Randomised study showed that recorded maternal voices reduced pain in preterm infants undergoing heel lance procedures in a neonatal intensive care unit

Effects of parents' voice on reducing heel puncture pain in high-risk newborns: A randomized controlled trial

BACKGROUND

High-risk newborns, such as premature or severely ill infants, often experience painful treatments and separation from their parents. While previous studies have focused on the positive impacts of a mother's voice on newborns' physiology and pain response, research on the father's voice and vocal acoustics in high-risk newborns is limited.

AIM

To examine whether parents' voices reduce heel puncture pain in high-risk newborns and the relationship between parents' vocal acoustics, physiological parameters and pain response.

STUDY DESIGN

A randomized controlled clinical trial was conducted with 105 high-risk newborn-parent dyads. Participants were randomly assigned to three groups: recorded mother's voice, recorded father's voice or control group without any recorded voice. Outcome measures included heart rate, respiratory rate, oxygen saturation and pain response assessed using the Neonatal Infant Pain Scale. Data analysis utilized generalized estimation equations, and parents' vocal acoustics were analysed using Praat voice credit software.

RESULTS

The mother's voice group exhibited significantly lower heart rates at 1, 5 and 10 min after the procedure, along with lower respiratory rates and pain levels at 5 and 10 min after the procedure compared with the control group. Similarly, the father's voice group demonstrated significantly lower heart rates at 1 and 5 min after the procedure, decreased respiratory rates at 5 and 10 min after the procedure and reduced pain levels at 1 and 5 to 10 min after the procedure compared with the control group. Higher minimum and mean pitches in parents' voices correlated with slower heart rates, while slower parental speech was associated with reduced newborn pain.

CONCLUSION

Both maternal and paternal vocal interventions alleviated pain during heel puncture procedures among high-risk newborns.

RELEVANCE TO CLINICAL PRACTICE

The noninvasive intervention serves as a reference for parental participation in care. Nurses can help parents to intervene with the acoustic characteristics that alleviate pain among high-risk newborns.

The effect of maternal voice and non-nutritional sucking on repeated procedural pain of heel prick in neonates: a quasi-experimental study

BACKGROUND

Neonates in the neonatal intensive care unit undergo frequent painful procedures. It is essential to reduce pain using safe and feasible methods.

PURPOSE

To evaluate the effects of non-nutritional sucking, mother's voice, or non-nutritional sucking combined with mother's voice on repeated procedural pain in hospitalized neonates.

METHODS

A quasi-experimental study was conducted in which 141 neonates were selected in a hospital in Changsha, China. Newborns were divided into four groups: non-nutritional sucking (NNS) (n = 35), maternal voice (MV) (n = 35), NNS + MV (n = 34), and control (n = 37) groups. The Preterm Infant Pain Profile-Revised Scale (PIPP-R) was used to assess pain.

RESULTS

During the heel prick, the heart rate value and blood oxygen saturation were significantly different between the groups (P < 0.05). Both non-nutritional sucking and maternal voice significantly reduced PIPP-R pain scores of hospitalized newborns (P < 0.05). The pain-relief effect was more robust in the combined group than in other groups.

CONCLUSIONS

This study showed that both non-nutritional sucking and the mother's voice alleviated repeated procedural pain in neonates. Therefore, these interventions can be used as alternatives to reduce repeated procedural pain.

Parent-led neonatal pain management-a narrative review and update of research and practices

Introduction

Research related to parent-led neonatal pain management is increasing, as is the clinical implementation. Skin-to-skin contact, breastfeeding and parents' vocalizations are examples of pain reducing methods that give parents an opportunity to protect their infant from harm while alleviating their anxiety and developing their parenting skills.

Methods

In this paper we will provide a narrative review and describe the current research about parent-led neonatal pain management. Based on this we will discuss clinical challenges, implementation strategies and implications for future research.

Results

Parents express great readiness to embrace opportunities to increase their self-efficacy in their ability to address infant pain. Parent-led pain-reducing methods are effective, feasible, cost-effective, culturally sensitive, and can be individualized and tailored to both the parent's and infant's needs. Both barriers and facilitators of parent-led pain care have been studied in research highlighting structural, organizational, educational, and intra- and interpersonal aspects. For example, health care professionals' attitudes and beliefs on parent-led methods, and their concern that parental presence during a procedure increases staff anxiety. On the other hand, the presence of a local pain champion whose duty is to facilitate the adoption of pain control measures and actively promote parent-professional collaboration, is crucial for culture change in neonatal pain management and nurses have a key role in this change. The knowledge-to-practice gap in parent-led management of infants' procedure-related pain highlight the need for broader educational applications and collaborative professional, parental and research initiatives to facilitate practice change.

Conclusion

Parent-led neonatal pain management is more than simply a humane and compassionate thing to do. The inclusion of parent-led pain care has been scientifically proven to be one of the most effective ways to reduce pain associated with repeated painful procedures in early life and parents report a desire to participate. Focus on enablers across interprofessional, organizational and structural levels and implementation of recommended pediatric pain guidelines can support the provision of optimal evidence-based family-centered neonatal pain management.

Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants

BACKGROUND

Preterm birth interferes with brain maturation, and subsequent clinical events and interventions may have additional deleterious effects. Music as therapy is offered increasingly in neonatal intensive care units aiming to improve health outcomes and quality of life for both preterm infants and the well-being of their parents. Systematic reviews of mixed methodological quality have demonstrated ambiguous results for the efficacy of various types of auditory stimulation of preterm infants. A more comprehensive and rigorous systematic review is needed to address controversies arising from apparently conflicting studies and reviews.

OBJECTIVES

We assessed the overall efficacy of music and vocal interventions for physiological and neurodevelopmental outcomes in preterm infants (< 37 weeks' gestation) compared to standard care. In addition, we aimed to determine specific effects of various interventions for physiological, anthropometric, social-emotional, neurodevelopmental short- and long-term outcomes in the infants, parental well-being, and bonding.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, RILM Abstracts, and ERIC in November 2021; and Proquest Dissertations in February 2019. We searched the reference lists of related systematic reviews, and of studies selected for inclusion and clinical trial registries.

SELECTION CRITERIA

We included parallel, and cluster-randomised controlled trials with preterm infants < 37 weeks` gestation during hospitalisation, and parents when they were involved in the intervention. Interventions were any music or vocal stimulation provided live or via a recording by a music therapist, a parent, or a healthcare professional compared to standard care. The intervention duration was greater than five minutes and needed to occur more than three times.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We analysed the treatment effects of the individual trials using RevMan Web using a fixed-effects model to combine the data. Where possible, we presented results in meta-analyses using mean differences with 95% CI. We performed heterogeneity tests. When the I2 statistic was higher than 50%, we assessed the source of the heterogeneity by sensitivity and subgroup analyses. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 trials recruiting 1532 infants and 691 parents (21 parallel-group RCTs, four cross-over RCTs). The infants gestational age at birth varied from 23 to 36 weeks, taking place in NICUs (level 1 to 3) around the world. Within the trials, the intervention varied widely in type, delivery, frequency, and duration. Music and voice were mainly characterised by calm, soft, musical parameters in lullaby style, often integrating the sung mother's voice live or recorded, defined as music therapy or music medicine. The general risk of bias in the included studies varied from low to high risk of bias. Music and vocal interventions compared to standard care Music/vocal interventions do not increase oxygen saturation in the infants during the intervention (mean difference (MD) 0.13, 95% CI -0.33 to 0.59; P = 0.59; 958 infants, 10 studies; high-certainty evidence). Music and voice probably do not increase oxygen saturation post-intervention either (MD 0.63, 95% CI -0.01 to 1.26; P = 0.05; 800 infants, 7 studies; moderate-certainty evidence). The intervention may not increase infant development (Bayley Scales of Infant and Toddler Development (BSID)) with the cognitive composition score (MD 0.35, 95% CI -4.85 to 5.55; P = 0.90; 69 infants, 2 studies; low-certainty evidence); the motor composition score (MD -0.17, 95% CI -5.45 to 5.11; P = 0.95; 69 infants, 2 studies; low-certainty evidence); and the language composition score (MD 0.38, 95% CI -5.45 to 6.21; P = 0.90; 69 infants, 2 studies; low-certainty evidence). Music therapy may not reduce parental state-trait anxiety (MD -1.12, 95% CI -3.20 to 0.96; P = 0.29; 97 parents, 4 studies; low-certainty evidence). The intervention probably does not reduce respiratory rate during the intervention (MD 0.42, 95% CI -1.05 to 1.90; P = 0.57; 750 infants; 7 studies; moderate-certainty evidence) and post-intervention (MD 0.51, 95% CI -1.57 to 2.58; P = 0.63; 636 infants, 5 studies; moderate-certainty evidence). However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention (MD -1.38, 95% CI -2.63 to -0.12; P = 0.03; 1014 infants; 11 studies; moderate-certainty evidence). This beneficial effect was even stronger after the intervention. Music/vocal interventions reduce heart rate post-intervention (MD -3.80, 95% CI -5.05 to -2.55; P < 0.00001; 903 infants, 9 studies; high-certainty evidence) with wide CIs ranging from medium to large beneficial effects. Music therapy may not reduce postnatal depression (MD 0.50, 95% CI -1.80 to 2.81; P = 0.67; 67 participants; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of music therapy on parental state anxiety (MD -0.15, 95% CI -2.72 to 2.41; P = 0.91; 87 parents, 3 studies; very low-certainty evidence). We are uncertain about any further effects regarding all other secondary short- and long-term outcomes on the infants, parental well-being, and bonding/attachment. Two studies evaluated adverse effects as an explicit outcome of interest and reported no adverse effects from music and voice.

AUTHORS' CONCLUSIONS

Music/vocal interventions do not increase oxygen saturation during and probably not after the intervention compared to standard care. The evidence suggests that music and voice do not increase infant development (BSID) or reduce parental state-trait anxiety. The intervention probably does not reduce respiratory rate in preterm infants. However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention, and this beneficial effect is even stronger after the intervention, demonstrating that music/vocal interventions reduce heart rates in preterm infants post-intervention. We found no reports of adverse effects from music and voice. Due to low-certainty evidence for all other outcomes, we could not draw any further conclusions regarding overall efficacy nor the possible impact of different intervention types, frequencies, or durations. Further research with more power, fewer risks of bias, and more sensitive and clinically relevant outcomes are needed.

Effects of recorded maternal voice on anthropometric parameters and heart rate in premature infants: A pilot randomised controlled trial

PURPOSE

To explore the benefits of a recorded maternal voice intervention on weight, recumbent length, head circumference, and heart rate of preterm infants in the neonatal intensive care unit.

METHODS

A pilot randomised controlled trial was conducted in this study. Preterm infants in the neonatal intensive care unit (N = 109) were recruited and randomly assigned to an intervention or control group. Both groups received routine nursing care, while preterm infants in the intervention group received a recorded maternal voice program of 20 min, twice daily for 21 days. Preterm infants' daily weight, recumbent length, head circumference, and heart rate were collected during the 21-day intervention. Participants' heart rate in the intervention group was also recorded once a day pre-during-after the recorded maternal voice program.

RESULTS

Preterm infants in the intervention group showed a significant increase in weight (-75.94, 95% CI -108.04, -43.85, P < 0.001), recumbent length (-0.54, 95% CI -0.76, -0.32, P < 0.001), and head circumference (-0.37, 95%CI -0.56, -0.18, P < 0.001) compared with the control group. Preterm infants in the intervention group also showed significant changes in heart rate pre-during-after the recorded maternal voice program. However, no significant differences were found in the heart rate scores between the two groups.

DISCUSSION

The changes in heart rate pre-during-after the intervention may help explain participants' more significant increase in weight, recumbent length, and head circumference.

PRACTICE IMPLICATIONS

The recorded maternal voice intervention could be incorporated into clinical practice to promote growth and development in preterm infants in the neonatal intensive care unit.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Register, https://www.anzctr.org.au/; (registration number: ACTRN12622000019707).

Effectiveness of technology-based interventions compared with other non-pharmacological interventions for relieving procedural pain in hospitalized neonates: a systematic review

OBJECTIVE

The objective of this review was to evaluate the effectiveness of technology-based interventions for relieving procedural pain among hospitalized neonates compared with other non-pharmacological interventions.

INTRODUCTION

Neonates who require hospital care often experience acute pain during medical procedures. The current best practice for relieving pain in neonates is the use of non-pharmacological interventions, such as oral solutions or intervention-based human touch. Technological solutions (eg, games, eHealth applications, mechanical vibrators) have become more commonplace in pediatric pain management over recent years; however, there is a sizeable knowledge gap around how effective technology-based interventions are for relieving pain in neonates.

INCLUSION CRITERIA

This review considered experimental trials that include technology-based, non-pharmacological interventions for relieving procedural pain among hospitalized neonates. The primary outcomes of interest include pain response to a procedure measured by a pain assessment scale validated for neonates, behavioral indicators, and changes in physiological indicators.

METHODS

The search strategy aimed to identify both published and unpublished studies. MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Cochrane Central Register of Controlled Trials, MedNar, and EBSCO Open Dissertations databases were searched for studies published in English, Finnish, or Swedish. Critical appraisal and data extraction were conducted by 2 independent researchers who adhered to JBI methodology. Meta-analysis could not be performed due to considerable heterogeneity in the studies; as a result, the findings are presented narratively.

RESULTS

A total of 10 randomized controlled trials involving 618 children were included in the review. The staff members delivering the interventions and the outcome assessors were not blinded in all of the studies, which introduced a potential risk of bias. The presented technology-based interventions were diverse, including laser acupuncture, noninvasive electrical stimulation of acupuncture points, robot platform, vibratory stimulation, recorded maternal voice, and recorded intrauterine voice. In the studies, pain was measured using validated pain scales, behavioral indicators, and physiological variables. In the studies in which pain was assessed with a validated pain measure (N=8), technology-based pain relief was significantly more effective than the comparator in 2 studies, whereas no statistically significant differences were observed in 4 studies and the technology-based intervention was less effective than the comparator in 2 studies.

CONCLUSIONS

The effectiveness of technology-based interventions in relieving neonatal pain, either as a standalone method or in combination with another non-pharmacological method, was mixed. Further research is needed to provide reliable evidence on which technology-based, non-pharmacological pain relief intervention is most effective for hospitalized neonates.

SUPPLEMENTAL DIGITAL CONTENT

A Finnish-language version of the abstract of this review is available as supplemental digital content [ http://links.lww.com/SRX/A19 ].

REVIEW REGISTRATION

PROSPERO CRD42021254218.

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.

The effect of using maternal voice, white noise, and holding combination interventions on the heel stick sampling

BACKGROUND

Heel stick sampling, a common procedure in newborns, causes acute pain.

AIMS

This study aims to measure the outcome of five various non-pharmacologic pain relief groups; maternal voice, white noise, holding, maternal voice+holding, and white noise+holding.

METHODS

The study is an open label, randomized controlled trial. A total of 178 newborns were included in this study. Newborns were randomly allocated to each group; white noise (n = 31), maternal voice (n = 31), holding (n = 30), white noise+holding (n = 29), maternal voice+holding (n = 28), and control (n = 29) interventions. Newborns' pain responses were evaluated using the Neonatal Infant Pain Scale (NIPS), and the Premature Infant Pain Profile (PIPP). The primary measured outcomes were the newborns' pain levels, while the secondary outcomes were the heart rate and changes in oxygen saturation. The mean values of pain in neonates between groups were evaluated one minute before (Phase1), during (Phase2), and one minute after (Phase3) the procedure.

RESULTS

The research results are given with comparisons in three time periods (Phase1, Phase2 and Phase3). White noise and white noise+holding were found to have the lowest mean NIPS and PIPP score (p < 0.001). The mean heart rate was found to be the lowest in the white noise+holding group (p < 0.001). There was no significant difference between the groups in terms of oxygen saturation score (p = 0.453).

CONCLUSION

The white noise+holding applied to newborns during heel stick sampling were effective in pain reduction. Nurses and midwives can use white noise+holding method.

IMPLICATIONS TO PRACTICE

These results contribute to the pain management of newborns.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

The effect of breastfeeding, breast milk odour and mother's heartbeat sound on pain level in newborns: A randomized trial

AIM

This study aimed to compare the effects of breastfeeding, breast milk odour and mother's heartbeat sounds on perceived pain during heel lance procedures in term newborns.

DESIGN

This was a randomized three-group experimental study.

METHODS

The sample of the study consisted of 90 newborns. The data were collected using pulse oximeter, fetal hand doppler, voice recorder, loudspeaker, a data collection form and the ALPS-Neo Pain and Stress Assessment Scale for Newborn Infants.

RESULTS

During the procedure, newborns in the breast milk odour group had high levels of pain and stress, those in the mother's heartbeat sounds group had mild pain and stress, and those in the breastfeeding group had no pain and stress. Additionally, a statistically significant difference was found between their crying times. This difference was the highest for newborns in the breast milk odour group, followed by the mother's heartbeat sounds and breastfeeding groups, respectively.

CONCLUSION

Breastfeeding and mother's heartbeat sounds, which are non-pharmacological pain relief methods, are effective in neonatal pain management. However, breast milk odour is not effective for pain control in newborns. Further studies should examine the efficacy combinations of these methods.

The Role of Music Therapy with Infants with Perinatal Brain Injury

Perinatal brain injury occurs in 5.14/1000 live births in England. A significant proportion of these injuries result from hypoxic ischaemic encephalopathy (HIE) in term infants and intracranial haemorrhage (IVH) or periventricular leukomalacia (PVL) in preterm infants. Standardised care necessitates minimal handling from parents and professionals to reduce the progression of injury. This can potentially increase parental stress through the physical inability to bond with their baby. Recent research highlights the ability of music therapy (MT) to empower parental bonding without handling, through sharing culturally informed personal music with their infant. This review therefore aimed to systematically evaluate the use of MT with infants diagnosed with perinatal brain injury in a neonatal intensive care unit (NICU). Search terms were combined into three categories (audio stimulation (MT), population (neonates) and condition (brain injury), and eight electronic databases were used to identify relevant studies following PRISMA guidelines. Eleven studies using music or vocal stimulation with infants diagnosed with perinatal brain injury were identified and quality assessed using Cochrane ROB2, the ROBINSI Tool and the Newcastle Ottawa Scale. Studies used either voice as live (n = 6) or pre-recorded (n = 3) interventions or pre-recorded instrumental music (n = 2). Studies had two primary areas of focus: developmental outcomes and physiological effects. Results suggested the use of music interventions led to a reduction of infants' pain scores during procedures and cardiorespiratory events, improved feeding ability (increase oral feeding rate, volume intake and feeds per day) and resulted in larger amygdala volumes than control groups. Additionally, MT intervention on the unit supported long-term hospitalised infants in the acquisition of developmental milestones. Vocal soothing was perceived to be an accessible intervention for parents. However, infants with PVL showed signs of stress in complex interventions, which also potentially resulted in an increase in maternal anxiety in one study. MT with infants diagnosed with perinatal brain injury can have positive effects on infants' behavioural and neurological parameters and support parental involvement in their infants' developmental care. Further feasibility studies are required using MT to determine appropriate outcome measures for infants and the support required for parents to allow future comparison in large-scale randomised control trials.

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.

Effects of maternal sound stimulation on preterm infants: A systematic review and meta‐analysis

AIMS

To evaluate the effects of maternal sound stimulation on preterm infants.

BACKGROUND

With an increased focus of studies on maternal sound stimulation for preterm infants, there is a need for an up-to-date systematic review and meta-analysis of randomized controlled trials to measure the effects of maternal sound stimulation on preterm infants.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, EMBASE, the Cochrane Library, CINAHL Complete, VIP Journal Integration Platform, China National Knowledge Infrastructure, Wanfang Data and China Biology Medicine disc from database establishment to 28 April 2021.

REVIEW METHODS

We conducted the meta-analysis using Review Manager 5.3. Integrative description was used for data that were not suitable for meta-analysis.

RESULTS

A total of 380 studies between 1979 and 2021 were retrieved and 26 were included in this systematic review. Maternal sound stimulation could significantly reduce the pain level and increase the comfort level of preterm infants during a painful procedure. Compared with routine care, maternal sound stimulation could help preterm infants achieve better physiological stability by reducing their heart rate and increasing their oxygen saturation.

CONCLUSION

Maternal sound stimulation is a feasible and effective intervention for preterm infants, which is highly recommended in the clinical setting.

RETRACTED: Effect of White Noise and Lullabies on Pain and Vital Signs in Invasive Interventions Applied to Premature Babies

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The editors have decided to retract the article based on the lack of ethical standard care interventions that should have been administered to the control group during planned blood collection. That standard of care includes known, evidence-based interventions such as massage, kangaroo care, listening to music, non-nutritive sucking/pacifier, and wrapping.

Psychosocial and Neurobiological Vulnerabilities of the Hospitalized Preterm Infant and Relevant Non-pharmacological Pain Mitigation Strategies

Background: Preterm pain is common in the Neonatal Intensive Care Unit (NICU), with multiple invasive procedures occurring daily. Objective: To review the psychosocial and neurobiological vulnerabilities of preterm infants and to provide an updated overview of non-pharmacological strategies for acute procedural pain in hospitalized preterm infants. Methods: We utilized a narrative review methodology, which also included a synthesis of key pieces of published systematic reviews that are relevant to the current work. Results and Conclusions: Preterm infants are uniquely susceptible to the impact of painful procedures and prolonged separation from caregivers that are often inherent in a NICU stay. Non-pharmacological interventions can be efficacious for mitigating procedural pain for preterm infants. Interventions should continue to be evaluated with high quality randomized controlled trials, and should endeavor to take into account the neurobiological and psychosocial aspects of preterm vulnerability for pain prevention and management strategies.

Factors associated with the socioemotional development of preterm infants

Preterm birth is a risk factor for problems in interactions with others. We compared the difference in socioemotional development between hospital discharge and at six months of corrected age of infants born ≤32 weeks and assessed the impact of maternal and infantile factors on socioemotional development rate within a 6 month's period. Mother-child dyads (n = 144) were assessed by the Mother-Baby Observation Protocol 0-6 months through a video microanalysis. Multivariate model was built. Neonatal, maternal and child factors were associated with interactive gaze, initiate contact, responsiveness, infantile vocalization, and thus contributed to the socioemocional development of preterm infants with their mothers.

Sensory Stimulation in the NICU Environment: Devices, Systems, and Procedures to Protect and Stimulate Premature Babies

Prematurity deprives infants of the prenatal sensory stimulation essential to their correct development; in addition, the stressful environment of the NICU impacts negatively on their growth. The purpose of this review was to investigate the effects of NICU noise pollution on preterm infants and parents. We focused on the systems and projects used to control and modulate sounds, as well as on those special devices and innovative systems used to deliver maternal sounds and vibrations to this population. The results showed beneficial effects on the preterm infants in different areas such as physiological, autonomic, and neurobehavioral development. Although most of these studies highlight positive reactions, there is also a general acknowledgement of the current limits: small and heterogeneous groups, lack of structured variable measurements, systematic control groups, longitudinal studies, and normative values. The mother's presence is always preferred, but the use of music therapy and the devices analyzed, although not able to replace her presence, aim to soften her absence through familiar and protective stimuli, which is a very powerful aid during the COVID-19 pandemic.

The Effect of Maternal Voice on Venipuncture Induced Pain in Neonates: A Randomized Study

BACKGROUND

Venipuncture is a common procedure in the neonatal intensive care unit (NICU) and causes significant pain for neonates.

AIM

To evaluate the effect of maternal voice on pain caused by venipuncture (including peripheral venipuncture and femoral venipuncture) in neonates hospitalized in the NICU.

DESIGN

Experimental, randomized controlled study.

SETTING

The study was conducted in the NICU of two hospitals in China from November 2017 to January 2019.

METHODS

One hundred and sixteen neonates were randomly assigned to the maternal voice or routine care groups. The maternal voice group received recorded maternal voice intervention before, during, and after venipuncture. Three phases of procedures were videotaped. Neonatal Infant Acute Pain Assessment Scale (NIAPAS) was assessed by the same evaluator at different phases.

RESULTS

The study showed that NIAPAS scores, behavioral indicator scores, and physiological indicator scores in the maternal voice group were significantly lower compared with those in the routine care group.

CONCLUSION

Recorded maternal voice can improve pain caused by venipuncture in neonates. These are simple, rapid, and cost-effective methods that nurses can implement during venipuncture in neonates.

Study protocol: parents as pain management in Swedish neonatal care - SWEpap, a multi-center randomized controlled trial

BACKGROUND

During the first period of life, critically ill as well as healthy newborn infants experience recurrent painful procedures. Parents are a valuable but often overlooked resource in procedural pain management in newborns. Interventions to improve parents' knowledge and involvement in infants' pain management are essential to implement in the care of the newborn infant. Neonatal pain research has studied a range of non-pharmacological pain alleviating strategies during painful procedures, yet, regarding combined multisensorial parent-driven non-pharmacological pain management, research is still lacking.

METHODS/DESIGN

A multi-center randomized controlled trial (RCT) with three parallel groups with the allocation ratio 1:1:1 is planned. The RCT "Parents as pain management in Swedish neonatal care - SWEpap", will investigate the efficacy of combined pain management with skin-to-skin contact, breastfeeding and live parental lullaby singing compared with standard pain care initiated by health care professionals, during routine metabolic screening of newborn infants (PKU-test).

DISCUSSION

Parental involvement in neonatal pain management enables a range of comforting parental interventions such as skin-to-skin contact, breastfeeding, rocking and soothing vocalizations. To date, few studies have been published examining the efficacy of combined multisensorial parent-driven interventions. So far, research shows that the use of combined parent-driven pain management such as skin-to-skin contact and breastfeeding, is more effective in reducing behavioral responses to pain in infants, than using the pain-relieving interventions alone. Combined parental soothing behaviors that provide rhythmic (holding/rocking/vocalizing) or orogustatory/orotactile (feeding/pacifying) stimulation that keep the parent close to the infant, are more effective in a painful context. In the SWEpap study we also include parental live lullaby singing, which is an unexplored but promising biopsychosocial, multimodal and multisensory pain alleviating adjuvant, especially in combination with skin-to-skin contact and breastfeeding.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04341194 ) 10 April 2020.

The effects of auditory interventions on pain and comfort in premature newborns in the neonatal intensive care unit; a randomised controlled trial

OBJECTIVE

This study investigated the effects of three auditory interventions; white noise, recorded mother's voice, and MiniMuffs, applied during a heel lance on pain and comfort in premature infants in the neonatal intensive care units.

DESIGN AND METHODS

This experimental, parallel, randomised controlled research was conducted in a state hospital tertiary-level neonatal intensive care unit. The sample comprised sixty-four premature infants with gestational ages of 31-36 weeks. The infants were randomly assigned to four groups: i) white noise, ii) recorded mother's voice, iii) MiniMuffs, and iv) control. Pain and comfort of newborns were evaluated according to the Neonatal Infant Pain Scale (NIPS) and the COMFORTneo scale. Oxygen saturation, heart rate, and crying time were also measured.

RESULTS

The mean of oxygen saturation levels in the white noise, recorded mother's voice, and MiniMuffs group were higher than the control group. The heart rate, crying time, mean NIPS score, COMFORTneo score of the premature neonates in the white noise, recorded mother's voice, and MiniMuffs groups were significantly lower than the control group (p < .001).

CONCLUSION

Auditory interventions used during heel lance reduce the pain and increase the comfort of the premature infants. White noise is extremely effective in preventing infants's pain.

Non-pharmacological pain management in the neonatal intensive care unit: Managing neonatal pain without drugs

Premature infants hospitalized after birth are exposed to repeated painful procedures as part of their routine medical care. Early neonatal exposure to unmanaged pain has been linked to numerous negative long-term outcomes, such as the development of pain hypersensitivity, detrimental psychological symptomology, and altered neurodevelopment. These findings emphasize the crucial role of pain management in neonatal care. The aim of this article is to give an overview of evidence-based non-pharmacological pain management techniques for hospitalized neonates. Research supporting the effectiveness of various proximal, distal, and procedural pain management methods in neonates will be presented. Additionally, understanding the larger biopsychosocial context of the infant that underpins the mechanisms of these pain management methods is essential. Therefore, two important models that inform non-pharmacological approaches to infant pain management (DIAPR-R [The Development of Infant Acute Pain Responding-Revised], Attachment Theory) will be discussed.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.