time, followed by sucrose alone, then control. The same trend was found with the proportion of children crying as with the mean pain score outcome measure.

CONCLUSIONS

Physical intervention of the 5 S's (swaddling, side/stomach position, shushing, swinging, and sucking) provided decreased pain scores on a validated pain scale and decreased crying time among 2- and 4-month-old infants during routine vaccinations. The use of 5S's did not differ from 5S's and sucrose.

The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates

BACKGROUND

Neonates in a neonatal intensive care unit are exposed to a high number of painful procedures. Since repeated and sustained pain can have consequences for the neurological and behaviour-oriented development of the newborn, the greatest attention needs to be paid to systematic pain management in neonatology. Non-pharmacological treatment methods are being increasingly discussed with regard to pain prevention and relief either alone or in combination with pharmacological treatment.

AIMS

To identify effective non-pharmacological interventions with regard to procedural pain in neonates.

METHODS

A literature search was conducted via the MedLine, CINAHL, Cochrane Library databases and complemented by a handsearch. The literature search covered the period from 1984 to 2004. Data were extracted according to pre-defined criteria by two independent reviewers and methodological quality was assessed.

RESULTS

13 randomised controlled studies and two meta-analyses were taken into consideration with regard to the question of current nursing practice of non-pharmacological pain management methods. The selected interventions were "non-nutritive sucking", "music", "swaddling", "positioning", "olfactory and multisensorial stimulation", "kangaroo care" and "maternal touch". There is evidence that the methods of "non-nutritive sucking", "swaddling" and "facilitated tucking" do have a pain-alleviating effect on neonates.

CONCLUSIONS

Some of the non-pharmacological interventions have an evident favourable effect on pulse rate, respiration and oxygen saturation, on the reduction of motor activity, and on the excitation states after invasive measures. However, unambiguous evidence of this still remains to be presented. Further research should emphasise the use of validated pain assessment instruments for the evaluation of the pain-alleviating effect of non-pharmacological interventions.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan. 

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation). 

SEARCH STRATEGY

We searched CENTRAL in The Cochrane Library (2011, Issue 1), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), PsycINFO (1967 to April 2011), Cumulative Index to Nursing and Allied Health Literature (1982 to 2011), Dissertation Abstracts International (1980 to 2011) and www.clinicaltrials.gov. We also searched reference lists and contacted researchers via electronic list-serves.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomized controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results.

DATA COLLECTION AND ANALYSIS

We refined search strategies with three Cochrane-affiliated librarians. At least two review authors extracted and rated 51 articles. Study quality ratings were based on a scale by Yates and colleagues. We analyzed the standardized mean difference (SMD) using the generic inverse variance method. We also provided qualitative descriptions of 20 relevant but excluded studies.

MAIN RESULTS

Fifty-one studies, with 3396 participants, were analyzed. The most commonly studied acute procedures were heel-sticks (29 studies) and needles (n = 10 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (preterm: SMD -0.42; 95% CI -0.68 to -0.15; neonate: SMD -1.45, 95% CI -2.34 to -0.57), kangaroo care (preterm: SMD -1.12, 95% CI -2.04 to -0.21), and swaddling/facilitated tucking (preterm: SMD -0.97; 95% CI -1.63 to -0.31). For immediate pain-related regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.38; 95% CI -0.59 to -0.17; neonate: SMD -0.90, 95% CI -1.54 to -0.25), kangaroo care (SMD -0.77, 95% CI -1.50 to -0.03), swaddling/facilitated tucking (preterm: SMD -0.75; 95% CI -1.14 to -0.36), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). The presence of significant heterogeneity limited our confidence in the lack of findings for certain analyses.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.

Procedural pain management for neonates using nonpharmacological strategies: Part 1: sensorial interventions

Neonates who are born preterm and are admitted to neonatal intensive care units endure frequent procedures that may be painful. Nonpharmacological interventions that have been studied to relieve their pain may be categorized in 2 main groups according to their nature: interventions that focus on creating a favorable environment and offering pleasant sensorial stimuli and interventions that are centered on maternal care. These interventions may be considered within the philosophy of developmental care, since they are aimed at adjusting the environment to the needs of the neonate and involve family-centered care. In this article, the first of a 2-part series, we will synthesize the evidence from experimental studies of interventions that focus on the environment and on tactile and gustatory stimulation. The mechanisms suggested by researchers as possible explanations for the efficacy of these interventions are pointed, and the implications for procedural pain management in neonatal care are drawn.

Reducing neonatal pain during routine heel lance procedures

PURPOSE

To measure the difference in pain scores for newborns who were held and swaddled while undergoing routine heel lance procedures compared to newborns who were lying on their backs and not swaddled during heel lance. Additionally, we sought to compare the total amount of time it took to collect the specimens in each group.

DESIGN AND METHODS

A total of 42 neonates recruited from a large tertiary hospital were enrolled in a randomized controlled trial. Infants in the experimental group (n = 22) were swaddled and held in an upright position during routine heel lance procedures while neonates in the control group (n = 20) remained in a standard care position. Pain was measured with the Neonatal Inventory Pain Scale (NIPS) at two points in time for each group (just before the heel lance procedure and at the completion of the heel lance). Total collection time was measured using a stopwatch accurate to 1/100th of a second. Specimen quality was measured based on the number of rejected specimens for each group. Descriptive statistics and t tests were used to analyze the data.

RESULTS

The mean NIPS score for neonates who were swaddled and held during the procedure (experimental group) was significantly lower (M = 1.3, SD = .9) than the score for infants in the standard position (control group) (M = 2.7, SD = 1.3), t (40) = -4.48, p < .001. Although the total collection time was lower for infants who were swaddled (2 minutes and 17 seconds, SD = 59) versus (2 minutes and 47 seconds, SD = 85) for controls, this was not a statistically significant difference (p = .45).

CLINICAL IMPLICATIONS

Swaddling combined with positioning neonates upright during routine heel lance procedures offers nurses a nonpharmacologic method of neonatal pain reduction for heel sticks. This technique can be easily implemented on any unit independent of facility protocols. Furthermore, the technique is not associated with any cost or policy development, making it more likely that nurses can use it in practice.

Pain in neonates is different

Pain processing and management in neonates, especially preterm neonates, differs from older populations. In this review, a brief background on pain processing in neonatal life, pain exposure in Neonatal Intensive Care Units (NICU), the consequences of untreated pain, and the difficulties in treating procedural pain pharmacologically will be presented. A more detailed review of non-pharmacological interventions for procedural pain in neonates will include sensory stimulation approaches, oral sweet solutions, and maternal interventions. Some possible mechanisms for the effectiveness of non-pharmacological interventions are offered. Finally, avenues of research into similar interventions as adjuvant therapies or drug-sparing effects in older populations are suggested.

Effects of breastfeeding on pain relief in full-term newborns

Breastfeeding may be useful for relieving procedural pain experienced by neonates. Researchers have compared breastfeeding against other pain relieving approaches in several studies, presenting marked methodologic heterogeneity.

OBJECTIVE

To investigate the effectiveness of breastfeeding in reducing pain in newborns undergoing blood collection for newborn screening.

METHOD

The sample of this randomized clinical trial study consisted of 60 full-term newborns: 31 in the experimental group and 29 in the control group. The experimental group was breastfed 5 minutes before, during, and for 5 minutes after the blood collection procedure. Neonates in the control group were held in mothers' arms but not fed or given a soother. The duration of breastfeeding was prolonged in comparison to previous studies.

RESULTS

The primary outcomes were Neonatal Facial Actions (Neonatal Facial Activity Coding System-upper face), sleep-wake state. Heart rate was considered as an index of arousal. Sucking frequency was only evaluated in the experimental group. Compared with the control group, the experimental group had significantly lower, Neonatal Facial Activity Coding System and sleep-wake state scores and heart rates changes. In the experimental group sucking frequency was highest during the first 5 minutes of breastfeeding before the procedure.

DISCUSSION

This study innovates from earlier studies in 4 respects: the different phases of the procedure were evaluated separately; the breastfeeding intervention covered the period from 5 minutes before the blood collection until the end of recovery; sleep-wake state was fully assessed (not merely crying) and the sucking frequency in the experimental group was assessed during the procedure. The conclusion was that breastfeeding was effective in reducing pain caused by blood collection for newborn screening.

A review of systematic reviews on pain interventions in hospitalized infants

BACKGROUND

Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews.

OBJECTIVE

To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants.

METHODS

A structured review was conducted on published systematic reviews and meta-analyses of pharmacological and nonpharmacological interventions of acute procedural pain in hospitalized infants. Searches were completed in the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL and PsycINFO. Two reviewers independently selected articles for review and rated the methodological quality of the included reviews using a validated seven-point quality assessment measure. Any discrepancies were resolved by a third reviewer.

RESULTS

Of 1469 potential systematic reviews on interventions for painful procedures in hospitalized infants, 11 high-quality reviews were included in the analysis. Pharmacological interventions supported by research evidence included premedication for intubation, dorsal penile nerve block and EMLA (AstraZeneca Canada, Inc) for circumcision, and sucrose for single painful procedures. Non-nutritive sucking, swaddling, holding, touching, positioning, facilitative tucking, breast feeding and supplemental breast milk were nonpharmacological interventions supported for procedural pain.

CONCLUSION

There is a growing number of high-quality reviews supporting procedural pain management in infants. Ongoing research of single, repeated and combined pharmacological and nonpharmacological interventions is required to provide the highest quality evidence to clinicians for decision-making on optimal pain management.

The development of potentially better practices to support the neurodevelopment of infants in the NICU

OBJECTIVE

To review the existing evidence used to identify potentially better care practices that support newborn brain development.

STUDY DESIGN

Literature review.

RESULT

Sixteen potentially better practices are identified and grouped into two operational clinical bundles based upon timing for recommended implementation.

CONCLUSION

Existing evidence supports the implementation of selected care practices that potentially may support newborn brain development.

A Review of CAM for Procedural Pain in Infancy: Part II. Other Interventions

This article is the second in a two-part series reviewing the empirical evidence for complementary and alternative medicine (CAM) approaches for the management of pain related to medical procedures in infants up to 6 weeks of age. Part I of this series investigated the effects of sucrose with or without non-nutritive sucking (NNS). The present article examines other CAM interventions for procedural pain including music-based interventions, olfactory stimulation, kangaroo care and swaddling. Computerized databases were searched for relevant studies including prior reviews and primary trials. Preliminary support was revealed for the analgesic effects of the CAM modalities reviewed. However, the overall quality of the evidence for these approaches remains relatively weak. Additional well-designed trials incorporating rigorous methodology are required. Such investigations will assist in the development of evidence-based guidelines on the use of CAM interventions either alone or in concert with conventional approaches to provide safe, reliable analgesia for infant procedural pain.

Evidence for best practices in the neonatal period

The purpose of this article is to provide a review of current nursing research that supports best practices during the newborn period. The literature review of peer-reviewed research articles published between January 2000 and October 2004 was conducted via keyword searches using the databases of the Cochrane Library, CINAHL, and MEDLINE. Key words included neonatal nursing, newborn, neonate, premature infant, preterm infant, and low birthweight. Content analysis revealed the following primary categories of studies that provide solid evidence for nursing practice: developmentally focused nursing care, neonatal skin care, feeding, skin-to-skin care, and pain management. Neonatal nurse researchers have made many important contributions to the research literature. Future research should expand the findings to date on the effective use of pain scales, the outcomes of skin-to-skin care and infant massage as standard practice for all neonates, and the effectiveness of nursing interventions to support the developmental sequelae of prematurity. Neonatal nurses should become familiar with and implement those findings from nursing research that strongly support evidence-based nursing practice.