Volume 40 Supplement 2

Proceedings of the XX National Congress of the Italian Society of Neonatology

Open Access

Non-pharmacological intervention for neonatal pain control

  • Paola Lago1Email author,
  • Elisabetta Garetti2,
  • Anna Pirelli3,
  • Daniele Merazzi4,
  • Carlo V Bellieni5,
  • Patrizia Savant Levet6,
  • Luisa Pieragostini7 and
  • Gina Ancora8
Italian Journal of Pediatrics201440(Suppl 2):A52

https://doi.org/10.1186/1824-7288-40-S2-A52

Published: 9 October 2014

Background

Acute pain and distress during medical procedures are commonplace in newborn admitted to Intensive Care Unit and can have detrimental effects, if uncontrolled.

Accumulating evidence suggests that neonate, as older children, could benefice of non pharmacological interventions (NPIs) to relive mild to moderate pain, anxiety and discomfort from minor invasive procedures. [1] These therapies include nonnutritive sucking (NNS) both with and without sucrose, swaddling, positioning, facilitated tucking (FT), kangaroo care or skin to skin contact (KMC), multi-sensorial stimulation (SS) and music therapy.

Material and methods

To assess efficacy of NPIs for acute procedural pain in neonate, a literature search covered the period 2000-2014 via Medline and Cochrane Library database, was undertaken. Inclusion criteria were preterm and newborn, involved in randomized controlled or crossover trial. Pain reactivity was described in term of physiological parameters (heart rate, oxygen saturation) behavioral indicators (duration of first cry and total crying time) and validated unidimensional, multidimensional and/or composite pain scores as PIPP, NIPS, DAN, NFCS etc. Two independent reviewers extracted data and methodological quality was assessed, according with GRADE system.

Results

Nineteen Randomized Controlled Trials and twelve meta-analysis and systematic reviews were taken in consideration. The efficacy of NPIs in reliving pain and distress from skin-breaking procedures has been demonstrated mostly in heel prick and venipuncture. (Table 1)
Table 1

Efficacy of environmental, behavioral and non-pharmacological strategies on pain reactivity in newborn.

Behavioral, cognitive and contextual interventions

Level of evidence

Grade of Recommendation

 

Heel Prick

Venipuncture

Other

 

Non-nutritive sucking (NNS): placing a pacifier or non-lactating nipple in an infant’s mouth to promote sucking behavior with no breast or formula milk to provide nourishment.

1

1

-

Strong

Facilitated tucking: holding the arms and legs in a flexed position

1

1

3 ET Suctioning

Strong

Swaddling: wrapping securely the neonate in a sheet/blanket

1

1

-

Strong

Positioning: laying the neonate supine

3

3

-

Weak

Maternal touching and holding: cradling the baby in the mother’s arms

3

3

-

Weak

Environmental care: controlling/ reducing light and noise, clustering care etc.

3

3

-

Weak

Individualized developmental care e.g. limiting environmental stimuli, lateral positioning, using supportive bedding, monitoring behavioural clues, respecting circadian rhythms

-

-

3 ROP screening

Weak

Skin to skin or Kangaroo Mother Care an infants is placed on their care-giver’s bare chest during a painful procedure or for soothing after a painful procedure

1

2

2 IM

Strong

Sensorial saturation: multiple sensorial stimulation at gustatory, auditory, olfactory and tactile level

1

-

-

Strong

Music therapy: music with intrauterine sounds or instrumental music in association with NNS

3

3

-

Weak

Sucrose 24%: in dose of 0.1-0.3 ml orally 2 minutes before the procedure in preterm infants and 1-2 ml in term infants.

1

1

-

Strong

Breastfeeding or expressed human milk

1

1

-

Strong

Glucose solutions 20-30% in dose of 1-2ml orally 2 minutes before the procedure.

1

1

-

Strong

ET suctioning= endotracheal suctioning, ROP= retinopathy of prematurity IM= intramuscular injection

Legend

1. Sufficient evidence supports efficacy for reducing pain-related behaviors (support of two or more trials)

2. Limited evidence suggests efficacy for reducing pain-related behaviors (e.g. support of 1 trial or heterogeneity among trial)

3. Limited evidence suggests inefficacy for reducing pain-related behaviors (e.g. support of 1 trial or heterogeneity among trial)

4. Sufficient evidence supports inefficacy for reducing pain-related behaviors ( support of two or more trial)

There are sufficient evidence that supports efficacy in reducing pain-relating behaviors for NNS, swaddling and FT in preterm and term neonates. [1] KMC appears to be effective, as measured by composite pain score including physiological and behavioral indicators and safe for single painful procedures, alone or combined with other NPIs. [2] Small volumes of 24% sucrose with or without NNS reduced efficiently behavioral expressions of pain and crying time, as well as PIPP scores. [3] Also expressed human milk or breastfeeding, if available, should be used to alleviate procedural pain [4], as well as 20-30% glucose [5]. SS is more effective than glucose and sucking, but there are no studies comparing SS and standard sucrose 24% and NNS with pacifier, which actually is the standard of care for heel lance. [6]

Limited evidence suggests that Music Therapy may be beneficial primarily for measures of behavior and pain, however the heterogeneity of the study preclude definitive conclusions. [7]

Conclusions

As the efficacy of the majority of NPIs is clearly demonstrated in preterm and neonates, they should be considered for inclusion in a graduated multidisciplinary algorithm for neonatal pain management.

Authors’ Affiliations

(1)
Woman’s and Child’s Health Department, Azienda Ospedaliera-University of Padova
(2)
Dept of Pediatrics, Azienda Ospedaliero-Universitaria-Policlinico di Modena
(3)
San Gerardo Hospital
(4)
Dept of Women's and Children's Health, Valduce Hospital
(5)
Dept of Pediatrics, University Hospital
(6)
Mother’s and Child’s Health Department, Maria Vittoria Hospital
(7)
San Filippo Neri Hospital
(8)
Azienda Ospedaliera Rimini

References

  1. Pillar Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L, Ahola Kohut S, Hillgrove Stuart J, Stevens B, Gerwitz-Sten A: Non-pharmacological management of infant and young child procedural pain. Cochrane Database of Systematic Reviews. 2011, CD006275-10Google Scholar
  2. Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R: Skin-to-skin for procedural pain in neonates. Cochrane Database of Systematic Reviews. 2014, CD008435-1Google Scholar
  3. Stevens B, Yamada J, Lee GY, Ohlsson A: Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews. 2013, CD001069-1Google Scholar
  4. Shah PS, Herbozo C, Aliwalas LL, Shah VS: Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database of Systematic Reviews. 2013, CD004950-12Google Scholar
  5. Bueno M, Yamada J, Harrison D, Khan S, Ohlsson A, Adams-Webber T, Beyene J, Stevens B: A systematic review and meta-analysis of nonsucrose sweet solutions for pain relief in neonates. Pain Res Manag. 2013, 18: 153-161.PubMed CentralPubMedGoogle Scholar
  6. Bellieni CV, Bagnoli F, Perrone S, Nenci A, Cordelli DM, Fusi M, Ceccarelli s, Buonocore G: Effect of multisensory stimulation on analgesia in term neonates: a randomized controlled trial. Pediatr Res. 2002, 51: 460-3. 10.1203/00006450-200204000-00010.View ArticlePubMedGoogle Scholar
  7. Harling L, Shaik MS, Tjosvold L, Leich R, Liang Y, Kumar M: Music for medical indications in the neonatal period: a systematic review of randomized controlled trials. Arch Dis Child Fetal Neonatal Ed. 2009, 94: F349-354. 10.1136/adc.2008.148411.View ArticleGoogle Scholar

Copyright

© Lago et al; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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