Improving the treatment of infant pain

Moultrie, Fiona; Slater, Rebeccah; Hartley, Caroline

doi:10.1097/spc.0000000000000270

Cited by 43 publications

(46 citation statements)

References 66 publications

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“…These findings may have been due to that since the nurses required many trials until they have succeeded in such procedures with the newborns, they required the use of nonpharmacological approaches to relieve pain for them after the procedures. Some painful procedures may need as many as 10 to 15 attempts for successful completion (Moultrie et al, 2017). Jeong et al (2014) in Korea, mentioned that the most common procedures where the nurses required the use of non-pharmacological techniques were venipuncture followed by IV catheter insertion.…”

Section: Discussionmentioning

confidence: 99%

Impact of an Educational Program on Pediatric Nurses’ Practice Regarding Non-Pharmacological Pain Management in Neonatal Intensive Care Units

Khalil

El-husseiny

Abed-Ella

et al. 2019

Port Said Scientific Journal of Nursing

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Background: Newborns in the neonatal intensive care units (NICU) can be exposed to many painful procedures and treatments. Aim: This study was to improve nurses' practice regarding non-pharmacological management of pain in newborns in neonatal intensive care units. Subjects and Method: A quasi-experimental research design was utilized in this study. The subjects of the study consists of all the nurses working in the NICUs in Port Said hospitals (N=40) affiliated to the Ministry of Health, including El-Nasr general hospital, Port Said general hospital, Port Fouad general hospital and El-Tadamon health insurance hospital. The data were collected using a observational checklists Conclusion: the nurses had statistically significant improvements in applying non-pharmacological pain management during painful procedures in newborns included; venous and arterial puncture, cannulation and umbilical catheter insertion. However, there were inadequate total scores regarding nurses' practice. Recommendation: continuous training courses should be provided to nurses in order to keep their practice regarding nonpharmacological pain management up to date. Also, nurses should be encouraged to attend national and international conferences and workshops about non-pharmacological management for newborns

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Section: Discussionmentioning

confidence: 99%

Impact of an Educational Program on Pediatric Nurses’ Practice Regarding Non-Pharmacological Pain Management in Neonatal Intensive Care Units

Khalil

El-husseiny

Abed-Ella

et al. 2019

Port Said Scientific Journal of Nursing

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“…23 Adopting a multimodal approach in clinical trials, through using behavioural pain scores, EEG and electromyography (EMG), can provide a greater mechanistic understanding of the effects of analgesic drugs by assessing their ability to effectively reduce clinical pain scores, nociceptive brain activity and spinal cord activity evoked by an acute painful procedure. 24…”

Section: Quantifying Pain In the Neonatal Populationmentioning

confidence: 99%

Oral morphine analgesia for preventing pain during invasive procedures in non-ventilated premature infants in hospital: the Poppi RCT

et al. 2019

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Background Identifying better pain management strategies for painful procedures performed in neonatal care is a clinical priority. Retinopathy of prematurity screening and heel-lance blood tests are essential clinical procedures, but adequate pain relief is not currently provided because of a lack of evidence-based analgesia. Morphine provides effective analgesia in older children and adults, but efficacy in infants is controversial. Morphine is, however, commonly used intravenously for sedation in ventilated infants. Objective The primary objective was to investigate whether or not a single 100 µg/kg morphine sulphate dose administered orally prior to painful clinical procedures provides effective analgesia. Design Single-centre, prospective, randomised controlled trial. Setting John Radcliffe Hospital, Oxford, UK. Participants Thirty-one infants of 34–42 weeks’ gestational age, requiring a heel lance and retinopathy of prematurity screening on the same test occasion. Interventions The study interventions were 100 µg/kg of oral morphine sulphate (intervention arm) or placebo (control arm) 1 hour before the clinically required procedures. Main outcome measures There were two co-primary outcomes: Premature Infant Pain Profile-Revised score (a higher score implies more nociceptive processing) during the 30-second period after retinopathy of prematurity screening, and the magnitude of noxious-evoked brain activity (a higher activity implies more nociceptive processing) following the heel lance. Physiological stability and safety were secondary outcomes. Results After 31 participants were randomised (30 studied and one withdrew), the predefined safety stopping boundary was passed as 3 of the 15 infants who received morphine had apnoeas requiring resuscitation with non-invasive positive-pressure ventilation in the 24 hours after drug administration, compared with 0 of the 15 infants who received placebo [difference in proportion 0.2, 80% confidence interval (adjusted to allow for planned multiple analyses) 0.05 to 1.00; p = 0.085]. The trial was therefore stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. There was no significant difference between the trial arms for either primary outcome (Premature Infant Profile-Revised score following retinopathy of prematurity screening mean score ± standard deviation – morphine: 11.1 ± 3.2; Premature Infant Pain Profile-Revised score following retinopathy of prematurity screening mean score ± standard deviation – placebo: 10.5 ± 3.4; mean difference in Premature Infant Pain Profile-Revised score following retinopathy of prematurity screening score 0.5, 95% confidence interval –2.0 to 3.0, p = 0.66; noxious-evoked brain activity following heel lancing median activity – morphine: 0.99, interquartile range 0.40–1.56; noxious-evoked brain activity following heel lancing median activity – placebo: 0.75, interquartile range 0.33–1.22; and median difference in noxious-evoked brain activity following heel lancing 0.25, 95% confidence interval –0.16 to 0.80, p = 0.25). Limitations The trial lacked power for the primary outcome measures because of early cessation. However, there was a trend across modalities favouring placebo, suggesting that it was unlikely that a clinically significant analgesic benefit would have been detected in the original proposed sample of 156 infants. Conclusions The administration of 100 µg/kg of oral morphine to non-ventilated premature infants has the potential for harm without analgesic benefit. Oral morphine is not recommended for retinopathy of prematurity screening, and caution is strongly advised if this is being considering for other acute painful procedures in non-ventilated premature infants. Future work Further clinical trials are essential to ascertain effective pain management for retinopathy of prematurity screening. Using multimodal measures with detailed physiological recordings provides a rigorous approach to assess analgesic efficacy and adverse effects, leading to greater mechanistic understanding of the drug effects. This is essential in future clinical trials of analgesics in infants. Patient and public involvement The research team worked closely with an on-site charity during the trial design, conduct, oversight and dissemination. Trial registration Clinical Controlled Trials ISRCTN82342359; EudraCT 2014-003237-25. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership. Funding was also received for the trial from the Wellcome Trust (reference numbers 095802 and 102076). The report will be published in full in Efficacy and Mechanism; Vol. 6, No. 9. See the National Institute for Health Research’s Journals Library website for further project information.

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“…Noxious stimulation elicits a wide range of responses mediated at different levels of the nervous system, including intensity graded reflex withdrawal of both the ipsilateral and contralateral limb, physiological changes such as increases in heart rate and decreases in oxygen saturation, behavioral responses such as crying and facial grimacing, and noxious‐evoked brain activity—with activation of brain regions thought to be involved in both sensory and affective processing . Thus, multimodal pain assessment might be best suited to capture the infant pain response …”

Section: Introductionmentioning

confidence: 99%

“…17,18 Thus, multimodal pain assessment might be best suited to capture the infant pain response. 19 Although a number of pain scores incorporate a variety of measures derived from one or multiple systems (hereafter referred to as modalities), 20 the relationships between modalities and their subcomponents, and the added value of including multiple measures within each modality is unclear. Behavioral measures are reported to be significantly more powerful in indicating pain than physiological measures.…”

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confidence: 99%

Multimodal pain assessment improves discrimination between noxious and non‐noxious stimuli in infants

Vaart

Duff

Raafat

et al. 2019

Paediatric and Neonatal Pain

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Infants in neonatal intensive care units frequently experience clinically necessary painful procedures, which elicit a range of behavioral, physiological, and neurophysiological responses. However, the measurement of pain in this population is a challenge and no gold standard exists. The aim of this study was to investigate how noxious‐evoked changes in facial expression, reflex withdrawal, brain activity, heart rate, and oxygen saturation are related and to examine their accuracy in discriminating between noxious and non‐noxious stimuli. In 109 infants who received a clinically required heel lance and a control non‐noxious stimulus, we investigated whether combining responses across each modality, or including multiple measures from within each modality improves our ability to discriminate the noxious and non‐noxious stimuli. A random forest algorithm was used to build data‐driven models to discriminate between the noxious and non‐noxious stimuli in a training set which were then validated in a test set of independent infants. Measures within each modality were highly correlated, while different modalities showed less association. The model combining information across all modalities had good discriminative ability (accuracy of 0.81 in identifying noxious and non‐noxious stimuli), which was higher than the discriminative power of the models built from individual modalities. This demonstrates the importance of including multiple modalities in the assessment of infant pain.

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Improving the treatment of infant pain

Cited by 43 publications

References 66 publications

Impact of an Educational Program on Pediatric Nurses’ Practice Regarding Non-Pharmacological Pain Management in Neonatal Intensive Care Units

Impact of an Educational Program on Pediatric Nurses’ Practice Regarding Non-Pharmacological Pain Management in Neonatal Intensive Care Units

Oral morphine analgesia for preventing pain during invasive procedures in non-ventilated premature infants in hospital: the Poppi RCT

Multimodal pain assessment improves discrimination between noxious and non‐noxious stimuli in infants

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