Using only behaviours to assess infant pain: a painful compromise?

Contextual factors associated with neonatal pain responses: clinical observational study

Objectives

This study aimed to identify the contextual factors of neonatal pain responses and provide clinical medical staff with evidence regarding effective means of evaluating neonatal pain and strengthen clinical pain management.

Methods

Two trained nurses independently used the Neonatal Infant Pain Scale (NIPS) to assess the pain scores of 198 neonates after they underwent painful medical procedures. Univariate linear regression analysis was performed to analyze the correlation between contextual factors and NIPS scores. Variables with statistically significant differences (p < 0.2) after univariate linear regression analysis were selected as independent variables, and the NIPS score was used as the dependent variable. Multiple linear regression was used to determine the salient factors associated with neonatal pain responses. This study was registered at the Chinese Clinical Trial Registry (ChiCTR2300074086).

Results

Univariate linear regression analysis showed that the NIPS scores were associated with days after birth, types of painful procedures, Apgar scores at 1 min after birth, and gestational age (GA) (p < 0.2). Multiple regression analysis showed that Apgar score at 1 min after birth (β = 0.272, p < 0.001) and GA (β = 0.503, p < 0.001) were independent associated factors of neonatal pain responses. Neonates with low Apgar scores at 1 min after birth and younger GA had less pronounced pain responses.

Conclusions

The Apgar score at 1 min after birth and GA affected the neonatal pain responses. In this regard, the current clinical method of pain assessment solely through observation of neonatal pain responses is occasionally inaccurate. The Apgar score at 1 min after birth and GA should be considered in determining the neonatal pain status and hence enhance the quality of neonatal pain management.

Behavioral and physiological pain structures of PIPP-R and parental stress: structural equation modeling approach

BACKGROUND

Although most non-acute pain assessment tools are multi-dimensional (behavioral and physiological measures) in their approach, the outputs of such tools are considered unidimensional. This study aimed to explore and determine the behavioral and physiological pain structures of Premature Infant Pain Profile-Revised (PIPP-R) for neonates and its association with parental stress.

METHODS

This cross-sectional study was conducted in 2022-2023 in Isfahan, Iran. We recruited 400 pre-term infants, i.e. with gestational age (GA) of less than 37weeks who were admitted to the NICU of educational hospitals. PIPP-R and Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) were used for data gathering. The latent structures of pain and its association with parental stress were explored using latent variable modeling approach.

RESULTS

A two-factor model, i.e. behavioral and physiological pain factors, was extracted, explaining 65% of the total variance. The results of confirmatory factor analysis showed that the identified structures in the exploratory factor analysis could be nearly replicated (CFI = 0.99، TLI = 0.98, RMSEA = 0.001). Behavioral pain structure, independent from gestational age had a significant direct association with parental stress score (β = 0.005, SE = 0.002, p = 0.026).

CONCLUSIONS

The PIPP-R assesses both behavioral and physiological pain factors. We also found that behavioral pain factor was associated with parental stress.

IMPACT

These results may provide a potential clue for physicians, nurses, and parents to manage the pain in preterm infant. The PIPP-R scores in preterm infants consist of "Behavioral and Physiological" pain factors. Single dependence on behavioral indicators (such as facial expression) has some limitations. Multidimensional tools may be the optimal method in detecting pain in preterm infants. Parental stress can affect behavioral pain structure in preterm infants. Intensive care nurses play an effective role in reducing the parental stress and pain severity of these preterm infants by including the help of mothers in procedures and providing them with psychological support.

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.

COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates?

OBJECTIVE

We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain.

STUDY DESIGN

This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity.

RESULT

Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively.

CONCLUSION

The COMFORTneo can be used to reliably and validly assess pain in NICU patients.

Effects of white noise on procedural pain-related cortical response and pain score in neonates: A randomized controlled trial

Objectives

To evaluate the effects of white noise on pain-related cortical response, pain score, and behavioral and physiological parameters in neonates with procedural pain.

Methods

A double-blind, randomized controlled trial was conducted. Sixty-six neonates from the Neonatal Intensive Care Unit in a university-affiliated general hospital were randomly assigned to listen to white noise at 50 dB (experimental group) or 0 dB (control group) 2 min before radial artery blood sampling and continued until 5 min after needle withdrawal. Pain-related cortical response was measured by regional cerebral oxygen saturation (rScO₂) monitored with near-infrared spectroscopy, and facial expressions and physiological parameters were recorded by two video cameras. Two assessors scored the Premature Infant Pain Profile-Revised (PIPP-R) independently when viewing the videos. Primary outcomes were pain score and rScO₂ during arterial puncture and 5 min after needle withdrawal. Secondary outcomes were pulse oximetric oxygen saturation (SpO₂) and heart rate (HR) during arterial puncture, and duration of painful expressions. The study was registered at the Chinese Clinical Trial Registry (ChiCTR2200055571).

Results

Sixty neonates (experimental group, n = 29; control group, n = 31) were included in the final analysis. The maximum PIPP-R score in the experimental and control groups was 12.00 (9.50, 13.00), 12.50 (10.50, 13.75), respectively (median difference −0.5, 95% CI −2.0 to 0.5), and minimum rScO₂ was (61.22 ± 3.07)%, (61.32 ± 2.79)%, respectively (mean difference −0.325, 95% CI −1.382 to 0.732), without significant differences. During arterial puncture, the mean rScO₂, HR, and SpO₂ did not differ between groups. After needle withdrawal, the trends for rScO₂, PIPP-R score, and facial expression returning to baseline were different between the two groups without statistical significance.

Conclusion

The white noise intervention did not show beneficial effects on pain-related cortical response as well as pain score, behavioral and physiological parameters in neonates with procedural pain.

Evaluation of the Premature Infant Pain Profile-Revised (PIPP-R) e-Learning Module: Immediate and Sustained Competency

BACKGROUND

Electronic health (e-health) learning is a potential avenue to educate health professionals about accurately using infant pain assessment tools, although little is known about the impact of e-health interventions on clinical competence.

PURPOSE

To evaluate whether an e-health learning module for teaching the accurate use of the Premature Infant Pain Profile-Revised (PIPP-R) pain assessment tool results in immediate and sustained competency to assess infant pain.

METHODS

Neonatal intensive care unit (NICU) nurses who participated in a larger study across 2 tertiary NICUs in Canada examining the implementation and clinical utility of the PIPP-R e-learning module completed 2 follow-up evaluations at 1 week and 3 months. Participants were asked to view a video recording of an infant undergoing a painful procedure and to assess the infant's pain intensity response using the PIPP-R measure. Immediate and sustained competency was assessed via interrater consensus of participant-reported PIPP-R scores compared with those of an experienced trained coder.

RESULTS

Of the 25 eligible nurses, 22 completed 1-week and 3-month follow-up evaluations. At the 1-week follow-up, 84% of nurses scored the video accurately compared with 50% at 3 months. Behavioral pain indicators were more likely to be scored incorrectly than physiological indicators.

IMPLICATIONS FOR PRACTICE

Follow-up training after completion of the initial e-learning module training may improve competency related to the clinical use of the PIPP-R tool to assess infant pain over time.

IMPLICATIONS FOR RESEARCH

Additional study regarding the need and timing of e-health training to optimize sustained competency in infant pain assessment is warranted.

Neonatal pain assessment: Do we have the right tools?

BACKGROUND

The assessment and management of neonatal pain is crucial for the development and wellbeing of vulnerable infants. Specifically, neonatal pain is associated with adverse health outcomes but is often under-identified and therefore under-treated. Neonatal stress may be misinterpreted as pain and may therefore be treated inappropriately. The assessment of neonatal pain is complicated by the non-verbal status of patients, age-dependent variation in pain responses, limited education on identifying pain in premature infants, and the clinical utility of existing tools.

OBJECTIVE

We review research surrounding neonatal pain assessment scales currently in use to assess neonatal pain in the neonatal intensive care unit.

METHODS

We performed a systematic review of original research using PRISMA guidelines for literature published between 2016 and 2021 using the key words "neonatal pain assessment" in the databases Web of Science, PubMed, and CINAHL. Fifteen articles remained after review, duplicate, irrelevant, or low-quality articles were eliminated.

RESULTS

We found research evaluating 13 neonatal pain scales. Important measurement categories include behavioral parameters, physiological parameters, continuous pain, acute pain, chronic pain, and the ability to distinguish between pain and stress. Provider education, inter-rater reliability and ease of use are important factors that contribute to an assessment tool's success. Each scale studied had strengths and limitations that aided or hindered its use for measuring neonatal pain in the neonatal intensive care unit, but no scale excelled in all areas identified as important for reliably identifying and measuring pain in this vulnerable population.

CONCLUSION

A more comprehensive neonatal pain assessment tool and more provider education on differences in pain signals in premature neonates may be needed to increase the clinical utility of pain scales that address the different aspects of neonatal pain.

The validity of skin conductance for assessing acute pain in mechanically ventilated infants: A cross-sectional observational study

BACKGROUND

Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants.

METHODS

A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12 months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures.

RESULTS

From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman's rho = 0.4-0.62) and the four-item NFCS (Spearman's rho = 0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve = 0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain.

CONCLUSIONS

SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation.

SIGNIFICANCE OF THE STUDY

Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.

Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care

OBJECTIVE

The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT).

MATERIALS AND METHODS

A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011).

RESULTS

Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P<0.001) for the Physiological Pain Measures factor, whereas Behavioral Pain Measures frequency was higher at term than at preterm (χ2(3)=8.1, P<0.043). A similar pattern was observed for postmenstrual age at assessment categories: Behavioral Pain Measures (χ2(3)=41.8, P<0.001) Physiological Pain Measures (χ2(3)=46.1, P<0.001). The 2-factor correlated model performed better at explaining the observed variances: (χ2(13)=41.6, P<0.001) compared with rival models.

DISCUSSION

The PAT assesses both Behavioral Pain and Physiological Pain Measures, and these dimensions need to be considered separately when assessing pain in infants in the neonatal intensive care unit. Behavioral item scores may be insufficient for detecting pain in premature infants if used alone.

An examination of the reciprocal and concurrent relations between behavioral and cardiac indicators of acute pain in toddlerhood

The aim of this study was to examine the concurrent and predictive relations between healthy toddlers' pain behavior and cardiac indicators (ie, heart rate [HR] and respiratory sinus arrhythmia [RSA]) during routine vaccinations. Caregiver-infant dyads were part of a longitudinal cohort observed during their 12- and 18-month vaccinations. Behavioral and cardiac data were simultaneously collected for 1-minute preneedle and 3-minutes postneedle. Videotapes were coded for pain behaviors (FLACC; Merkel et al., 1997), and cardiac data were analyzed (HR, RSA) during sequential 30-second epochs. Four separate cross-lagged path models were estimated using data from the 12- (n = 147) and 18-month (n = 122) vaccinations. Across 12- and 18-month vaccinations, predictive within-measure relations were consistent for FLACC, HR, and RSA, reflecting good stability of these pain indicators. Behavioral indicators predicted subsequent HR and RSA within the immediate postneedle period. Both baseline behavior and HR/RSA predicted future pain scores. Concurrent residual relations between behavioral and cardiac indicators were inconsistent across time and indicators. Results suggest that behavioral and cardiac indicators reflect unique aspects of the nociceptive response. As such, multimodal assessment tools should be used and contextualized by child age, cardiac indicator, baseline behavior/physiology, and pain phase.

Cerebral hemodynamic response to a therapeutic bed for procedural pain management in preterm infants in the NICU: a randomized controlled trial

INTRODUCTION

We developed a novel device, Calmer, that mimics key components of skin-to-skin holding to reduce stress in preterm infants. Our feasibility trial showed that Calmer worked 50% better than no treatment and no differently from our standard of care, facilitated tucking (FT), for reducing pain scores during a heel lance in preterm infants in the neonatal intensive care unit.

OBJECTIVE

We compared the effects of Calmer on regional cerebral hemodynamic activity during a noxious stimulation to FT.

METHODS

During a clinically required heel lance, we measured frontal cortex tissue oxygenation in a subsample of 29 preterm infants (27-33 weeks gestational age) from our larger randomized controlled trial. Infants were randomized to either FT (n = 16) or Calmer treatment (n = 12). The outcome measure, obtained using near-infrared spectroscopy, was a change in the tissue oxygenation index (TSI) across study phases (Baseline, Heel Lance, Recovery; median duration 517 seconds [421-906 seconds]).

RESULTS

No statistically significant differences were found between groups in the median TSI during any of the study phases. In response to the heel lance, 7 infants (27.6%) had a TSI that dipped below the 60% threshold (3 in the Calmer group 25% and 4 in the FT group 25%); none below 50%.

CONCLUSIONS

Infants on Calmer maintained normal regional cerebral oxygen levels (55%-85%) no differently from infants receiving a human touch intervention during blood collection. Parental skin-to-skin holding is one of the most effective strategies to relieve procedural pain in preterm infants. When parents or FT are not available, Calmer shows potential for filling this gap in care.

Validity and reliability testing of the Toddler and Infant (TANDI) Health Related Quality of Life instrument for very young children

BACKGROUND

Despite the high burden of disease in younger children there are few tools specifically designed to estimate Health Related Quality of Life (HRQoL) in children younger than 3 years of age. A previous paper described the process of identifying a pool of items which might be suitable for measuring HRQoL of children aged 0-3 years. The current paper describes how the items were pruned and the final draft of the measure, Toddler and Infant (TANDI) Health Related Quality of Life, was tested for validity and reliability.

METHODS

A sample of 187 caregivers of children 1-36 months of age were recruited which included children who were either acutely ill (AI), chronically ill (CI) or from the general school going population (GP). The TANDI, an experimental version of the EQ-5D-Y proxy, included six dimensions with three levels of report and general health measured on a Visual Analogue Scale (VAS) from 0 to 100. The content validity had been established during the development of the instrument. The TANDI, Ages and Stages Questionnaire (ASQ), Faces, Leg, Activity, Cry, Consolabilty (FLACC) or Neonatal Infant Pain Scale (NIPS) and a self-designed dietary information questionnaire were administered at baseline. The TANDI was administered 1 week later in GP children to establish test-retest reliability. The distribution of dimension scores, Cronbach's alpha, rotated varimax factor analysis, Spearman's Rho Correlation, the intraclass correlation coefficient, Pearson's correlation, analysis of variance and regression analysis were used to explore the reliability, and validity of the TANDI.

RESULTS

Concurrent validity of the different dimensions was tested between the TANDI and other instruments. The Spearman's Rho coefficients were significant and moderate to strong for dimensions of activity and participation and significant and weak for items of body functions. Known groups were compared and children with acute illness had the lowest ranked VAS (median 60, range 0-100), indicating worse HRQoL. The six dimensions of the TANDI were tested for internal consistency and reliability and the Cronbach's α as 0.83. Test-retest results showed no variance for dimension scores of movement and play, and high agreement for pain (83%), relationships (87%), communication (83%) and eating (74%). The scores were highly correlated for the VAS (ICC = 0.76; p < 0.001).

CONCLUSION

The TANDI was found to be valid and reliable for use with children aged 1-36 months in South Africa. It is recommended that the TANDI be included in future research to further investigate HRQoL and the impact of interventions in this vulnerable age group. It is further recommended that future testing be done to assess the feasibility, clinical utility, and cross-cultural validity of the measure and to include international input in further development.

Trajectories of post-surgical pain in infants admitted to neonatal intensive care

BACKGROUND

The aim of this study was (a) to statistically identify distinct trajectories of pain following surgery in infants less than 6 months of age, and (b) to compare these trajectories to descriptions of chronic pain in infants in the neonatal intensive care unit (NICU).

METHODS

This was a retrospective medical record review of infants admitted to a NICU between 2008 and 2018 following surgery. All infants who underwent one major procedure to the abdomen or thorax and returned to the NICU following surgery were included. Pain was assessed regularly using a validated Pain Assessment Tool. Group-based trajectory analysis was used to determine the trajectory of recovery from pain following surgery.

RESULTS

A total of 726 infants were included in the study. A two-group trajectory model, defined as typical and atypical pain trajectories, was selected. The typical group (n = 467) consisted of infants who had significantly fewer days (1.5 ± 2.3 vs 5.3 ± 5.5, p < .001) and recorded instances of pain (2.0 ± 3.4 vs 9.7 ± 10.5, p < .001) compared to infants in the atypical group (n = 259). The incidence of iatrogenic neonatal abstinence syndrome was greater in the atypical than the typical group (11% vs 5%, p = .001).

CONCLUSIONS

This study has revealed two distinct pain trajectories in infants after surgery. While recovery from pain occurs within days in the typical group, the atypical group demonstrates pain for a significantly longer period, often weeks and months following surgery. This latter group adheres closely to current descriptions of chronic pain in infants.

Expert assessment of the “Neonatal Pain Assessment Program” online course

ABSTRACT Objectives: to assess layout quality, visual identity and content of the “Neonatal Pain Assessment Program” (Programa de Avaliação da Dor Neonatal) online course. Methods: a descriptive exploratory study. The course was assessed by 24 experts in pain, neonatology and education. A form containing 20 questions on technical, interface and educational aspects was used. For each item, the score ranged from 0 to 1. Mean scores above 0.7 were considered indicative of high quality of the items. Descriptive statistics were used for data analysis. Results: navigation, clarity, ease of localization, content relevance, contextualization, content correction, multiple windows, ease of use, ease of return, ergonomics, esthetics, special brands, audiovisual resources, information and portability were assessed. All aspects obtained a mean ≥ 0.70 and no changes were required. Conclusions: the Neonatal Pain Assessment Program is considered as quality educational technology and promising strategy for health education.

The Validity of Skin Conductance For Assessing Acute Pain in Infants: A Scoping Review

OBJECTIVES

Measuring pain in infants is important but challenging, as there is no "gold standard." The measurement of skin conductance (SC) is considered to be a measure of stress and as a surrogate indicator of pain. The objectives of this study were to identify the extent of research conducted and to synthesize the validity evidence of SC for assessing acute pain in infants.

METHODS

The Arksey and O'Malley framework for scoping reviews was followed, and 9 electronic databases were searched. Data were analyzed thematically and presented descriptively including the following main categories: study information/details, sampling information, characteristics of participants and settings, SC outcome measures, and validity evidence.

RESULTS

Twenty-eight studies with 1061 infants were included, including 23 cross-sectional observation studies and 5 interventional studies. The most studied infants were those with mild severity of illness (n=13) or healthy infants (n=12). The validity evidence of SC was tested in relation to referent pain measures (13 variables), stimuli (13 variables), age (2 variables), and other contextual variables (11 variables). SC was not significantly correlated with vital signs, except for heart rate in 2 of the 8 studies. SC was significantly correlated with the unidimensional behavioral pain assessment scales and crying time rather than with multidimensional measurements. Fourteen of 15 studies (93.3%) showed that SC increased significantly during painful procedures.

CONCLUSIONS

Inconsistent findings on validity of SC exist. Future research should aim to identify the diagnostic test accuracy of SC compared with well-accepted referent pain measures in infants, study the validity evidence of SC in critically ill infants, and utilize rigorous research design and transparent reporting.

The Complexities of Nurses' Pain Assessment in Hospitalized Preverbal Children

BACKGROUND

Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited.

AIMS

The aim of this study was to explore nurses' assessment of pain in hospitalized preverbal children based on self-selected clinical examples.

DESIGN

Qualitative, descriptive design.

SETTINGS

Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use.

PARTICIPANTS/SUBJECTS

Nurses (N = 22) with ≥1 year experience caring for preverbal children.

METHODS

Individual, semistructured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment.

CONCLUSIONS

Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

The influence of gestational age in the psychometric testing of the Bernese Pain Scale for Neonates

BACKGROUND

Assessing pain in neonates is challenging because full-term and preterm neonates of different gestational ages (GAs) have widely varied reactions to pain. We validated the Bernese Pain Scale for Neonates (BPSN) by testing its use among a large sample of neonates that represented all GAs.

METHODS

In this prospective multisite validation study, we assessed 154 neonates between 24 2/7 and 41 4/7 weeks GA, based on the results of 1-5 capillary heel sticks in their first 14 days of life. From each heel stick, we produced three video sequences: baseline; heel stick; and, recovery. Five blinded nurses rated neonates' pain responses according to the BPSN. The underlying factor structure of the BPSN, interrater reliability, concurrent validity with the Premature Infant Pain Profile-Revised (PIPP-R), construct validity, sensitivity and specificity, and the relationship between behavioural and physiological indicators were explored. We considered GA and gender as individual contextual factors.

RESULTS

The factor analyses resulted in a model where the following behaviours best fit the data: crying; facial expression; and, posture. Pain scores for these behavioural items increased on average more than 1 point during the heel stick phases compared to the baseline and recovery phases (p < 0.001). Among physiological items, heart rate was more sensitive to pain than oxygen saturation. Heart rate averaged 0.646 points higher during the heel stick than the recovery phases (p < 0.001). GA increased along with pain scores: for every additional week of gestation, the average increase of behavioural pain score was 0.063 points (SE = 0.01, t = 5.49); average heart rate increased 0.042 points (SE = 0.01, t = 6.15). Sensitivity and specificity analyses indicated that the cut-off should increase with GA. Modified BPSN showed good concurrent validity with the PIPP-R (r = 0.600-0.758, p < 0.001). Correlations between the modified behavioural subscale and the item heart rate were low (r = 0.102-0.379).

CONCLUSIONS

The modified BPSN that includes facial expression, crying, posture, and heart rate is a reliable and valid tool for assessing acute pain in full-term and preterm neonates, but our results suggest that adding different cut-off points for different GA-groups will improve the BPSN's clinical usefulness.

TRIAL REGISTRATION

The study was retrospectively registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461 . Registration date: 12 April 2016.

Development and Usability Evaluation of a Desktop Software Application for Pain Assessment in Infants

BACKGROUND

Pain assessment is a key component of pain management and research in infants. We developed software to assist in coding of pain in infants called PAiN (Pain Assessment in Neonates).

AIMS

The aims of this study were to evaluate the usability of PAiN in terms of effectiveness, efficiency, and satisfaction among novice and expert users and to compare the efficiency and satisfaction of PAiN to existing software for coding of infant pain among expert users.

METHODS

A quantitative usability testing approach was conducted with two participant groups, representing novice and expert end-users. Testing included an observed session with each participant completing a pain assessment coding task, followed by administration of the Post Study System Usability Questionnaire and Desirability Toolkit. For comparison, the usability of existing coding software was also evaluated by the expert group.

RESULTS

Twelve novice and six expert users participated. Novice users committed 14 noncritical navigational errors, and experts committed six. For experts, the median time for completing the coding task was 28.6 min in PAiN, compared to 46.5 min using the existing software. The mean Post Study System Usability Questionnaire score among novice (1.89) and expert users (1.40) was not significantly different (P = 0.0917). Among experts, the score for the existing software (4.83) was significantly (P = 0.0277) higher compared to PAiN (1.40). Lower scores indicate more positive responses.

CONCLUSIONS

Users were highly satisfied with PAiN. Experts were more efficient with PAiN compared to the existing software. The study was critical to ensuring that PAiN is error free and easy to use prior to implementation.

Nociceptive Cortical Activity Is Dissociated from Nociceptive Behavior in Newborn Human Infants under Stress

Newborn infants display strong nociceptive behavior in response to tissue damaging stimuli, and this is accompanied by nociceptive activity generated in subcortical and cortical areas of the brain [1, 2]. In the absence of verbal report, these nociceptive responses are used as measures of pain sensation in newborn humans, as they are in animals [3, 4]. However, many infants are raised in a physiologically stressful environment, and little is known about the effect of background levels of stress upon their pain responses. In adults, acute physiological stress causes hyperalgesia [5, 6, 7], and increased background stress increases pain [8, 9, 10], but these data cannot necessarily be extrapolated to infants. Here we have simultaneously measured nociceptive behavior, brain activity, and levels of physiological stress in a sample of 56 newborn human infants aged 36–42 weeks. Salivary cortisol (hypothalamic pituitary axis), heart rate variability (sympathetic adrenal medullary system), EEG event-related potentials (nociceptive cortical activity), and facial expression (behavior) were acquired in individual infants following a clinically required heel lance. We show that infants with higher levels of stress exhibit larger amplitude cortical nociceptive responses, but this is not reflected in their behavior. Furthermore, while nociceptive behavior and cortical activity are normally correlated, this relationship is disrupted in infants with high levels of physiological stress. Brain activity evoked by noxious stimulation is therefore enhanced by stress, but this cannot be deduced from observation of pain behavior. This may be important in the prevention of adverse effects of early repetitive pain on brain development.

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Infant pain behavior and nociceptive brain activity are generally correlated

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Stress disrupts the relationship between infant pain brain activity and behavior

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Stress is associated with increased nociceptive brain activity, but not behavior

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Stress is an important factor when assessing infant pain experience

Assessment of continuous pain in newborns admitted to NICUs in 18 European countries

AIM

Continuous pain occurs routinely, even after invasive procedures, or inflammation and surgery, but clinical practices associated with assessments of continuous pain remain unknown.

METHODS

A prospective cohort study in 243 neonatal intensive care units (NICUs) from 18 European countries recorded the frequency of pain assessments, use of mechanical ventilation, sedation, analgesia or neuromuscular blockade for each neonate for up to 28 days after NICU admission.

RESULTS

Only 2113 of 6648 (31.8%) of neonates received assessments of continuous pain, occurring variably among tracheal ventilation (TrV, 46.0%), noninvasive ventilation (NiV, 35.0%) and no ventilation (NoV, 20.1%) groups (p < 0.001). Daily assessments for continuous pain occurred in only 10.4% of all neonates (TrV: 14.0%, NiV: 10.7%, NoV: 7.6%; p < 0.001). More frequent assessments of continuous pain occurred in NICUs with pain guidelines, nursing champions and surgical admissions (all p < 0.01), and for newborns <32 weeks gestational age, those requiring ventilation, or opioids, sedatives-hypnotics, general anaesthetics (O-SH-GA) (all p < 0.001), or surgery (p = 0.028). Use of O-SH-GA drugs increased the odds for pain assessment in the TrV (OR:1.60, p < 0.001) and NiV groups (OR:1.40, p < 0.001).

CONCLUSION

Assessments of continuous pain occurred in less than one-third of NICU admissions and daily in only 10% of neonates. NICU clinical practices should consider including routine assessments of continuous pain in newborns.

Individual contextual factors in the validation of the Bernese pain scale for neonates: protocol for a prospective observational study

Background

The Bernese Pain Scale for Neonates (BPSN) is a multidimensional pain assessment tool that is already widely used in clinical settings in the German speaking areas of Europe. Recent findings indicate that pain responses in preterm neonates are influenced by individual contextual factors, such as gestational age (GA), gender and the number of painful procedures experienced. Currently, the BPSN does not consider individual contextual factors. Therefore, the aim of this study is the validation of the BPSN using a large sample of neonates with different GAs. Furthermore, the influence of individual contextual factors on the variability in pain reactions across GA groups will be explored. The results will be used for a modification of the BPSN to account for individual contextual factors in future clinical pain assessment in neonates.

Methods and design

This prospective multisite validation study with a repeated measures design will take place in three university hospital neonatal intensive care units (NICUs) in Switzerland (Bern, Basel and Zurich). To examine the impact of GA on pain responses and their variability, the infants will be stratified into six GA groups ranging from 24 0/7 to 42 0/7. Among preterm infants, 2–5 routine capillary heel sticks within the first 14 days of life, and among full-term infants, two heel sticks during the first days of life will be documented. For each heel stick, measurements will be video recorded for each of three phases: baseline, heel stick, and recovery. The infants’ pain responses will be rated according to the BPSN by five nurses who are blinded as to the number of each heel stick and as to the measurement phases. Individual contextual factors of interest will be extracted from patient charts.

Discussion

Understanding and considering the influence of individual contextual factors on pain responses in a revised version of the BPSN will help the clinical staff to more appropriately assess pain in neonates, particularly preterm neonates hospitalized in NICUs. Pain assessment is a first step toward appropriate and efficient pain management, which itself is an important factor in later motor and cognitive development in this vulnerable patient population.

Trial registration

The study is registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461. Registration date: 12 April 2016.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonatesThe secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double- or single-blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Twenty-five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes.Seventeen studies (n = 810) compared SSC to a no-treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of -10.78 beats per minute (95% CI -13.63 to -7.93) favouring SSC. Meta-analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI -4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta-analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta-analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = -34.16, 95% CI -42.86 to -25.45), and two (n = 100) following IM injection (MD = -8.83, 95% CI -14.63 to -3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD -3.21, 95% CI -3.94 to -2.47), at 60 seconds (3 studies; n = 156) (MD -1.64, 95% CI -2.86 to -0.43), and at 90 seconds (n = 156) (MD -1.28, 95% CI -2.53 to -0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI -1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta-analysis findings.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother-providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions.

Morphine Pharmacodynamics in Mechanically Ventilated Preterm Neonates Undergoing Endotracheal Suctioning

To date, morphine pharmacokinetics (PKs) are well quantified in neonates, but results about its efficacy are ambiguous. This work presents an analysis of a previously published study on pain measurements in mechanically ventilated preterm neonates who received either morphine or placebo to improve comfort during invasive ventilation. The research question was whether morphine reduces the pain associated with endotracheal or nasal suctioning before, during, and after suctioning. Because these neonates cannot verbalize their pain levels, pain was assessed on the basis of several validated pain measurement instruments (i.e., COMFORT‐B, preterm infant pain profile [PIPP], Neonatal Infant Pain Scale (NIPS), and visual analogue scale (VAS)). The item response theory (IRT) was used to analyze the data in order for us to handle the data from multiple‐item pain scores. The analysis showed an intra‐individual relationship between morphine concentrations and pain reduction, as measured by COMFORT‐B and VAS. However, the small magnitude of the morphine effect was not considered clinically relevant for this intervention in preterm neonates.

Paracetamol and morphine for infant and neonatal pain; still a long way to go?

INTRODUCTION

Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.