The efficacy of kangaroo mother care, sucrose and pacifier to reduce responses of preterm infants to procedural pain

Tese de doutoramento, Enfermagem, Universidade de Lisboa, com a participação da Escola Superior de Enfermagem, 2011Preterm neonates in intensive care units endure frequent procedures that may cause pain, warranting the study of interventions that will decrease this pain. The primary aim of this study was to compare the efficacy of the combination of sucrose, pacifier and kangaroo mother care (S+KMC), with that of sucrose and pacifier (S), in reducing the pain responses of preterm infants undergoing venepuncture. Secondary objectives addressed to babies in S+KMC were to examine the relationship between maternal anxiety and the pain responses of the babies; and to explore mothers’ perceptions of KMC during venepuncture. A randomized-controlled trial was conducted in two neonatal intensive care units in Portugal. One-hundred and ten preterm infants without severe illness, stratified by gestational age, were randomly assigned to receive S+KMC or S for venepuncture. Measures of pain responses were the Premature Infant Pain Profile, heart rate, oxygen saturation, facial actions, behavioral state, heart rate variability and recovery time, which were analysed with repeated-measures ANOVA. Mothers’ anxiety was measured with the State-Trait Anxiety Inventory. Their perceptions were obtained through content analysis of semi-structured interviews. Compared to infants in S, infants in S+KMC displayed significantly less facial action; were more likely to have recovered heart rate baseline values at 60 and 90 seconds after the procedure, if they were 32 weeks gestational age and above; and changed from sleep to wake states significantly less. Maternal anxiety was low to moderate and was not correlated to specific pain responses. Mothers emphasized their feelings of wellbeing in comforting and protecting the babies. In conclusion, combining sucrose, pacifier and kangaroo mother care is effective and safe in preterm infants undergoing venepuncture for blood-draw; low to moderate levels of anxiety of mothers do not interfere with the pain responses; mothers appreciate holding the baby skin-to-skin when the infants are enduring pain.Os recém-nascidos pretermo que necessitam de cuidados intensivos são frequentemente submetidos a procedimentos diagnósticos e terapêuticos que podem causar dor. Contrariamente ao que se pensava há duas décadas, a evolução ontogenética da dor iniciase cedo e, a partir das 24 semanas de gestação, o feto dispõe do equipamento neurosensorial necessário à experiência de dor. Todavia, as vias de controlo descendente não se encontram ainda suficientemente desenvolvidas, resultando em hipersensibilidade dolorosa. As consequências da exposição repetida à dor no período neonatal têm vindo a ser estudadas, sendo hoje conhecidos os efeitos a curto prazo da dor não tratada, como a hiperalgesia e a alodinia nos recém-nascidos, e alguns efeitos a médio e longo prazo como as alterações da sensibilidade e da reactividade ao stress em crianças de idade escolar. O alívio da dor nesta população vulnerável é, pois, uma tarefa imperiosa. Dado o reduzido leque de fármacos disponíveis para estas idades e o seu potencial para efeitos adversos, torna-se necessária a investigação de intervenções não-farmacológicas. Entre estas, a sacarose oral com chupeta tem sido exaustivamente demonstrada como eficaz, sendo utilizada por norma em muitas unidades neonatais antes da realização de procedimentos como a punção do calcanhar e a punção venosa. Durante estes procedimentos, também o contacto pele-a-pele entre mãe e bebé, conhecido como canguru materno, pode ser utilizado como forma de reduzir as respostas de dor dos recém-nascidos. Desconhecia-se, todavia, se ao adicionar o canguru materno ao uso da sacarose com chupeta seria possível reduzir ainda mais as respostas de dor dos recém-nascidos pretermo. Por outro lado, dada a co-regulação fisiológica mãe-bebé, colocava-se a questão de saber se a ansiedade materna poderia comprometer o efeito analgésico do canguru materno. Finalmente, as percepções das mães sobre a realização de canguru materno durante a venopunção não haviam sido exploradas. Assim, os objectivos definidos para este estudo foram: 1) comparar as respostas de dor dos recém-nascidos pretermo aos quais é proporcionado canguru materno, sacarose oral e chupeta durante a punção venosa para colheita de sangue, com as respostas dos recém-nascidos aos quais é proporcionada apenas sacarose oral com chupeta; 2) analisar a relação entre a ansiedade materna e as respostas de dor dos recém-nascidos que efectuaram canguru materno; e 3) explorar as percepções maternas sobre a realização de canguru materno durante a venopunção. Para dar resposta ao primeiro objectivo, foi realizado um estudo randomizado, controlado, cego, em duas unidades de cuidados intensivos neonatais portuguesas. Cento e dez recém-nascidos sem doença grave, estratificados por idade gestacional (28 a 31 semanas e seis dias, e 32 a 36 semanas e seis dias) foram aleatoriamente alocados a dois grupos: um recebeu sacarose oral com chupeta (grupo Sacarose); o outro recebeu sacarose oral com chupeta e canguru materno (grupo S+CM) antes, durante e após venopunção. As respostas de dor foram medidas através da escala Premature Infant Pain Profile (PIPP) e foram analisadas a frequência cardíaca, a saturação de oxigénio da hemoglobina, as acções faciais (percentagem de tempo em saliência interciliar, olhos apertados e prega nasolabial), o estado comportamental, a variabilidade da frequência cardíaca (baixa frequência, alta frequência e ratio entre ambas) e o tempo de recuperação da frequência cardíaca inicial após o final do procedimento. As acções faciais foram gravadas em vídeo e as variáveis fisiológicas foram registadas através do Somté® Compumedics, ao longo de cinco fases: antes do procedimento, preparação da pele, punção, compressão e repouso. Para a determinação do score PIPP, a análise das gravações foi efectuada por codificadores cegos aos propósitos do estudo. Para dar resposta ao segundo objectivo, foi realizado um estudo descritivo-correlacional analisando a relação entre a ansiedade materna medida pela escala de Estado de Ansiedade do State-Trait Anxiety Inventory (STAI) e as respostas de dor dos recém-nascidos (N= 60). As percepções maternas foram estudadas através da análise de conteúdo das entrevistas semi-estruturadas realizadas às mães que tinham efectuado canguru materno (N= 52). A comparação dos dois grupos de intervenção quanto a variáveis socio-demográficas e clínicas não revelou diferenças significativas. Em todos os testes foi utilizado como nível de significância α< .05. A ANOVA de medidas repetidas (fases do procedimento) a dois factores (intervenção e idade gestacional) revelou o efeito principal da intervenção sobre a percentagem de tempo em saliência interciliar, F(1, 98)= 5.12, p= .026, e olhos apertados, F(1, 98)= 6.02, p= .015. A análise posthoc mostrou que no momento da punção, a saliência interciliar ocorria durante menos tempo nos recém-nascidos do grupo S+CM (M= 15.89, EP= 4.58) do que no grupo Sacarose (M= 29.22, EP= 4.75). O mesmo se verificou para o tempo em olhos apertados (M= 13.85, EP= 4.36 no grupo S+CM e M= 29.13, EP= 4.52, no grupo Sacarose). O efeito principal da idade gestacional verificou-se na frequência cardíaca mínima e média e no índice baixa frequência da variabilidade da frequência cardíaca. A reactividade dos recém-nascidos durante o procedimento foi semelhante nos dois grupos de intervenção, observando-se o efeito principal da fase do procedimento sobre a PIPP, a frequência cardíaca, a saturação máxima de oxigénio, as expressões faciais e o índice baixa frequência da variabilidade da frequência cardíaca. Tal indica uma variação significativa destes sinais de dor ao longo das fases do procedimento, com aumento dos sinais de dor desde o momento antes do procedimento até à punção, seguido de uma diminuição desses sinais até ao repouso. O teste de Qui-Quadrado para cada fase do procedimento mostrou uma associação significativa entre intervenção e estado comportamental: em todas as fases, a proporção de bebés em estado de sono (versus estado de alerta) era significativamente mais elevada no grupo S+CM. Apesar não ter havido uma diferença significativa no tempo médio de recuperação da frequência cardíaca de base após o procedimento, a probabilidade (odds-ratio) de ter recuperado aos 60 e 90 segundos após o procedimento foi cerca de 3 vezes mais elevada nos recém-nascidos do grupo S+CM com 32 ou mais semanas de gestação, do que nos do grupo Sacarose. Durante o procedimento não se verificaram efeitos adversos em qualquer dos grupos de intervenção. A ansiedade materna foi baixa, sendo significativamente mais baixa nas mães do grupo S+CM (M= 37.78, SD= 9.13) do que nas mães do grupo Sacarose (M= 43.48, SD= 9.82), t(87)= 2.65, p= .009. Nas entrevistas, as mães salientaram a sensação de bem-estar em ter o bebé em contacto pele-a-pele, o contentamento em poder protegê-lo da dor e a importância que esse acontecimento havia tido para a realização do seu papel parental. Estes resultados demonstram que a combinação sacarose, chupeta e canguru materno é eficaz e segura em recém-nascidos pretermo, permitindo reduzir a expressão facial e o tempo de recuperação quando comparada com a utilização de sacarose com chupeta; níveis baixos e moderados de ansiedade materna não interferem na redução das respostas de dor dos bebés; as mães apreciam o contacto pele-a-pele durante o procedimento doloroso e sentem o seu papel parental reforçado por poderem participar no alívio da dor do seu bebé. Em conclusão, o canguru materno pode ser adicionado ao uso da sacarose com chupeta para reduzir as respostas de dor de recém-nascidos pretermo acima das 28 semanas de gestação durante a colheita de sangue por venopunção. Palavras-chave: dor, recém-nascido pretermo, sacarose, canguru materno, punção venosa

Barriers to Effective Pain Management in Preterm and Critically Ill Neonates

The purpose of this dissertation is to explore potential barriers nurses experience in providing effective pain management for preterm and critically ill infants in neonatal intensive care units (NICUs). The specific aims of the study conducted are to examine (a) NICU caregivers’ knowledge about pain, (b) scales used to evaluate pain in infants, (c) NICU nurses’ documented pain practices, and (d) bias in treating pain of certain types of infants. This dissertation is comprised of three manuscripts. The first manuscript is an integrated review of the literature describing caregiver knowledge, barriers, and bias in the management of pain in neonates. The second manuscript is a systematic review of multidimensional pain scales developed for use in preterm and critically ill infants. The final manuscript reports a descriptive exploratory study designed to examine nurses’ knowledge of pain, knowledge of intensity and appropriate management of procedural pain, bias in treating pain of certain types of infants, and documented pain management practices. Over the past 25 years, caregiver knowledge of pain in preterm and critically ill infants has advanced from beliefs that neonates do not feel pain, to the knowledge that preterm infants experience more pain than term infants, older children, and adults. Nine multidimensional pain scales with varying levels of reliability and validity have been developed, yet a gold standard for pain assessment in preterm and critically ill neonates has not emerged. In this study, baccalaureate prepared nurses (BSN) and nurses with higher total years of nursing experience had better knowledge of pain in this population than associate degree nurses (ADN). However, pain management was inconsistent, resulting in pain that was untreated as often as 80% of the time. Nurses reported that physician practice was the primary obstacle to providing effective pain management. Additional concerns included knowledge deficits of nurses and physicians, lack of communication and teamwork, and rushed care. Nurses reported biases in managing pain and were less likely to invest time and energy treating the pain of infants experiencing neonatal abstinence syndrome

The Effect of Moderating Noise Pollution on Premature Infants' Behavioral and Physiological Responses in Neonatal Intensive Care Unit

Background: The aim of the study was to determine the effect of moderating noise pollution on premature infants' behavioral and physiological responses in a neonatal intensive care unit (NICU). Methods: 110 premature infants hospitalized in the NICU ward of hospitals in Tehran were selected. All the infants who met the research criteria were allocated and assigned to the experimental and control group (n = 55). The sampling method was non-probability and convenient. In the first section of time, each infant with inclusion criteria, inserted in the control group and then in the second section of time, infant with inclusion criteria placed in the experiment group. In the first section, the educated nurse measured the LAeq, LC, LA, infants’ behavioral responses, and physiological responses. In the second section, noise modifying interventions were implemented in the experimental group for 6 weeks, and then LAeq, LC, LA, infants’ behavioral responses and physiological responses were measured with the same methods. Results: Infants' heart rate in the experimental group was significantly lower than the control group (Pvalue&lt;0.05), and atrial blood O2 Saturation was significantly higher than the control group (Pvalue&lt;0.05). There was no statistically significant difference in the mean number of crying, sleeping, and Moro reflex of premature infants in the two groups. Also, the sound-pressure level in the C-weighted network in the experimental group was lower than the control group (Pvalue=0.021). The sound-pressure level of the C-weighted network was obtained in the same way (Pvalue=0.008). Conclusions: Based on the results, moderating noise pollution in NICU can lead to heart rate deceleration and atrial blood O2 Saturation acceleration in premature infants. Keywords: Noise pollution, Premature infants, Behavioral responses, Physiological responses, Neonatal Intensive care unit

Effects of Kangaroo Care on Procedural Pain in Preterm Infants: A Systematic Review

Approximately 64,000 preterm infants are born annually in the United States. With preterm infants enduring between 10-16 painful procedures daily, it is important for nurses to use interventions that effectively decrease pain. Procedural pain in premature infants may result in short-term and long-term negative physical, cognitive, and emotional effects. Kangaroo care is the act of holding an infant making skin on skin contact. The purpose of this systematic review is to identify, review, and critically appraise the evidence from studies examining the effect of Kangaroo Care on procedural pain in premature infants. Literature was searched in university databases and Google Scholar for relevant studies, which were selected based on criteria of intervention studies, sampling methods, use of Kangaroo Care, and use of measurable pain scales. Studies are discussed based on the pain measurement tool, type of procedure, and specific study characteristics. The evidence was critically appraised. Limitations and gaps in knowledge are described. Recommendations for further studies and implementation of Kangaroo Care are identified

The Effect of Moderating Noise Pollution on Premature Infants' Behavioral and Physiological Responses in Neonatal Intensive Care Unit

Background: The aim of the study was to determine the effect of moderating noise pollution on premature infants' behavioral and physiological responses in a neonatal intensive care unit (NICU). Methods: 110 premature infants hospitalized in the NICU ward of hospitals in Tehran were selected. All the infants who met the research criteria were allocated and assigned to the experimental and control group (n = 55). The sampling method was non-probability and convenient. In the first section of time, each infant with inclusion criteria, inserted in the control group and then in the second section of time, infant with inclusion criteria placed in the experiment group. In the first section, the educated nurse measured the LAeq, LC, LA, infants’ behavioral responses, and physiological responses. In the second section, noise modifying interventions were implemented in the experimental group for 6 weeks, and then LAeq, LC, LA, infants’ behavioral responses and physiological responses were measured with the same methods. Results: Infants' heart rate in the experimental group was significantly lower than the control group (Pvalue&lt;0.05), and atrial blood O2 Saturation was significantly higher than the control group (Pvalue&lt;0.05). There was no statistically significant difference in the mean number of crying, sleeping, and Moro reflex of premature infants in the two groups. Also, the sound-pressure level in the C-weighted network in the experimental group was lower than the control group (Pvalue=0.021). The sound-pressure level of the C-weighted network was obtained in the same way (Pvalue=0.008). Conclusions: Based on the results, moderating noise pollution in NICU can lead to heart rate deceleration and atrial blood O2 Saturation acceleration in premature infants. Keywords: Noise pollution, Premature infants, Behavioral responses, Physiological responses, Neonatal Intensive care unit

Soothability and Growth in Preterm Neonates

This proposal seeks to understand the relationship between soothability, weight gain and length of hospital stay in premature infants when the infants receive a simple, non-invasive treatment to help them cope with the noxious environment of the special care nursery. Thousands of premature infants are born every year in the United States, and the numbers are increasing. Prematurity is the leading cause of mortality in infants. Despite numerous technological and medical advances in treatment and care, premature infants still have difficulty adapting to life outside the uterus as a result of immature nervous systems and significant differences in the pre and post delivery environments. Developmental Care and Family Centered Care have made significant improvements in the lives of hospitalized premature infants. However, care continues to be costly and complex, encouraging health care providers to continue to search for simpler and less expensive methods to care for these tiny patients. This paper describes the effect of a flax seed pillow, placed on the back of premature infants in a prone position on their ability to sooth themselves, moderate their activity, gain weight and the length of hospital stay. Each infant will receive two 15 minute treatments, twice a day, over the course of five consecutive days. Measurements will be obtained on various physiologic parameters including temperature, heart rate, respiratory rate, and pain scores and activity. The design is a randomized control study, with infants stratified for birth weight. Infants in the treatment group had decreases in heart rate, respiratory rate and pain scores significantly greater than infants in the control group. Infants in the treatment group also gained more weight in the first three weeks of life, however this difference was lost by time of discharge. Hospital length of stay did not vary between the two groups. The treatment of the flax seed pillow is a new method to assist premature infants to cope with the stressful environment of the nursery. The pillow is simple, easy to use and was not associated with any adverse events. Further research is recommended to explore the efficacy of this intervention in other populations

Kangaroo mother care diminishes pain from heel lance in very preterm neonates: A crossover trial

BACKGROUND: Skin-to-skin contact, or kangaroo mother care (KMC) has been shown to be efficacious in diminishing pain response to heel lance in full term and moderately preterm neonates. The purpose of this study was to determine if KMC would also be efficacious in very preterm neonates. METHODS: Preterm neonates (n = 61) between 28 0/7 and 31 6/7 weeks gestational age in three Level III NICU's in Canada comprised the sample. A single-blind randomized crossover design was employed. In the experimental condition, the infant was held in KMC for 15 minutes prior to and throughout heel lance procedure. In the control condition, the infant was in prone position swaddled in a blanket in the incubator. The primary outcome was the Premature Infant Pain Profile (PIPP), which is comprised of three facial actions, maximum heart rate, minimum oxygen saturation levels from baseline in 30-second blocks from heel lance. The secondary outcome was time to recover, defined as heart rate return to baseline. Continuous video, heart rate and oxygen saturation monitoring were recorded with event markers during the procedure and were subsequently analyzed. Repeated measures analysis-of-variance was employed to generate results. RESULTS: PIPP scores at 90 seconds post lance were significantly lower in the KMC condition (8.871 (95%CI 7.852-9.889) versus 10.677 (95%CI 9.563-11.792) p &lt; .001) and non-significant mean differences ranging from 1.2 to1.8. favoring KMC condition at 30, 60 and 120 seconds. Time to recovery was significantly shorter, by a minute(123 seconds (95%CI 103-142) versus 193 seconds (95%CI 158-227). Facial actions were highly significantly lower across all points in time reaching a two-fold difference by 120 seconds post-lance and heart rate was significantly lower across the first 90 seconds in the KMC condition. CONCLUSION: Very preterm neonates appear to have endogenous mechanisms elicited through skin-to-skin maternal contact that decrease pain response, but not as powerfully as in older preterm neonates. The shorter recovery time in KMC is clinically important in helping maintain homeostasis. TRIAL REGISTRATION: (Current Controlled Trials) ISRCTN63551708

Physiological measurements of transition and resuscitation at birth

The neonatal transition is characterized by major physiological changes in respiratory and hemodynamic function, which are predominantly initiated by breathing and clamping of the umbilical cord. Lung aeration leads to the establishment of functional residual capacity, allowing pulmonary gas exchange to commence. This triggers a significant decrease in pulmonary vascular resistance, consequently increasing pulmonary blood flow and venous return. Clamping the umbilical cord contributes to these hemodynamic changes by altering the cardiac preload and increasing peripheral systemic vascular resistance. The resulting changes in the systemic and pulmonary circulations influence blood flow through both the oval foramen and ductus arteriosus. This eventually leads to closure of these structures and the separation of the pulmonary and systemic circulations. Most of our knowledge on human neonatal transition is based on human (fetal) data from the 1970s and extrapolation from animal studies. However, there is renewed interest in performing measurements directly at birth. By using less cumbersome techniques, (n.b. and probably more accurate), our previous understanding of the physiologic transition at birth is challenged, as well as the causes and consequences for when this transition fails to progress. This thesis provides an overview of physiological measurements of the respiratory and hemodynamic transition at birth.UBL - phd migration 201

Non‐Pulmonary Management of Newborns with Respiratory Distress

Due to the developmental immaturity of the lungs and other organs, the premature newborns are more prone to develop respiratory distress syndrome (RDS) and other problems of prematurity. The prevention of heat and water loses improves survival. Intolerance to excessive fluids and electrolytes in the transitional period may affect urine and sodium excretion together with maladaptation of cardiovascular system, the development of heart failure, and deterioration of RDS due to patent ductus arteriosus (PDA) and further development of bronchopulmonary dysplasia (BPD). Closure of PDA is frequently needed. The “trophic feeding” and intensive nutrition as soon as possible prevent weight loss and further growth restriction. Greater sensitivity to pain, short‐ and long‐term effects of inappropriately treated pain, use of opioids and sedatives are of concern in the short‐ and long‐term outcomes. Cardiovascular stability and adequate perfusion of the brain both affect the neurological outcome. Delayed cord clamping and erythropoietin help maintaining adequate levels of circulating hemoglobin which might affect later cognitive outcomes. In the following sections, detailed descriptions of non‐pulmonary management will be presented. We conducted electronic searches of articles on supportive (non‐pulmonary) management of newborns with RDS. Consensus guidelines on newborns with respiratory distress have been reviewed