Specific Newborn Individualized Developmental Care and Assessment Program Movements Are Associated With Acute Pain in Preterm Infants in the Neonatal Intensive Care Unit

Abstract

Objective. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is widely used in neonatal intensive care units and comprises 85 discrete infant behaviors, some of which may communicate infant distress. The objective of this study was to identify developmentally relevant movements indicative of pain in preterm infants.Methods. Forty-four preterm infants were assessed at 32 weeks' gestational age (GA) during 3 phases (baseline, lance/squeeze, and recovery) of routine blood collection in the neonatal intensive care unit. The NIDCAP and Neonatal Facial Coding System (NFCS) were coded from separate continuous bedside video recordings; mean heart rate (mHR) was derived from digitally sampled continuous electrographic recordings. Analysis of variance (phase × gender) with Bonferroni corrections was used to compare differences in NIDCAP, NFCS, and mHR. Pearson correlations were used to examine relationships between the NIDCAP and infant background characteristics.Results. NFCS and mHR increased significantly to lance/squeeze. Eight NIDCAP behaviors also increased significantly to lance/squeeze. Another 5 NIDCAP behaviors decreased significantly to lance/squeeze. Infants who had lower GA at birth, had been sicker, had experienced more painful procedures, or had greater morphine exposure showed increased hand movements indicative of increased distress.Conclusions. Of the 85 NIDCAP behaviors, a subset of 8 NIDCAP movements were associated with pain. Particularly for infants who are born at early GAs, addition of these movements to commonly used measures may improve the accuracy of pain assessment.Major advances in neonatal care now enable a high proportion of preterm infants to survive. During a time when medical concerns focused primarily on stabilizing the physiologic needs of preterm infants, Als, a developmental psychologist, developed a theory and systematic method of assessing the developmental needs of preterm newborns, the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).1 Als hypothesized is a high priority for caregivers in the NICU because early pain exposure may alter nociceptive pathways 9 , 10 and may also contribute to changes in other areas of development. , 12Although improved pain assessment and management is a clinical priority, accurate identification of pain responses is complex for a number of reasons. First, preterm infants respond with facial, motor, and physiologic changes to acute pain, but they differ from termborn infants in that their responses are of smaller magnitude, particularly at younger gestational ages (GAs). 13 , 14 Second, preterm infants at earlier GAs may display different pain behaviors than infants at later GAs as a result of neurologic immaturity. Such behaviors may not be captured in the current pain scales because the behaviors chosen have been based on behaviors seen in term infants. Third, no physiologic or behavioral threshold specifically marks the presence of pain. Finally, although using a single pain index is eas...

The Effectiveness of Developmentally Supportive Positioning on Preterm Infants' Pain Response at Neonatal Intensive Care Units

“…This reflect the efficacy of researcher teaching to nursing staff at NICU about the importance of adopting developmentally positioning during their nursing intervention using available materials as rolled linen which also eliminate control group pain score. This finding was in agreement with the result of Holsti, Grunau, Oberlander, and Whitfiels (2014) [26] who found in their study that, the distress and pain scores associated with diaper change was significantly less during the nested condition compared with the non-nested.…”

Pain in preterm infants: Effects of sex, gestational age, and neonatal illness severity.

“…Additionally, infants who were sicker earlier during the neonatal period (SNAP-II on day 1) displayed more facial reactions (Holsti et al, 2004). found that greater illness severity (SNAP-II) was significantly associated with lower heart rate variability in the very low gestational age group of infants born between 29 and 32 weeks of gestational age.…”

“…According to the results of Holsti et al (2004), infants born at a gestational age of <30 weeks (gestational age 25-30 weeks of gestational age) showed more behavioral responses (i.e., facial and body activity from the NIDCAP) during a heel lance procedure compared with older infants (gestational age 30-32 weeks of gestational age). Evans et al (2005) found that, according to a multidimensional pain measure reflected by Premature Infant Pain Profile (PIPP) scores, infants born at 27-30 weeks and infants born at 33-36 weeks of gestational age showed significantly less physiological and behavioral responses during hospitalization in the NICU than infants born at 31-33 weeks of gestational age.…”

“…Preterm neonates perceive painful stimuli and exhibit biobehavioral reactivity to pain reflected by facial activity (Stevens, Ridell, Oberlander, & Gibbins, 2007a), body movements (Holsti, Grunau, Oberlander, & Whitfield, 2004), physiological responses (Grunau, Haley, Whitfield, Weinberg, Yu, & Thiessen, 2007), and cortical activity (Bartocci, Bergqvist, Lagercrantz, & Anand, 2006;Slater et al, 2010).…”

Family-centered developmental supportive care: a holistic and humane approach to reduce stress and pain in neonates

“…35 Moreover, these behavioral signs have recently been validated with a conventional pain assessment. 36 On the basis of such observations, current developmental goals for each infant are formulated. Caregiving plans, including recommendations concerning individualized care and environmental changes based on the current developmental stage of the infant and the needs of the family, are designed.…”