A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants

Acupuncture for procedural pain in newborn infants

RATIONALE

Procedural pain management in newborns, particularly those in neonatal intensive care units (NICUs), presents challenges due to limited safe and effective options. Acupuncture, a Traditional Chinese Medicine practice, has emerged as a potential alternative for pain relief in this population.

OBJECTIVES

To assess the benefits and harms of acupuncture in newborn infants undergoing painful procedures.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, and clinical trial registries up to August 2023. We checked the references of included studies and related systematic reviews.

ELIGIBILITY CRITERIA

We included parallel and cross-over randomized controlled trials (RCTs) comparing acupuncture with no treatment or sham treatment; any non-pharmacological treatment; any pharmacological treatment; or one type of acupuncture compared to another type of acupuncture.

OUTCOMES

Our outcomes were: pain scores; harms; parental, family, and caregiver satisfaction with the intervention; use of additional pharmacological intervention for pain relief; episodes of bradycardia/apnea/desaturation; neonatal mortality; mortality during initial hospitalization; intraventricular hemorrhage; late-onset sepsis; duration of hospital stay; major neurodevelopmental disability.

RISK OF BIAS

We used Cochrane's RoB 1 tool for RCTs.

SYNTHESIS METHODS

We conducted meta-analyses using fixed-effect models to calculate risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardized mean difference (SMD, when combining different pain scales) and standard deviation for continuous outcomes. We summarized the certainty of evidence according to the GRADE approach.

INCLUDED STUDIES

We included 11 RCTs enrolling 852 infants. Five studies compared acupuncture to no treatment or sham treatment; four studies to non-pharmacological treatment (oral sucrose or glucose); and two studies compared acupuncture to other types of Traditional Chinese Medicine treatments, which we refer to as 'type B acupuncture,' such as foot massage or reflexology. No studies compared acupuncture to any pharmacological treatment. We identified four ongoing studies.

SYNTHESIS OF RESULTS

We have listed outcomes reported in at least one study. Acupuncture compared to no treatment or sham treatment Acupuncture may reduce pain assessed during the procedure with any validated scale compared to no intervention (SMD -0.56, 95% CI -0.75 to -0.37; 7 studies, 471 infants; low-certainty evidence). It may result in little to no difference in any harms compared to no intervention (RR 0.35, 95% CI 0.01 to 8.31; 2 studies, 138 infants; low-certainty evidence). Acupuncture compared to any non-pharmacological treatment The evidence is very uncertain about the effect of acupuncture on pain assessed with a validated scale during the procedure compared to non-pharmacological intervention (SMD 0.29, 95% CI 0.04 to 0.54; 4 studies, 267 infants; very low-certainty evidence). Acupuncture may result in little to no difference in any harms compared to non-pharmacological treatment (RR not estimable, RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 247 infants; low-certainty evidence). Acupuncture type A (e.g. penetration of the skin with a needle) compared to acupuncture type B (e.g. foot massage or reflexology) The evidence is very uncertain about the effect of acupressure on pain assessed with any validated scale during the procedure compared to foot massage (SMD 0.05, 95% CI -0.26 to 0.36; 2 studies, 163 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Acupuncture may reduce pain assessed with different scales during the procedure, with little to no difference in any harms, when compared to no intervention. The evidence is very uncertain about the effect of acupuncture on pain assessed with different scales during the procedure when compared to any non-pharmacological treatment; acupuncture may result in little to no difference in any harms. The evidence is very uncertain about the effect of acupressure on pain assessed during the procedure when compared to foot massage or reflexology.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol (2023): doi.org/10.1002/14651858.CD015894.

The effect of the Yakson and Gentle Human Touch methods applied to preterm infants during endotracheal aspiration on pain, comfort, and physiological parameters

BACKGROUND

Preterm infants in the neonatal intensive care unit are exposed to various painful procedures; thus, different non-pharmacological pain control techniques are used to alleviate pain.

OBJECTIVES

The aim of this study is to determine the effect of Yakson and Gentle Human Touch (GHT) methods during endotracheal suctioning on pain, comfort, and physiological parameters response in preterm infants.

DESIGN

A randomised controlled crossover trial.

SETTING

This study was conducted in the neonatal intensive care unit between July 2022 and June 2023.

METHODS

Thirty infants were included in this study based on inclusion criteria. The samples randomly received a sequence of suctioning with Yakson and GHT and routine care. Neonatal Pain Agitation and Sedation Scale (N-PASS) and COMFORTneo were used to collect the data.

RESULTS

The pain and comfort scores of preterm infants who received GHT and Yakson touch during and after endotracheal suctioning were statistically significantly lower than the infants in the routine care (p < 0.001). It was determined that the difference was in favour of the Yakson group (p < 0.001). The infants who received GHT and Yakson application had lower heart rates and higher oxygen saturation levels after the application compared to the control group (p < 0.001).

CONCLUSION

The application of Yakson and GHT during endotracheal aspiration in preterm infants has been found to be effective in pain and comfort management, as well as in the regulation of physiological parameters.

Assessment of cortisol as a neonatal pain biomarker in the application of non-pharmacological analgesia therapies: systematic review and meta-analysis

BACKGROUND

In the history of Neonatology, decades ago pain has been little studied because it was believed that newborns didn't have the capacity to experience pain. Nowadays, there is enough evidence for the existence of neonatal pain but its adequate treatment is an aspect that is continuously evolving. The objective of this study was to evaluate the effectiveness of non-pharmacological analgesia therapies used to alleviate pain in newborns by analysing neonatal cortisol levels as biological markers of pain.

METHODS

A systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and the Cochrane Collaboration Handbook. Searches were performed in databases such as PubMed, Web of Science, Scopus, CINAHL, Cochrane Library and Science Direct until the end of May 2024. The search identified 1075 articles, of which 10 studies met the inclusion criteria and had the necessary data to develop the meta-analysis. Furthermore, in each meta-analysis, subgroups were performed: non-pharmacological analgesia vs. placebo, and pre-post intervention by gestational age.

RESULTS

The meta-analysis found that breastfeeding exhibited a moderate effect size (SMD = -0.63; 95% CI = -1.07 to -0.19), sucrose showed a small effect (SMD = -0.15; 95% CI = -0.55 to 0.26), and skin to skin contact exhibited a large effect (SMD = -1.34; 95% CI = -2.21 to -0.46). Patients under 28 weeks have less post-intervention pain and showed a large effect (SMD = 1.44; 95% CI = 0.47 to 2.40), between 28 and 32 weeks they have more post-intervention pain and presented a small effect (SMD = -0.43; 95% CI = -0.86 to -0.0), and over 32 weeks they have an increased post-intervention pain and exhibited a large effect (SMD = -1.08; 95% CI = -1.65 to -0.51).

CONCLUSIONS

Non-pharmacological therapies showed efficacy in pain reduction based on neonatal cortisol levels. Skin to skin contact is the most effective method to reduce pain from invasive procedures, such as heel pricks in preterm infants under 28 weeks. Breastfeeding also demonstrated to be an effective and safe alternative to use for pain relief and to reduce cortisol levels. However, the cortisol results indicate that sucrose was not effective in reducing neonatal pain.

TRIAL REGISTRATION

PROSPERO: CRD42023463831.

Effect of the application of humanized nursing care on the clinical outcomes of neonates with hyperbilirubinemia

BACKGROUND

Neonatal hyperbilirubinemia is a potentially fatal condition that has toxic effects on the brain and may have negative effects. Humanized care is a comprehensive approach that focuses on the nutritional, therapeutic and hygienic needs of neonates, which helps in the resolution of hyperbilirubinemia.

METHOD

A quasi-experimental design was utilized in this study to evaluate the effect of humanized nursing care application on the clinical outcomes of neonates with hyperbilirubinemia. It was carried out at the Neonatal Intensive Care Unit at Tanta Main University Hospital. A total of 120 neonates with hyperbilirubinemia who fit the inclusion criteria were randomly assigned to both the study and control groups. The data were collected using the biosocial-demographic characteristics of the studied neonates and neonatal clinical outcome measures for humanized care.

RESULTS

On the seventh day after receiving humanized care, total bilirubin levels in the study group decreased to 4.03 ± 1.48 compared to 10.21 ± 2.08 in the control group; there was also a decline in the time of jaundice regression with a mean of 3.966 ± 1.09 in the study group compared to 4.66 ± 1.29. in the control group. The mean days of phototherapy were 1.83 ± 0.73 in the study group and 2.41 ± 1.01 in the control group. Additionally, oxygen saturation increased significantly on the 7th day in the study group compared to the control group; the mean amount of daily milk intake was 752.8 ± 262.9 ml in the study group compared with 600.76 ± 290.31 ml in the control group.

CONCLUSION

Applying humanized care improved neonatal clinical outcomes, including O2 saturation, jaundice regression, enhanced newborn feeding and decreased duration of phototherapy.

White noise's effect on premature infants' physiological parameters during peripheral intravenous catheter insertion

BACKGROUND

Early and continuous exposure to painful stimuli in premature infants leads to short-and long-term complications. Listening to white noise is an accessible and inexpensive non-invasive method that can be used as a safe nursing intervention in hospitals. This study aimed to assess white noise's effect on premature Infants' physiological parameters during peripheral intravenous catheter insertion.

METHODS

The present experimental study was conducted on 40 premature Infants. From 5 min before Indwelling catheters to 10 min after, white noise was played through headphones to infants at a controlled volume in the test group. Using a monitor, physiological parameters were recorded from 10 min before to 30 min after the Indwelling catheter. Statistical analysis was done through the SPSS version 27 software program.

RESULTS

Regarding respiratory rate, there was no statistically significant difference between the two groups in the first, second, and sixth stages (p < 0.05). However, in the third, fourth, and fifth stages, RR in the control group was significantly higher than the test group (p ≤ 0.05). In terms of mean arterial blood pressure, there was no statistically significant difference between the two groups in any of the stages (p < 0.05). In terms of heart rate, there was no statistically significant difference between the two groups in the first, second, and sixth stages (p < 0.05). However, in the third, fourth, and fifth stages, HR in the control group was significantly higher than the test group (p ≤ 0.05). Regarding oxygen saturation percentage, there was no statistically significant difference between the two groups in the first, second, third, and sixth stages (p < 0.05). In contrast, in the fourth and fifth stages, the oxygen saturation percentage in the test group was significantly higher than in the control group (p < 0.05).

CONCLUSIONS

Although in both groups the painful procedure led to an increase in physiological variables (respiratory rate, heart rate, mean arterial blood pressure) and a decrease in blood oxygen saturation, in the test group these variables approached their initial state more quickly within half an hour after exposure to white noise. This confirms that the effect of white noise on the improvement of physiological variables is gradual.

CLINICAL TRIAL NUMBER

Not applicable.

Frequency and pain intensity of painful procedures in premature infants hospitalized in the neonatal intensive care unit

BACKGROUND

Various painful therapeutic and diagnostic procedures are performed daily for hospitalized infants. These procedures are very effective in their growth and recovery process. This study was conducted to determine "the frequency and pain intensity of painful procedures in premature infants hospitalized in NICU."

MATERIALS AND METHODS

This cross-sectional study was conducted from February 10, 2023 to April 10, 2023 on all infants who met the inclusion criteria and were admitted to NICU. The data collection tool was a multi-part questionnaire including demographic data, types of painful procedures, and NIPS pain scale. After collecting the data, it was entered into SPSS23 software and analyzed at a significance level of less than 0.05.

RESULTS

The highest frequency of painful procedures in each of the neonates during hospitalization, respectively, was related to orogastric tube insertion (24.43 ± 20.17), venipuncture (3.81 ± 1.03), IV cannula removal (3.74 ± 0.90) and intravenous insertion (3.72 ± 1.10). Pain intensity was moderate in 62.1% and severe in 36.2% of procedures. Endotracheal intubation, eye examination, nasogastric tube insertion, heel lance, oral suction, intramuscular injection, nasal suction, intravenous insertion, and venipuncture had the highest intensity of pain, respectively. Pain intensity was significantly higher in infants weighing more than 1500 g (P = 0.007) and gestational age more than 32 weeks (P = 0.031).

CONCLUSION

Premature infants admitted to the NICU frequently undergo painful procedures with moderate or severe pain intensity. Therefore, it is recommended to use appropriate pain management to increase growth and development, maintain and promote health in infants.

Effects of White Noise and Therapeutic Touch on Pain and Comfort in Newborns during Heel Lance: A Randomized Controlled Study

BACKGROUND

Nonpharmacological methods such as white noise and therapeutic touch can be used in pain management in neonates.

PURPOSE

This randomized controlled study evaluated the effects of white noise and therapeutic touch during heel lance procedures on pain, comfort levels, and physiological parameters in healthy neonates.

METHODS

This parallel, randomized controlled study was conducted in the Obstetrics and Gynecology Service of a regional hospital. The sample comprised 160 neonates with gestational ages of >35 weeks randomly assigned to 4 groups (white noise [WN], therapeutic touch [TT], white noise + therapeutic touch [WT], and control [CG] group). Pain and comfort levels were evaluated according to the Neonatal Infant Pain Scale, and the COMFORTneo Scale. The primary outcomes were pain and comfort levels, and the secondary outcomes were heart rate and SpO2 levels. The Kruskal-Wallis test was used to compare the scale scores among groups.

RESULTS

There were significant differences among groups in terms of Neonatal Infant Pain Scale and COMFORTneo scores (P < .05). The pain scores for the white noise, therapeutic touch, and white noise + therapeutic touch groups were 4.2 ± 2.0, 5.2 ± 1.6, and 3.3 ± 1.7, respectively. There was a significant difference in average heart rate during the heel lance procedure among the groups (P < .05). Pain scores of the intervention groups were lower compared to the control group.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The combination of white noise and therapeutic touch was more effective in reducing pain and increasing comfort levels. Nurses could reduce procedural pain by applying these pain relief methods.

The impact of skin-to-skin contact upon stress in preterm infants in a neonatal intensive care unit

Introduction

Neonatal stress significantly affects the early adaptation, maturation and long-term development of preterm infants.

The objective of the study

To investigate the effect of skin-to-skin contact (SSC) on stress level in preterm infants.

Materials and methods

The research was a prospective study. Stress indicators (cortisol, melatonin) were measured before the SSC began (pre-intervention level) and after this intervention (post-intervention).

Results

The study included 150 preterm infants in the NICU with gestational age (GA) ≤36 weeks. Pre-intervention salivary cortisol level was higher in extremely and very preterm neonates compared to moderate and late preterm newborns (p = 0.028), in children with low Apgar scores (p = 0.041), in those who were on mechanical ventilation (p = 0.005), and suffered neonatal sepsis (p = 0.005). Pre-intervention melatonin level was lower in children with low Apgar scores (p = 0.032). Salivary cortisol levels were significantly decreased after SSC in preterm infants [pre-intervention: 0.294 (0.111; 0.854) μg/dL vs. post-intervention: 0.127 (0.070; 0.229) μg/dL, p < 0.001], and urinary melatonin levels were significantly increased after SSC [pre-intervention: 4.01 (2.48; 6.34) ng/mL vs. post-intervention: 5.48 (3.39; 9.17) ng/mL, p < 0.001]. A greater reduction in cortisol levels after skin-to-skin contact was revealed in infants with a lower gestational age (p = 0.022), in boys compared to girls (p = 0.012), in infants with respiratory distress syndrome (p = 0.048), in those who had mechanical ventilation compared to non-ventilated neonates (p = 0.008), and in infants with seizures (p = 0.036). The melatonin levels increased more intensively in infants with low Apgar scores (p = 0.002), and in those with late-onset sepsis (p = 0.006).

Conclusion

The reduction in cortisol levels and the increase in melatonin levels provided strong evidence that SSC ameliorated the NICU-related stress in preterm infants. We found higher indicators of stress and more dramatic responses to SSC in reducing indicators of stress in infants with lower GA than in infants with higher GA, indicating that SSC may be even more important for lower GA infants. The infants who need SSC the most should not be denied the care they need to reduce the stress they experience from being born too soon and continuing their gestational development in the stressful environment of the NICU.

Effect of mechanical vibration and ShotBlocker® on pain levels during heel lance in healthy term neonates: A randomized controlled trial

PURPOSE

This study aimed to examine the effect of mechanical vibration and the ShotBlocker® device on pain level, crying time, and procedure time during a heel lance in healthy term neonates.

DESIGN AND METHODS

A total of 105 healthy-term neonates were randomized into three groups: control (n = 36), mechanical vibration (n = 33), and ShotBlocker® (n = 36). The control group underwent a routine heel lance procedure. The neonates in the mechanical vibration group received mechanical vibration to the extremity for 30 s before the heel was lanced. For the ShotBlocker® group, a ShotBlocker® was placed on the area where the heel lance procedure would occur and the heel was lanced. The heel lance procedure was videotaped, and the neonates' pain scores at 1 min before, 2 min after, and 5 min after the procedure, crying time, and procedure duration were recorded and were evaluated by two independent raters. Data were evaluated using the chi-square test and analysis of variance. The analysis of variance, Bonferroni, Dunnett T3 analysis, and effect size were used in the analyses of repeated measures. The study was approved by an ethics committee. Informed consent was obtained from parents.

RESULTS

The pain level of the neonates in the mechanical vibration group was lower than those of the control and ShotBlocker® group during and at 2 min and 5 min after the procedure (F = 12.063, p = 0.000; F = 4.580, p = 0.012; and F = 6.145, p = 0.003, respectively). The duration of neonate crying time in the mechanical vibration group was lower than in the control and ShotBlocker® groups (F = 4.598, p = 0.012). The heel lance duration was similar in the groups (F = 1.369, p = 0.259).

CONCLUSION

Mechanical vibration is an effective method to reduce the pain level and crying time associated with heel lance procedures in neonates.

PRACTICE IMPLICATIONS

This study provides evidence to nurses that the ShotBlocker is not an effective method for reducing pain associated with the heel lance procedure but that mechanical vibration is an effective method.

CLINICAL TRIALS REGISTRATION

The study was registered at Clinical-Trials.gov (NCT06380556).

Hush, little baby: The role of C-tactile afferents in babywearing infants with neonatal opioid withdrawal

Social touch through infant holding, skin-to-skin contact, and infant carrying (babywearing) decreases infant distress and promotes secure attachment. Unknown is the extent to which these effects are the result of the activation of C-Tactile afferents (CTs), the constellation of nerve fibers associated with affective touch, primarily located in the head and trunk of the body. The purpose of the present study was to compare dynamic touch (CTs activated) to static touch (CTs less activated) during a babywearing procedure among infants experiencing Neonatal Opioid Withdrawal Syndrome (NOWS). NOWS is a spectrum of clinical symptoms, including elevated heart rate (HR), associated with withdrawal from intrauterine opioid exposure. We hypothesized that stroking an infant's head during babywearing would amplify the pleasurable effect of babywearing as measured by changes in infant HR. Twenty-nine infants in a Neonatal Intensive Care Unit (NICU) in the Southwestern USA were worn in an infant carrier starting at five days old (M = 5.4, SD = 2.6; 46.2 % White, 26.9 % Latinx, 11.5 % Native American) and physiological readings were conducted daily; heart rates of infants and caregivers were taken every 15-seconds for 5-minutes, before, during, and after babywearing (30 min per phase). Each day infants alternated (randomly) in a static touch (hands-free babywearing) or dynamic touch condition (stroking the top of the infants' head at a velocity of 3 cm/s while babywearing). On average, infants completed 3 dynamic and 3 static babywearing sessions. Hospital and research staff participated in babywearing when a parent was not available (31.0 % of infants were exclusively worn by volunteers, 27.6 % were exclusively worn by parents). We analyzed the data using Hierarchical Linear Models due to the 3-level nested design (N = 29 infants, N = 191 readings, N = 11,974 heart rates). Compared to baseline (infant calm/asleep and without contact), infant's HRs significantly declined during and after babywearing, controlling for pharmacological treatment. These effects were significantly stronger during the dynamic touch condition (reduction in HR of 11.17 bpm) compared to the static touch condition (reduction in HR of 3.74 bpm). These effects did not significantly vary by wearer (mother, father, volunteer). However, differences between the dynamic and static conditions were significantly stronger in earlier babywearing sessions, potentially indicating a learning effect. There was evidence for a calming effect among caregivers as well, particularly in the dynamic touch condition, when caregivers were engaged in active touch. Activation of CTs appears to be an important mechanism in the physiological benefits of babywearing and in the symbiotic role of caregiver-infant attachment.

Comparison of Sucrose vs. Swaddling in Pain Management during Birth Dose of Hepatitis B Vaccine: A Randomized Control Trial

OBJECTIVES

To evaluate the efficacy of pain management of 1 ml of 24% sucrose given orally compared to routine care given one minute before vaccination for reduction of pain.

METHODS

This double-blind randomized controlled trial included term neonates visiting Pediatric OPD for immunization. Neonates were randomly assigned into two groups (Group A- Sucrose, Group B- Swaddling). Commercially available sucrose solution (StayHappi solution 24%) was given in a dose of 1 ml to the neonates. Video recording of the neonate's facial expression was done during the procedure. Duration of cry, latency of onset of cry as well Modified Neonatal Facial Coding Score (MFCS) were the outcome variables.

RESULTS

The mean (SD) of birth weight and gestational age was 2729 (321.6) g and 38.24 (0.84) d, respectively. Analysis showed significant difference in total MFCS across the groups (P <0.001). Total MFCS was significantly lower in sucrose group [4.88 (1.07) vs. 7.17 (0.95)]. The duration of cry (in seconds) was also found to be significantly lower in sucrose group.

CONCLUSIONS

Administration of 1 ml 24% sucrose one minute prior to immunization is efficacious in pain management during injectable immunization.

Nonpharmacological Interventions to Mitigate Procedural Pain in the NICU: An Integrative Review

BACKGROUND

Small infants experience a myriad of stimuli while in the Neonatal Intensive Care Unit (NICU), with many being painful or stressful experiences, although medically necessary.

PURPOSE

To determine what is known about nonpharmacological developmental care interventions used in the NICU to mitigate procedural pain of infants born under 32 weeks gestation.

SEARCH/STRATEGY

Five electronic databases were searched: Medline, CINAHL, Scopus, Embase and the Cochrane Library. The inclusion criteria were as follows: experimental and nonexperimental studies from all publication years with infants born at less than 32 weeks gestational age; peer-reviewed research articles studying nonpharmacological interventions such as skin-to-skin care, facilitated tucking, nonnutritive sucking, hand hugs, and swaddling; and English language articles. Our search yielded 1435 articles. After the elimination of 736 duplicates, a further 570 were deemed irrelevant based on their abstract/titles. Then, 124 full-text articles were analyzed with our inclusion and exclusion criteria.

FINDINGS

Twenty-seven studies were reviewed. Sucrose, facilitated tucking, pacifier, skin-to-skin care, and human milk appeared to lessen pain experienced during heel sticks, suctioning, nasogastric tube insertions, and echocardiograms. All nonpharmacological interventions failed to prove efficacious to adequately manage pain during retinopathy of prematurity (ROP) examinations.

IMPLICATIONS FOR PRACTICE

Evidence review demonstrates that healthcare practitioners should use nonpharmacological measures to help prevent pain from day-to-day procedures in the NICU including heel sticks, nasogastric tube insertions, suctioning, echocardiograms, and subcutaneous injections.

IMPLICATIONS FOR RESEARCH

Future research is necessary to better understand and measure how pain is manifested by very small premature infants. Specific research on mitigating the pain of examinations for retinopathy of prematurity is also needed.

The Effect of Breast Milk Odor on the Pain and Stress Levels of the Newborn During the Endotracheal Suction Procedure

Objective: The study aimed to determine the effect of the breast milk odor on the pain and stress levels of the newborn during the endotracheal suction procedure. Method: The study was conducted in the randomized-controlled experimental design at the neonatal intensive care unit of the hospital in eastern Turkey between March 2022 and December 2023. The study population included newborns at the 37th to 41st gestational weeks who were receiving mechanical ventilation treatment in the neonatal intensive care unit of a hospital in eastern Turkey. All newborns who met the inclusion criteria during the data collection phase were included in the study. The study was completed with 88 newborns (44 in the intervention group and 44 in the control group). The Newborn Introductory Information Form, ALPS-Neo Newborn Pain and Stress Assessment Scale, and follow-up form were used to collect the study data. The breast milk odor of the mothers of the newborns was used as the intervention group in the study. The mothers of the newborns were contacted to obtain breast milk, and the information was obtained from the mother on the day of the procedure. One milliliter of breast milk was taken and dropped into a sterile sponge, and it was held 10 cm away from the baby's nose from 5 minutes before to 5 minutes after endotracheal suction. A routine endotracheal suction process was performed in the control group. Ethical principles were followed in the study. Results: We found that the intervention group's pain and stress score averages were lower than the control group during and after the endotracheal suction procedure (p < 0.05). Conclusion: We found that the breast milk odor reduced the pain, stress levels, and crying duration of newborns during the endotracheal suction process.

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

"Thai Nurses' and Midwives' Perceptions Regarding Barriers, Facilitators, and Competence in Neonatal Pain Management"

BACKGROUND

Effective neonatal pain management is reliant upon the expert care of nurses and midwives working in neonatal intensive care units (NICUs). Previous research has explored barriers, facilitators, and some aspects of nurse competence in managing neonatal pain; however, this research has been predominantly performed in Western countries. To date, little is known about the barriers, facilitators, and perceived competence of Thai nurses and midwives in relation to neonatal pain management in NICUs. Exploring Thai nurses' and midwives' perceptions in these areas is crucial for understanding the contextual nuances of neonatal pain management, which can guide the provision of care for these high-risk neonates.

PURPOSE

To investigate nurses' and midwives' perceptions of barriers, facilitators, and competence regarding effective neonatal pain management in Thai NICUs.

METHODS

Data were collected using virtual one-to-one, semistructured interviews with 12 neonatal nurses and midwives between July and August 2021 in 3 units of 2 tertiary hospitals in Southern Thailand. Inductive thematic analysis was used to examine interview data.

RESULTS

These data revealed following 3 major themes: ( a ) barriers to effective neonatal pain management, ( b ) facilitators of effective neonatal pain management, and ( c ) perceptions of competence.

IMPLICATIONS FOR PRACTICE

Assisting nurses and midwives in overcoming barriers and strengthening facilitators while enhancing their competence may result in better neonatal pain management.

IMPLICATIONS FOR RESEARCH

This study adds to our understanding that further research is needed to develop the interventions designed to change at individual, unit, and organizational levels, particularly implementing parent-friendly visitation and ongoing professional development in neonatal pain management.

Long-term Effects of Cannabidiol and/or Fentanyl Exposure in Rats Submitted to Neonatal Pain

The current study aimed to evaluate anxiety behavior, hippocampal ionized calcium-binding adaptor molecule 1 (Iba1) and cannabinoid receptor 1 (CB1) gene expression, and nociceptive response in adulthood after a combination of fentanyl and cannabidiol (CBD) for nociceptive stimuli induced during the first week of life in rats. Complete Freund's adjuvant-induced inflammatory nociceptive insult on postnatal day (PN) 1 and PN3. Both fentanyl and CBD were used alone or in combination from PN1 to PN7. Behavioral and nociceptive tests were performed at PN60 and PN62. The expression of the microglial calcium-binding proteins Iba1 and CB1 was detected in the hippocampus using reverse Quantitative polymerase chain reaction (qPCR) and immunohistochemistry. Our results suggest that the anxiety behavior response and immune activation in adult life depend on the CBD dose combined with fentanyl for the nociceptive stimuli induced during the first week of life. Treatment of neonatal nociceptive insult with CBD and opioids showed significant dose-dependent and male-female differences. The increased gene expression in the hippocampus of the analyzed cannabinoid gene supports this data. In addition, treatment with fentanyl led to an increase in CB1 protein expression. Moreover, the expression of Iba1 varied according to the administered dose of CBD and may or may not be associated with the opioid. A lower dose of CBD during the inflammatory period was associated with enhanced anxiety in adult life. PERSPECTIVE: The treatment of nociceptive stimuli with CBD and opioids during the first week of life demonstrated significant sex differences in adult life on anxiety behavior and supraspinal pain sensitivity.

Long-term effects of neonatal pain and sucrose treatment

Purpose

In neonatal intensive care units, applying sucrose solution for analgesia is now a routine treatment for mild procedural pain. Studies of animal and human infants provide clear evidence of benefits in the short term, but few studies have investigated the long term benefits. Thus, we determined whether sucrose could ameliorate painful stimulation during infancy in Sprague-Dawley rats and also explored the long-term effects of repeated sucrose administration during infancy. Female and male rats were included to investigate sex-related differences.

Methods

Rat pups were stimulated either with painful or tactile stimuli for the first 14 days of their lives. Pups were pretreated either with sucrose or not treated before stimulation. Behavioral tests were conducted during adolescence and adulthood. Hotplate, rotarod, open field, elevated plus maze, and radial arm water maze tests were employed to assess the behavioral consequences of early life manipulations and treatments.

Results

Painful stimulation during infancy increased the sensitivity to pain later in life, and sucrose did not remedy this effect. Motility, coordination, anxiety, and cognition tests in adulthood obtained mixed results. Pain during infancy appeared to increase anxiety during adulthood. Learning and memory in adulthood were affected by pain during infancy, and sucrose had a negative effect even in the absence of pain. No sex-related differences were observed in any of the behavioral tests by employing this model of neonatal pain.

Conclusion

Painful stimulation during infancy resulted in deficiencies in some behavioral tests later in life. Sucrose pretreatment did not mitigate these shortcomings and it actually resulted in negative outcomes.

Effect of non-pharmacological interventions on pain in preterm infants in the neonatal intensive care unit: a network meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of different non-pharmacological interventions for pain management in preterm infants and provide high-quality clinical evidence.

METHODS

Randomized controlled trials (RCTs) of various non-pharmacological interventions for pain management in preterm infants were searched from PubMed, Web of Science, Embase, and the Cochrane Library from 2000 to the present (updated March 2023). The primary outcome was pain score reported as standardized mean difference (SMD). The secondary outcomes were oxygen saturation and heart rate reported as the same form.

RESULTS

Thirty five RCTs of 2134 preterm infants were included in the meta-analysis, involving 6 interventions: olfactory stimulation, combined oral sucrose and non-nutritive sucking (OS + NNS), facilitated tucking, auditory intervention, tactile relief, and mixed intervention. Based on moderate-quality evidence, OS + NNS (OR: 3.92, 95% CI: 1.72, 6.15, SUCRA score: 0.73), facilitated tucking (OR: 2.51, 95% CI: 1.15, 3.90, SUCRA score: 0.29), auditory intervention (OR: 2.48, 95% CI: 0.91, 4.10, SUCRA score: 0.27), olfactory stimulation (OR: 1.80, 95% CI: 0.51, 3.14, SUCRA score: 0.25), and mixed intervention (OR: 2.26, 95% CI: 0.10, 4.38, SUCRA score: 0.14) were all superior to the control group for pain relief. For oxygen saturation, facilitated tucking (OR: 1.94, 95% CI: 0.66, 3.35, SUCRA score: 0.64) and auditory intervention (OR: 1.04, 95% CI: 0.22, 2.04, SUCRA score: 0.36) were superior to the control. For heart rate, none of the comparisons between the various interventions were statistically significant.

CONCLUSION

This study showed that there are notable variations in the effectiveness of different non-pharmacological interventions in terms of pain scores and oxygen saturation. However, there was no evidence of any improvement in heart rate.

Non-pharmacological pain relief interventions in preterm neonates undergoing screening for retinopathy of prematurity: a systematic review

OBJECTIVE

The objective of this review was to determine the efficacy of non-pharmacological interventions for pain management during retinopathy of prematurity (ROP) screening.

METHODS AND ANALYSIS

Electronic search of Ovid MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Google Scholar and ClinicalTrials.gov (USA) was conducted. Search terms from the research question and inclusion criteria were used to select randomised control trials (RCT) published from January 2000 to May 2023. Relevant data were extracted, and risk of bias was assessed using the Cochrane Risk of Bias tool V.2. Critical appraisal and grading of the quality of evidence were done using the Critical Appraisal Skills Programme tool for RCTs and the Grading of Recommendations Assessment, Development and Evaluation, respectively.

RESULTS

Twenty-one RCTs were included; 14 used sweet taste, while 7 used modified developmental care, touch or positioning, multisensory stimulation, non-nutritive sucking or music. Six studies on sweet taste and all seven latter studies showed a difference in the pain scores in favour of the interventions. The quality of evidence was however judged low and moderate due to some concerns in the randomisation process, measurement of outcome assessment and selection of reported results domains.

CONCLUSION

The use of gentle touch, nesting, positioning, music, multisensory stimulation and developmental care in reducing pain during ROP screening is promising, however, larger studies designed to eliminate the identified concerns are needed. More evidence is also needed before sweet taste interventions can be recommended in routine practice.

Parental Participation in Their Infants' Procedural Pain Alleviation with Nonpharmacologic Methods in Estonia

BACKGROUND

Aim: To describe parent's participation in their infants' procedural pain alleviation using nonpharmacologic methods in neonatal and neonatal intensive care units.

METHOD

A descriptive cross-sectional survey study was carried out in four Estonian hospitals between 2019 and 2020. Data were collected by using a validated questionnaire comprised of three sections: (1) background information of parents and infants; (2) nonpharmacologic methods used by parents; and (3) parental guidance by nurses on the methods. Altogether 280 questionnaires were distributed to parents and 232 of them were received back. Finally, 189 of them were included in the study (response rate 67.5%). The data were analyzed using descriptive and analytical statistics. Analysis of open-ended questions followed principles of inductive content analysis.

RESULTS

Most participants reported using nonpharmacologic methods, such as holding and placing the infant in a more comfortable position, nearly always/always (61%, 62%, respectively). However, rarely used methods included skin-to-skin contact (7%), breastfeeding the infant (7%), and listening to recorded music (3%). While studying a correlation between the parents' use of nonpharmacologic methods and their guidance, we found a correlation among all nonpharmacologic methods. However, almost half (48%) of the parents reported that the nurses advised them "sometimes" or "nearly always/ always" to go elsewhere during painful procedures rather than participating in alleviation of the infant´s pain.

CONCLUSIONS

The parents reported using mostly the nonpharmacologic methods that were easy to implement and did not require thorough instructions in preparation. In addition, it seemed that parents wanted to be more involved in their infant's pain alleviation, but they were advised not to take part in painful procedures and pain alleviation for various reasons. Therefore, more attention should be paid to the principles of family-centered care. As health care providers, we should welcome all families as team members to involve in their infants' pain alleviation in the neonatal and neonatal intensive care units.

The effect of a live music therapy intervention on critically ill paediatric patients in the intensive care unit: A quasi-experimental pretest-posttest study

BACKGROUND

Music therapy as a nonpharmacological means of managing patient pain, anxiety, and discomfort is a recognised technique, although it is not widely used in the paediatric intensive care unit (PICU).

AIM

The aim of this study was to assess the clinical effect of a live music therapy intervention on vital signs and levels of discomfort and pain for paediatric patients in the PICU.

METHODS

This was a quasi-experimental pretest-posttest study. The music therapy intervention was carried out by two music therapists who were specifically trained, each possessing a master's degree in the field of hospital music therapy. Ten minutes before the start of the music therapy session, the investigators recorded the vital signs of the patients and assessed their levels of discomfort and pain. The procedure was repeated at the start of the intervention; at 2, 5, and 10 min during the intervention; and at 10 min following the conclusion of the intervention.

RESULTS

Two hundred fifty-nine patients were included; 55.2% were male, with a median age of 1 year (0-21). A total of 96 (37.1%) patients suffered a chronic illness. The main reason for PICU admission was respiratory illness, at 50.2% (n = 130). Significantly lower values were observed for heart rate (p = 0.002), breathing rate (p < 0.001), and degree of discomfort (p < 0.001) during the music therapy session.

CONCLUSIONS

Live music therapy results in reduced heart rates, breathing rates, and paediatric patient discomfort levels. Although music therapy is not widely used in the PICU, our results suggest that using interventions such as that used in this study could help reduce patient discomfort.

Perinatal palliative care: focus on comfort

Providing comfort while a patient is living with a life-limiting condition or at end of life is the hallmark of palliative care regardless of the patient's age. In perinatal palliative care, the patient is unable to speak for themselves. In this manuscript we will present guidelines garnered from the 15-year experience of the Neonatal Comfort Care Program at Columbia University Irving Medical Center, and how they provide care for families along the perinatal journey. We will describe essential tools and strategies necessary to consider in assessing and providing comfort to infants facing a life-limiting diagnosis in utero, born at the cusp of viability or critically ill where the burden of care may outweigh the benefit.

Non-opioid analgesics for procedural pain in neonates

BACKGROUND

Neonates are an extremely vulnerable patient population, with 6% to 9% admitted to the neonatal intensive care unit (NICU) following birth. Neonates admitted to the NICU will undergo multiple painful procedures per day throughout their stay. There is increasing evidence that frequent and repetitive exposure to painful stimuli is associated with poorer outcomes later in life. To date, a wide variety of pain control mechanisms have been developed and implemented to address procedural pain in neonates. This review focused on non-opioid analgesics, specifically non-steroidal anti-inflammatory drugs (NSAIDs) and N-methyl-D-aspartate (NMDA) receptor antagonists, which alleviate pain through inhibiting cellular pathways to achieve analgesia.  The analgesics considered in this review show potential for pain relief in clinical practice; however, an evidence summation compiling the individual drugs they comprise and outlining the benefits and harms of their administration is lacking. We therefore sought to summarize the evidence on the level of pain experienced by neonates both during and following procedures; relevant drug-related adverse events, namely episodes of apnea, desaturation, bradycardia, and hypotension; and the effects of combinations of drugs.  As the field of neonatal procedural pain management is constantly evolving, this review aimed to ascertain the scope of non-opioid analgesics for neonatal procedural pain to provide an overview of the options available to better inform evidence-based clinical practice.  OBJECTIVES: To determine the effects of non-opioid analgesics in neonates (term or preterm) exposed to procedural pain compared to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL), PubMed, Embase, and two trial registries in June 2022. We screened the reference lists of included studies for studies not identified by the database searches.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs), quasi-RCTs, and cluster-RCTs in neonates (term or preterm) undergoing painful procedures comparing NSAIDs and NMDA receptor antagonists to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our main outcomes were pain assessed during the procedure and up to 10 minutes after the procedure with a validated scale; episodes of bradycardia; episodes of apnea; and hypotension requiring medical therapy.

MAIN RESULTS

We included two RCTs involving a total of 269 neonates conducted in Nigeria and India.  NMDA receptor antagonists versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention One RCT evaluated using oral ketamine (10 mg/kg body weight) versus sugar syrup (66.7% w/w at 1 mL/kg body weight) for neonatal circumcision.  The evidence is very uncertain about the effect of ketamine on pain score during the procedure, assessed with the Neonatal Infant Pain Scale (NIPS), compared with placebo (mean difference (MD) -0.95, 95% confidence interval (CI) -1.32 to -0.58; 1 RCT; 145 participants; very low-certainty evidence). No other outcomes of interest were reported on. Head-to-head comparison of different analgesics One RCT evaluated using intravenous fentanyl versus intravenous ketamine during laser photocoagulation for retinopathy of prematurity. Neonates receiving ketamine followed an initial regimen (0.5 mg/kg bolus 1 minute before procedure) or a revised regimen (additional intermittent bolus doses of 0.5 mg/kg every 10 minutes up to a maximum of 2 mg/kg), while those receiving fentanyl followed either an initial regimen (2 μg/kg over 5 minutes, 15 minutes before the procedure, followed by 1 μg/kg/hour as a continuous infusion) or a revised regimen (titration of 0.5 μg/kg/hour every 15 minutes to a maximum of 3 μg/kg/hour). The evidence is very uncertain about the effect of ketamine compared with fentanyl on pain score assessed with the Premature Infant Pain Profile-Revised (PIPP-R) scores during the procedure (MD 0.98, 95% CI 0.75 to 1.20; 1 RCT; 124 participants; very low-certainty evidence); on episodes of apnea occurring during the procedure (risk ratio (RR) 0.31, 95% CI 0.08 to 1.18; risk difference (RD) -0.09, 95% CI -0.19 to 0.00; 1 study; 124 infants; very low-certainty evidence); and on hypotension requiring medical therapy occurring during the procedure (RR 5.53, 95% CI 0.27 to 112.30; RD 0.03, 95% CI -0.03 to 0.10; 1 study; 124 infants; very low-certainty evidence). The included study did not report pain score assessed up to 10 minutes after the procedure or episodes of bradycardia occurring during the procedure. We did not identify any studies comparing NSAIDs versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention or different routes of administration of the same analgesics. We identified three studies awaiting classification.  AUTHORS' CONCLUSIONS: The two small included studies comparing ketamine versus either placebo or fentanyl, with very low-certainty evidence, rendered us unable to draw meaningful conclusions. The evidence is very uncertain about the effect of ketamine on pain score during the procedure compared with placebo or fentanyl. We found no evidence on NSAIDs or studies comparing different routes of administration. Future research should prioritize large studies evaluating non-opioid analgesics in this population. As the studies included in this review suggest potential positive effects of ketamine administration, studies evaluating ketamine are of interest. Furthermore, as we identified no studies on NSAIDs, which are widely used in older infants, or comparing different routes of administration, such studies should be a priority going forward.

Effect of Non-Pharmacological Methods in the Reduction of Neonatal Pain: Systematic Review and Meta-Analysis

In neonatology, neonates have traditionally been considered incapable of feeling pain, due to the immaturity of their nervous system. Currently, there is sufficient information on the perception of pain in neonates; however, this treatment at this crucial stage for development requires a better approach. For this reason, the aim of this study was to analyse the efficacy of non-pharmacological analgesia interventions during heel prick, and to assess their effects on heart rate (HR), premature infant pain profile (PIPP) and O2 saturation. A systematic review and meta-analysis was performed following the guidelines of the preferred reporting items for systematic reviews and meta-analyses (PRISMA), and the Cochrane collaboration handbook. The databases PubMed, Cochrane Library, Web of Science, Scopus, CINAHL and Science Direct were searched until the end of January 2022. The DerSimonian and Laird methods were used to estimate the effect size with a 95% confidence interval (CI95%). Effect size estimates were 0.05 (95% CI: -0.19, 0.29) for HR, -0.02 (95% CI: -0.24, 0.21) for PIPP scale, and -0.12 (95% CI: -0.29, 0.05) for O2 saturation. The non-pharmacological interventions analysed (breastfeeding, kangaroo-mother care method, oral sucrose and non-nutritive sucking) were not statistically significant in reducing neonatal pain, but did influence the decrease in pain score and a faster stabilisation of vital signs.

The effect of regional massage performed before blood collection on pain and vital signs in newborns

AIM

This randomised-controlled trial aims to examine the effect of regional massage performed before blood collection on pain and vital signs in term newborns.

METHODS

The study sample consisted of a total of 96 term newborns, 49 in the experimental group and 47 in the control group, in the neonatal intensive care unit (NICU). Before the blood collection process, those in the experimental group received two (2) minutes of massage on their blood collection region, and their pain levels and vital signs were observed. Data were collected using a newborn information form, an intervention follow-up form, and the Neonatal Infant Pain Scale (NIPS). Statistical analyses of the collected data included descriptive statistics, Chi-squared test, independent-samples t test, paired-samples t test and Cohen's kappa statistic. A value of P < 0.05 was considered statistically significant.

RESULTS

While 51% (n = 49) of the newborns were included in the experimental group, 38.5% (n = 37) were born at the 38th gestational week. Their mean post-natal age was 4.82 ± 4.04 days. The newborns in the experimental and control groups had similar demographic characteristics and blood collection experiences, and there was no statistically significant difference between them (P > 0.05). The mean crying time in the control group (56.9 ± 25.4 s) was significantly longer than that in the experimental group (30.6 ± 29.3 s) (P < 0.05). The newborns in the experimental group had shorter crying times, lower pain levels and heart rate, and higher oxygen saturation than those in the control group.

CONCLUSION

The regional massage intervention reduced pain in term newborns. Therefore, neonatal nurses can be trained to use massage as an alternative infant care practice.

Interventions for the Management of Pain and Sedation in Newborns Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: A Systematic Review

BACKGROUND

Newborn infants undergoing therapeutic hypothermia (TH) are exposed to multiple painful and stressful procedures. The aim of this systematic review was to assess benefits and harms of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing TH for hypoxic-ischemic encephalopathy.

METHODS

We included randomized and observational studies reporting any intervention (either drugs or non-pharmacological interventions) to manage pain and sedation in newborn infants (> 33 weeks' gestational age) undergoing TH. We included any dose, duration and route of administration. We also included any type and duration of non-pharmacological interventions. Our prespecified primary outcomes were analgesia and sedation assessed using validated pain scales in the neonatal population; circulatory instability; mortality to discharge; and neurodevelopmental disability. A systematic literature search was conducted in the PubMed, Embase, CINAHL, Cochrane CENTRAL, Scopus, and Web of Science databases, with no language restrictions. Included studies underwent risk-of-bias assessment (Cochrane risk-of-bias tool and ROBINS-I) and data extraction performed by two authors independently. The plan had been to use effect measures such as mean difference for continuous outcomes and risk ratio for dichotomous outcomes, however the included studies are presented in a narrative synthesis due to their paucity and heterogeneity.

RESULTS

Ten studies involving 3551 infants were included-one trial and nine observational studies. Most studies examined the use of phenobarbital or other antiepileptic drugs with primary outcomes related to seizure activity. The single trial that was included compared pentoxifylline with placebo. Among the primary outcomes, six studies reported circulatory instability and five reported mortality to discharge without relevant differences; two studies reported on neurodevelopmental disability and one study reported on pain scale. Three studies were ongoing.

CONCLUSIONS

We found limited evidence to establish the benefits and harms of the interventions for the management of pain and sedation in newborn infants undergoing TH. Long-term outcomes were not reported. Given the very low certainty of evidence-due to imprecision of the estimates, inconsistency and limitations in study design (all nine observational studies with overall serious risk of bias)-for all outcomes, clinical trials are required to determine the most effective interventions in this population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020205755.

Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia

BACKGROUND

Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life.

OBJECTIVES

To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge.

SEARCH METHODS

We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions.  Primary outcomes were analgesia and sedation, and all-cause mortality to discharge.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data.  MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine.

AUTHORS' CONCLUSIONS

We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.

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.

An integrative review of clinician-administered comforting touch interventions and acute stress responses of preterm infants

PROBLEM

Preterm infants experience numerous stressors in the neonatal intensive care unit. Non-pharmacological interventions, including maternal comforting touch, reduce stress responses of preterm infants; however, the effects of clinician-administered comforting touch are unclear. The purpose of this integrative review was to synthesize findings from clinical trials to determine the effect of clinician-administered comforting touch on preterm infants' acute stress responses.

ELIGIBILITY CRITERIA

Eligible clinical trials were published in English between 2001 and October 2021 and reported effects of clinician-administered comforting touch on acute stress responses in preterm infants.

SAMPLE

Thirty clinical trials were included.

RESULTS

Researchers tested the effect of comforting static touch, massage, massage with kinesthetic stimulation, sensorial saturation, and Yakson. There was significant heterogeneity in study design, comparison condition, and context of intervention delivery. Results varied; some studies demonstrated efficacy of comforting touch in reducing acute stress responses and others showed no effect. Generally, comforting touch provided during stressful procedures was associated with lower stress responses compared to standard care and was an effective adjunct to other stress management strategies. However, comforting touch alone was insufficient for managing pain, especially during skin-breaking procedures.

CONCLUSIONS

While comforting touch may be a useful part of stress management plans for preterm infants, additional research is needed to determine when comforting touch is appropriate and effective.

IMPLICATIONS

Comforting touch is beneficial to preterm infants and should be provided for stress management. For highly intrusive or painful procedures, comforting touch can be provided as part of a comprehensive stress management plan.

The effect of three different methods applied during peripheral vascular access in prematures on pain and comfort levels

PURPOSE

This research was carried out to determine the influence of kangaroo care, fetal position, and swaddling on pain and comfort levels in preterm infants during peripheral vascular access.

DESIGN AND METHODS

The study was conducted as a randomized experimental study with a control group. It included 148 premature infants (kangaroo group = 37, swaddling group = 37, fetal position = 37, control group = 37) of 32-37 weeks of age who had peripheral vascular access in the NICU of a state hospital in eastern Turkey between December 2019 and June 2020. While the infants in the experimental group received kangaroo care, fetal position, and swaddling procedures during and after peripheral vascular access, the infants in the control group received conventional peripheral vascular access without extra intervention. "Newborn Infant Pain Scale (NIPS)" and "Premature Infant Comfort Scale (PICS)" were used to collect data. Data were analyzed using percentile, chi-square and ANOVA tests.

RESULTS

Further analysis revealed that the fetal position was the most beneficial intervention for reducing NIPS scores and boosting PICS scores during and after peripheral vascular access in the experimental groups, followed by kangaroo care and lastly swaddling.

CONCLUSION

It was discovered that kangaroo care, fetal position, and swaddling were useful in lowering discomfort and boosting comfort levels in premature infants during and after peripheral vascular access.

PRACTICE IMPLICATIONS

Kangaroo care, fetal position and swaddling methods can be used in clinical practice in order to reduce the pain level and increase the comfort level during and after peripheral vascular access in prematures.

Non-Pharmacological Management for Vaccine-Related Pain in Children in the Healthcare Setting: A Scoping Review

Purpose

To examine how research was conducted on non-pharmacological management in children with vaccine-related pain in the healthcare setting, so as to provide reference for the relief of vaccine-related pain in children.

Methods

This study conducted a scoping review guided by the methodological framework of Arksey and O'Malley. MEDLINE, Cochrane Library, EMBASE, CINAHL, PubMed databases were searched in detail, and search strategy included the keyword "vaccine", the keyword "pain", and the keyword "children". Two researchers conducted literature screening and data extraction independently, and any disagreements were resolved through team consultation.

Results

This study retrieved 1017 literatures, of which 22 were finally included, including 18 randomized controlled studies, 3 quasi-experimental studies and 1 cohort study. Non-pharmacological management measures were summarized in the study, mainly involving taste, tactile, olfactory, visual, exercise, and postural interventions and injection technique. All the above non-pharmacological management were effective in mitigating vaccine-related pain in children. The study population in the included literatures was mainly neonates and infants. Regarding the analgesic effects of taste intervention, breastfeeding was better than sweeteners, and sweeteners were better than sterile water or non-nutritive sucking. However, there was a lack of comparative studies on the analgesic effects of other non-pharmacological management.

Conclusion

There are many non-pharmacological management measures with varying analgesic effects. Diversified non-pharmacological management measures can provide more analgesic choices for children. For reducing vaccine-related pain in newborns and infants, breastfeeding is recommended first, then sweeteners, and then non-nutritious sucking. In addition to the taste intervention, the analgesic effects of other non-pharmacological management measures need further comparative studies. Moreover, medical staff can use a combination of non-pharmacological analgesic measures to maximize the analgesic effect, and medical staff should also fully consider the analgesia willingness of children and parents.

The Impact of Breast Milk Taste and Smell in Reducing Pain in Infants Undergoing Blood Drawing Procedure: A Randomized Controlled Study

Background: Infants hospitalized in neonatal intensive care units (NICUs) are exposed to numerous procedures that cause pain. In the literature, pain management methods in infants are evaluated by using breast milk in various ways. However, no study was found on whether the smell of breast milk, its taste, or both are more effective in pain management. Aim: The purpose of this study is to comparatively investigate the efficacy of breast milk taste and/or smell in reducing pain responses in infants undergoing a blood drawing procedure. Methods: The population of this study, which has a randomized controlled prospective design, consisted of infants who were treated in a NICU and met the inclusion criteria. The heart rate (HR), oxygen saturation (SpO₂), and pain of the infants were evaluated before, during, and after the blood drawing procedure in all groups. Results: During and after the procedure, there were significant differences in terms of pain levels, SpO₂ levels, and HR between the groups (p = 0.000). The lowest pain score during the procedure was found in the infants to whom breast milk taste and smell were administered together. The group with the second-lowest pain score was exposed to the taste of breast milk. The group with the highest pain score was the control group. Conclusion: Breast milk smell and taste are recommended for use as a nursing intervention to reduce pain, decrease the HR, and increase SpO₂ in the NICU during painful procedures. Future research needs to explore different interventional practices.

Effect of physical therapy on bone remodelling in preterm infants: a multicenter randomized controlled clinical trial

Background

Preterm infants have a low level of bone mineralization compared to those born at term, since 80% of calcium incorporation occurs at the end of pregnancy. The purpose of the present study was to investigate the effect of reflex locomotion therapy on bone modeling and growth in preterm infants and to compare its effect with those of other Physiotherapy modalities.

Methods

A multicentre randomized controlled clinical trial was conducted (02/2016 – 07/2020). 106 preterm infants born at the Virgen de la Arrixaca University Clinical Hospital, the General University Hospital of Elche and the Torrecárdenas University Hospital of Almería, between 26 and 34 weeks with hemodynamic stability, complete enteral nutrition and without any metabolic, congenital, genetic, neurological or respiratory disorders were evaluated for inclusion. Infants were randomly assigned to three groups: one group received reflex locomotion therapy (EGrlt); another group received passive mobilizations with gentle joint compression (EGpmc); and the control group received massage (CG). All treatments were carried out in the neonatal units lasting one month. The main outcome measure was bone formation and resorption measured with bone biomarkers. A mixed ANOVA was used to compare the results of bone biomarkers, and anthropometric measurements.

Results

Infants were randomized to EGrlt (n = 38), EGpmc (n = 32), and CG (n = 36). All groups were similar in terms of gender (p = 0.891 female 47.2%), gestational age (M = 30.753, SD = 1.878, p = 0.39) and birth weight (M = 1413.45, SD = 347.36, p = 0.157). At the end of the study, significant differences were found between the groups in their interaction in bone formation, measured with osteocalcin [F (2,35) = 4.92, p = 0.013, η_p² = 0.043], in benefit of the EGrlt.

Conclusions

Reflex locomotion therapy has been effective in improving bone formation, more so than other Physiotherapy modalities. Therefore, reflex locomotion therapy could be considered one of the most effective physiotherapeutic modalities for the prevention and treatment of osteopenia of prematurity.

Trial registrstion

Trial retrospectively registered at ClinicalTrials.gov. First posted on 22/04/2020. Registration number: NCT04356807.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03402-2.

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.

Interventions for the management of Pain and Sedation in Newborns undergoing Therapeutic hypothermia for hypoxic-ischemic encephalopathy (IPSNUT): protocol of a systematic review

BACKGROUND

Clinical research has shown that therapeutic hypothermia after neonatal hypoxic-ischemic injury improves survival without disability. There is no consensus regarding pain relief or sedation during therapeutic hypothermia in newborns; however, therapeutic hypothermia seems to be associated with pain and stress, and adequate analgesia and sedation are central to maximize the effect of therapeutic hypothermia. Pain needs to be adequately managed in all patients, especially the newborn infant due to the potential short- and long-term negative effects of inadequately treated pain in this population.

METHODS

We will perform a systematic review of pharmacological and non-pharmacological interventions for the management of pain and sedation in newborn infants undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy. We will include randomized, quasi-randomized controlled trials and observational studies. The use of pharmacological or non-pharmacological interventions will be compared to other pharmacological and or non-pharmacological interventions or no intervention/placebo. The primary outcomes for this review will be analgesia and sedation assessed with validated pain scales, circulatory instability, mortality to discharge, and moderate-to-severe neurodevelopmental disability. We will search the following databases: CINAHL, ClinicalTrials.gov , Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Two independent researchers will screen the records for inclusion, extract data using a data extraction form, and assess the risk of bias in the included trials.

DISCUSSION

The result of this review will summarize the knowledge regarding the management of pain and sedation in infants treated with therapeutic hypothermia and potentially provide clinicians with guidance on the effective and safe methods.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020205755.

The Effect of Endotracheal Suctioning Using the Four-handed Care on Physiological Criteria and Behavioral Responses of the Preterm Infants: Randomized Crossover Clinical Trial

Background: Endotracheal suctioning, despite its necessity, is one of the procedures that can cause pain and stress for infants admitted to neonatal intensive care units. Pain and stress manifest with physiological and behavioral responses in infants. Purpose: This study is a cross-sectional clinical trial that aimed to investigate the effect of endotracheal suctioning using four-handed care on the physiological criteria and behavioral responses of preterm infants. Methods:In this study, 40 infants were randomly divided into two groups of 20, one group was first suctioned by the routine method (two hands) and then with the four-handed method. The other group was first suctioned by the four-handed method and then with the routine one. The ALPS NEO was used to evaluate behavioral criteria. One camera recorded facial expressions and body movements, and physiological data were recorded from the monitor simultaneously. Results:Four-handed suctioning method can prevent an increase in heart rate during and two minutes after suctioning but it did not affect behavioral responses and oxygen saturation of the preterm infants admitted to NICUs. Since one of the symptoms of pain and stress in infants is the change of vital signs, especially the heart rate, stable heart rate during painful procedures can be an indication of the effectiveness of the four-hand method in invasive procedures such as suctioning. Implications for Practice: We recommend four-handed method for suctioning of endotracheal tube. Implications for Research: Evaluate the effect of four-handed care by mother on physiological criteria and behavioral responses of the preterm infants.

Efficacy of Breast Milk Olfactory and Gustatory Interventions on Neonates’ Biobehavioral Responses to Pain during Heel Prick Procedures

This study aimed to evaluate the efficacy of breast milk odor either alone or in combination with breast milk taste (via syringe-feeding) to alleviate neonates’ biobehavioral responses to pain during heel-prick procedures. This prospective randomized controlled trial recruited 114 neonates by convenience sampling from a newborn unit of a medical center in Taiwan. Neonates were randomly assigned to three groups: control (gentle touch + human voice), control + breast milk odor, and control + breast milk odor + breast milk taste. Heart rate, oxygen saturation, and voice recordings of crying were measured across heel-prick procedures: baseline, no stimuli (stage 0); during heel prick (Stages 1–4); and recovery (Stages 5–10). Generalized estimating equations and Kaplan–Meier survival analysis compared differences in changes between groups for heart rate, oxygen saturation, and time to crying cessation. Changes in mean heart rate and oxygen saturation in neonates receiving breast milk odor or breast milk odor + breast milk taste were significantly less than those at the corresponding stage for the control group. Among neonates receiving breast milk odor or breast milk odor + breast milk taste, hazard rate ratios for crying cessation were 3.016 and 6.466, respectively. Mother’s breast milk olfactory and gustatory interventions could stabilize the biobehavioral responses to pain during heel prick procedures in neonates.

An investigation on the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit

OBJECTIVES

To investigate the current status of the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit (NICU).

METHODS

A self-made scale was developed according to "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)" and was used to distribute questionnaires to the medical staff in the NICU from the member units of Jiangsu Province Medical Quality Control Centre of Neonatal Department to evaluate their levels of understanding the basic knowledge, assessment, and management of neonatal pain.

RESULTS

A total of 957 questionnaires (from 383 doctors and 574 nurses) were collected. Doctors and nurses had mean correct rates of 38% and 39% respectively in answering the questions on the basic knowledge of neonatal pain. They had median correct rates of 0% and 50% respectively in answering the questions on neonatal pain assessment, and mean correct rates of 73% and 68% respectively in answering on analgesia management. Compared with those who did not receive the training on neonatal pain, the medical staff who received such training had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment (P<0.05). The medical staff from tertiary hospitals had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment than those from secondary hospitals (P<0.05).

CONCLUSIONS

The medical staff in the NICU have insufficient cognition of neonatal pain, and thus it is necessary to carry out the special training on neonatal pain, focusing on the promotion and practical application of "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)", in order to improve the level of neonatal pain assessment and analgesia management among medical staff in the NICU.

Pain in Preterm Infants: Different Perspectives

In the last decades, there has been a tremendous change in approaching and managing neonates' pain. These changes began with rebutting the previous misconception about neonates' , particularly preterm infants' , pain. The development in neuroimaging has revealed that by 24 weeks of gestation the peripheral nervous system is mature and function fully. Researchers now know that neonates experience pain and premature infants have even lower pain thresholds. Since that time, a mounting amount of literature has addressed the issue of neonatal pain. Many pharmacological and non pharmacological pain reduction strategies have been investigated for their safety and analgesic effectiveness. Many interventions such as nonnutritive sucking (NNS), skin-to-skin contact (SSC), and facilitated tucking are effective in controlling neonates pain.

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

OBJECTIVE

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

INTRODUCTION

Neonates requiring 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 (such as games, eHealth applications, and mechanical vibrators) have become more commonplace in pediatric pain management over recent years. However, there is a knowledge gap about how effective technology-based interventions are at relieving pain in neonates.

INCLUSION CRITERIA

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

METHODS

MEDLINE (Ovid), CINAHL (EBSCO), Scopus (Elsevier), Cochrane Central Register of Controlled Trials, and the MEDIC databases will be searched for studies published in English, Finnish, and Swedish. Critical appraisal and data extraction will be conducted by two independent researchers following JBI methodology. Quantitative data will be pooled in statistical meta-analyses. If statistical analysis is not possible, the findings will be reported narratively.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021254218.

A Systematic Review of Assessments and Interventions for Chronic Pain in Young Children With or at High Risk for Cerebral Palsy

BACKGROUND

Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy.

METHODS

A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences.

RESULTS

Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable.

CONCLUSION

A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

Physical contact in parent-infant relationship and its effect on fostering a feeling of safety

The infant-caregiver relationship involves physical contact for feeding, moving, and other cares, and such contact also encourages the infant to form an attachment, an emotional bond with the caregivers. Physical contact always accompanies somatosensory perception, which is detected by mechanosensory neurons and processed in the brain. Physical contact triggers sensorimotor reflexes such as Transport Response in rodent infants, and calm human infants while being carried. Tactile sensation and deep pressure in physical interactions, such as hugging, can function as emotional communication between infant and caregiver, which can alter the behavior and mood of both the infant and caregiver. This review summarizes the findings related to physical contact between the infant and the caregiver in terms of pleasant, noxious, and neutral somatosensation and discusses how somatosensory perceptions foster a feeling of safety that is important for infant's psychosocial development.

Nurse Perceptions of Babywearing for Neonates With Neonatal Abstinence Syndrome in the Neonatal Intensive Care Unit

BACKGROUND

Infants diagnosed with neonatal abstinence syndrome (NAS) often spend several weeks in a neonatal intensive care unit (NICU) and have difficulty being consoled. Infant carriers may be used to help with irritability, while allowing the adult user to be more mobile, through the practice of babywearing (the facilitated holding of an infant using a soft cloth infant carrier worn on the body).

PURPOSE

To examine the experience of babywearing infants diagnosed with NAS while admitted in the NICU from the perspective of the nurses who care for them.

METHODS

Nurses (N = 18; mean age = 35.44 years, SD = 9.45) were recruited and interviewed using a semistructured interview method from a 38-bed NICU in the Southwestern United States.

RESULTS

A thematic content analyses using an open coding scheme yielded 6 themes that fell into 2 categories: (1) benefits of babywearing infants with NAS in the NICU (Infant Consoling, Adult Multitasking, Caregiver-Infant Trust); and (2) suggestions to maximize babywearing in the NICU (Infection Control, Reoccurring Infant Carrier Education, and Reduced Patient Load).

IMPLICATIONS FOR PRACTICE

Many NICUs incorporate kangaroo care (or skin-to-skin contact) as a treatment option; however, NICU staff cannot participate in kangaroo care. Babywearing is a practical alternative for nurses and support staff. Nurses supported the practice of babywearing as a means to improve the well-being of infants with NAS while also allowing for increased efficiency in nursing tasks.

IMPLICATIONS FOR RESEARCH

More prospective studies are needed that evaluate the carryover effects and long-term impact of babywearing for infants diagnosed with NAS.

Skin-to-Skin Care by Mother vs. Father for Preterm Neonatal Pain: A Randomized Control Trial (ENVIRON Trial)

OBJECTIVE

To compare skin-to-skin care (SSC) given by mother and father for preterm neonatal pain control by premature infant pain profile (PIPP) score.

METHODS

64 stable preterm (28-36 weeks gestational age) neonates born at a level-3 neonatal intensive care unit were included in the trial. Random allocation with the help of a computer-generated sequence was done. In group A, SSC was given by the mother 15 minutes before the first heel-stick, and subsequently, SSC was given by the father before the second heel-stick. In group B, the sequence of SSC provider was reversed. Blinded PIPP score assessment at 0, 1, and 5 minutes of heel-stick were done by two independent assessors using video recording.

RESULTS

The mean (SD) birth weight was 1665.18 (339.35) grams, and mean (SD) gestational age was 34.28 (2.24) weeks. The PIPP score at 0, 1, and 5 minutes had no statistical or clinically significant differences between both groups (PIPP score mean (SD) at 0 minute = 3.20 (1.11) vs. 3.01 (1.29), p value = 0.38; 1 minute = 8.59 (4.27) vs. 8.26 (4.08), p value = 0.66; 5 minutes = 3.79 (1.40) vs. 3.93 (1.99), p value = 0.65 in SSC by mother and father group, respectively). Furthermore, there was no statistical difference between the groups for any components of the PIPP score (all p values > 0.05). The PIPP score at 5 minutes almost attained the 0-minute level in both the groups.

CONCLUSION

Father is as effective as the mother for providing skin-to-skin care for preterm neonatal pain control. This trial is registered with CTRI/2018/01/016783.

"Babywearing" in the NICU: An Intervention for Infants With Neonatal Abstinence Syndrome

BACKGROUND

The US opioid epidemic has resulted in an increase of infants at risk for developing neonatal abstinence syndrome (NAS). Traditionally, treatment has consisted of pharmacological interventions to reduce symptoms of withdrawal. However, nonpharmacological interventions (eg, skin-to-skin contact, holding) can also be effective in managing the distress associated with NAS.

PURPOSE

The purpose of this study was to examine whether infant carrying or "babywearing" (ie, holding an infant on one's body using cloth) can reduce distress associated with NAS among infants and caregivers.

METHODS

Heart rate was measured in infants and adults (parents vs other adults) in a neonatal intensive care unit (NICU) pre- (no touching), mid- (20 minutes into being worn in a carrier), and post-babywearing (5 minutes later).

RESULTS

Using a 3-level hierarchical linear model at 3 time points (pre, mid, and post), we found that babywearing decreased infant and caregiver heart rates. Across a 30-minute period, heart rates of infants worn by parents decreased by 15 beats per minute (bpm) compared with 5.5 bpm for infants worn by an unfamiliar adult, and those of adults decreased by 7 bpm (parents) and nearly 3 bpm (unfamiliar adult).

IMPLICATIONS FOR PRACTICE

Results from this study suggest that babywearing is a noninvasive and accessible intervention that can provide comfort for infants diagnosed with NAS. Babywearing can be inexpensive, support parenting, and be done by nonparent caregivers (eg, nurses, volunteers).

IMPLICATIONS FOR RESEARCH

Close physical contact, by way of babywearing, may improve outcomes in infants with NAS in NICUs and possibly reduce the need for pharmacological treatment.See the video abstract for a digital summary of the study. VIDEO ABSTRACT AVAILABLE AT:.

The effect of Yakson and Gentle Human Touch methods on pain and physiological parameters in preterm infants during heel lancing

BACKGROUND

Various non-pharmacologic methods are used to alleviate pain in preterm infants who spend their first days in neonatal intensive care units (NICU) because they are exposed to numerous painful interventions.

OBJECTIVE

To determine the effects of Yakson and Gentle Human Touch (GHT) methods on pain and physiologic parameters during heel lancing procedures in preterm infants.

DESIGN AND METHODS

This was a randomised controlled trial. The study was conducted in a NICU between June 2018 and June 2019. A total of 90 preterm infants were divided into three groups: 30 infants in the Yakson group, 30 infants in the GHT group, and 30 infants in the control group. All preterm infants were randomly divided into groups. Pain responses were evaluated using the Neonatal Infant Pain Scale.

RESULTS

It was found that pain scores and heart rates were significantly lower during and after heel lancing in preterm infants in the Yakson and GHT groups than in the control group, the difference was statistically significant (p < .001).

PRACTICAL IMPLICATIONS

Yakson and GHT applied to preterm infants during heel lancing has positive effects on pain and physiologic parameters.

The Calming Effect of Maternal Breast Milk Odor on Term Infant: A Randomized Controlled Trial

Purpose: This study was carried out to assess the effect of the odor of breast milk and formula milk on reducing the acute pain of newborn infants during the heel-prick blood sampling. Methods: Eighty-four newborn were randomly assigned into two groups (formula milk group and breast milk group) with 42 infant searches. The pain that the newborn felt before, during, and after heel-prick blood sampling was assessed using Neonatal Infant Pain Scale; their heart rate and blood oxygen saturation were measured with a pulse oximeter. Saliva samples were taken from newborns before and after sampling, and their salivary cortisol level was measured. During sampling, the crying duration of newborn was recorded with a chronometer. Results: The pain threshold and heart rates of the newborn in the breast milk group were significantly lower than those in the formula milk group (p < 0.001). Salivary cortisol in the formula milk group increased and oxygen saturation levels in these infants decreased significantly more as compared to the breast milk group (p < 0.05). Conclusions: The odor of breast milk may be helpful in reducing the pain of newborn during heel-prick blood sampling.