Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive care unit hospitalization: a single-blind randomized controlled trial.

Preterm neonates hospitalized in the neonatal intensive care unit undergo frequent painful procedures daily, often without pain treatment, with associated long-term adverse effects. Maternal-infant skin-to-skin contact, or kangaroo care (KC), and sweet-tasting solutions such as sucrose are effective strategies to reduce pain during a single procedure; however, evidence of sustained efficacy over repeated procedures is limited. We aimed to determine the relative sustained efficacy of maternal KC, administered alone or in combination with 24% sucrose, to reduce behavioral pain intensity associated with routine neonatal procedures, compared with 24% sucrose alone. Stable preterm infants (n = 242) were randomized to receive KC and water, KC and 24% sucrose, or 24% sucrose before all routine painful procedures throughout their neonatal intensive care unit stay. Pain intensity, determined using the Premature Infant Pain Profile, was measured during 3 medically indicated heel lances distributed across hospitalization. Maternal and neonatal baseline characteristics, Premature Infant Pain Profile scores at 30, 60, or 90 seconds after heel lance, the distribution of infants with pain scores suggesting mild, moderate, or severe pain, Neurobehavioral Assessment of the Preterm Infant scores, and incidence of adverse outcomes were not statistically significantly different between groups. Maternal KC, as a pain-relieving intervention, remained efficacious over time and repeated painful procedures without evidence of any harm or neurological impact. It seemed to be equally effective as 24% oral sucrose, and the combination of maternal KC and sucrose did not seem to provide additional benefit, challenging the existing recommendation of using sucrose as the primary standard of care.

Pain in Child Health from 2002 to 2015: The early years of an international research training initiative.

Background: The 2018 Global Year for Excellence in Pain Education, an initiative of the International Association for the Study of Pain, brought worldwide attention to the need for education that crosses narrow disciplinary boundaries, addresses up-to-date research methods and findings, and encourages teamwork among trainees and mentors at different levels of training and with different perspectives. Aims: This commentary describes the development of Pain in Child Health (PICH), an interdisciplinary training program for researchers in pediatric pain at the undergraduate, graduate, and postdoctoral levels of training. Methods: Based on documentation of the structure, training processes, leadership, and membership of PICH, we outline its organization and its challenges and accomplishments over the first 12 years of its growth into a well-known international program. Results and Conclusions: Pain in Child Health began as a Strategic Training Initiative of the Canadian Institutes of Health Research in 2002 and developed into an international research training consortium featuring cross-site and cross-discipline mentorship and collaboration. PICH trainees and alumni have contributed extensively to the current scientific literature on children's pain. PICH could serve as a possible model for training and mentorship in other specialized health research domains within and outside thestudy of pain.

Contexte: En 2018, l'Année internationale pour l'excellence en éducation sur la douleur, une initiative de l'Association internationale pour l'étude de la douleur, a attiré l'attention partout dans le monde sur l'importance d'une éducation qui transcende les frontières étroites entre les disciplines, qui aborde les méthodes et les résultats de la recherche les plus actuels et qui encourage le travail d'équipe parmi les apprenants et les mentors à différents niveaux de formation et à partir de différentes perspectives.But: Ce commentaire décrit l'évolution de Pain in Child Heath (PICH), un programme de formation interdisciplinaire destiné aux chercheurs en douleur pédiatrique à tous les niveaux de formation : premier cycle, cycles supérieurs et postdoctoral.Méthodes: À partir de la documentation portant sur la structure, les processus de formation, le leadership et les caractéristiques des membres du PICH, nous décrivons son organisation, ses difficultés et ses accomplissements au cours de ses premiers douze ans, jusqu'à ce qu'il devienne un programme international de renom.Résultats et conclusions: À ses débuts, Pain in Child Health était une initiative de formation stratégique des Instituts de recherche en santé du Canada en 2002. Il s'est par la suite transformé en consortium international de formation à la recherche axé sur le mentorat et la collaboration entre différents sites et différentes disciplines. Les étudiants et les anciens du PICH ont largement contribué à la littérature scientifique sur la douleur pédiatrique. Le PICH pourrait possiblement servir de modèle en matière de formation et de mentorat dans d'autres domaines de recherche spécialisée en santé, que ce soit dans le contexte de l'étude de la douleur ou dans un autre contexte.

Analgesia, nil or placebo to babies, in trials that test new analgesic treatments for procedural pain.

UNLABELLED: This review assessed how often neonates in control groups experienced unnecessary pain during clinical trials involving procedural pain. We retrieved 45 studies in the 30 months up to June 2015 and found that in 29 (64%) the control babies received either placebos or no treatment. Placebos were used in 15/25 (60%) studies involving heel pricks and in 6/8 (75%) involving venepuncture. CONCLUSION: Despite international guidelines, neonates included in control groups during painful procedures do not receive analgesia in the majority of cases. Several historical reasons can explain this, but in the light of present knowledge, this should not continue. Ethical committees are thereof invited since now to not permit clinical trials that do not explicitly rule out pain during treatments and journals are invited to not publish them.

Effect of cobedding twins on coregulation, infant state, and twin safety.

OBJECTIVE: To evaluate the efficacy of cobedding on twin coregulation and twin safety. DESIGN: Randomized controlled trial (RCT). SETTING: Two university affiliated Level III neonatal intensive care units (NICUs). PARTICIPANTS: One hundred and seventeen sets (N = 234) of stable preterm twins (<37 weeks gestational age at birth) admitted to the NICU. METHODS: Sets of twins were randomly assigned to be cared for in a single cot (cobedded) or in separate cots (standard care). State response was obtained from videotaped and physiologic data measured and recorded for three, 3-hour sessions over a one-week study period. Tapes were coded for infant state by an assessor blind to the purpose of the study. RESULTS: Twins who were cobedded spent more time in the same state (p < .01), less time in opposite states (p < .01), were more often in quiet sleep (p < .01) and cried less (p < .01) than twins who were cared for in separate cots. There was no difference in physiological parameters between groups (p = .85). There was no difference in patient safety between groups (incidence of sepsis, p = .95), incidence of caregiver error (p = .31), and incidence of apnea (p = .70). CONCLUSIONS: Cobedding promotes self-regulation and sleep and decreases crying without apparent increased risk.

Understanding kangaroo care and its benefits to preterm infants.

The holding of an infant with ventral skin-to-skin contact typically in an upright position with the swaddled infant on the chest of the parent, is commonly referred to as kangaroo care (KC), due to its simulation of marsupial care. It is recommended that KC, as a feasible, natural, and cost-effective intervention, should be standard of care in the delivery of quality health care for all infants, regardless of geographic location or economic status. Numerous benefits of its use have been reported related to mortality, physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breastfeeding duration, and degree of exclusivity) domains, as an effective therapy to relieve procedural pain, and improved neurodevelopment. Yet despite these recommendations and a lack of negative research findings, adoption of KC as a routine clinical practice remains variable and underutilized. Furthermore, uncertainty remains as to whether continuous KC should be recommended in all settings or if there is a critical period of initiation, dose, or duration that is optimal. This review synthesizes current knowledge about the benefits of KC for infants born preterm, highlighting differences and similarities across low and higher resource countries and in a non-pain and pain context. Additionally, implementation considerations and unanswered questions for future research are addressed.

Training highly qualified health research personnel: the pain in Child Health consortium.

BACKGROUND AND OBJECTIVES: Pain in Child Health (PICH) is a transdisciplinary, international research training consortium. PICH has been funded since 2002 as a Strategic Training Initiative in Health Research of the Canadian Institutes of Health Research, with contributions from other funding partners and the founding participation of five Canadian universities. The goal of PICH has been to create a community of scholars in pediatric pain to improve child health outcomes. METHODS: Quantitative analyses enumerated PICH faculty, trainees, training activities and scientific outputs. Interviews with PICH stakeholders were analyzed using qualitative methods capturing perceptions of the program's strengths, limitations, and opportunities for development and sustainability. RESULTS: PICH has supported 218 trainee members from 2002 through 2013, from 14 countries and more than 16 disciplines. The faculty at the end of 2013 comprised nine co-principal investigators, 14 Canadian coinvestigators, and 28 Canadian and international collaborators. Trainee members published 697 peer-reviewed journal articles on pediatric pain through 2013, among other research dissemination activities including conference presentations and webinars. Networks have been established between new and established researchers across Canada and in 13 other countries. Perceptions from stakeholders commended PICH for its positive impact on the development of pediatric pain researchers. Stakeholders emphasized skills and abilities gained through PICH, the perceived impact of PICH training on this research field, and considerations for future training in developing researchers in pediatric pain. CONCLUSIONS: PICH has been successfully developing highly qualified health research personnel within a Canadian and international community of pediatric pain scholarship.

Co-bedding between preterm twins attenuates stress response after heel lance: results of a randomized trial.

OBJECTIVE: To examine the effect of co-bedding between preterm twins on stress response after heel lance. METHODS: Using a multisite randomized controlled trial design, stable preterm twins (67 sets, N=134 infants) between 28 and 36 completed weeks' gestational age, stratified by gestational age (≤ and >32 weeks) and site, were randomly assigned to a co-bedding group, cared for continuously in the same incubator or crib or a standard care group, cared for in a separate incubator or crib, and underwent a medically indicated heel lance after at least 24 hours and no greater than 10 days of group allocation. The reported outcome was cortisol from saliva samples from 89 twins (n=49 co-bedding, n=40 standard care) collected immediately before the heel lance (baseline levels) and 113 twins (n=58 co-bedding, n=55 standard care) collected 20 minutes after heel lance (stress levels) as an index of stress response. RESULTS: No group differences were noted in baseline salivary cortisol levels: 0.36 µg/dL (SD 0.25) in the co-bedding group and 0.43 µg/dL (SD 0.50) in the standard care group. Twenty minutes after lance, levels were significantly lower in the co-bedding group, 0.28 µg/dL (SD 0.25) versus 0.50 µg/dL (SD 0.73) in the standard group (P=0.04). Similarly, the mean of paired changes in salivary cortisol from baseline was lower in the co-bedding group (-0.06 µg/dL) compared with the standard care group (0.14 µg/dL, P<0.05). DISCUSSION: Co-bedding attenuates the stress response of preterm twins undergoing heel lance. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT009176.

Cobedding and recovery time after heel lance in preterm twins: results of a randomized trial.

OBJECTIVES: Cobedding of preterm twin infants provides tactile, olfactory, and auditory stimulation and may affect pain reactivity. We carried out a randomized trial to assess the effect of cobedding on pain reactivity and recovery in preterm twin neonates. METHODS: Stable preterm twins (n = 67 sets) between 28 and 36 weeks of gestational age were randomly assigned to a cobedding group (cared for in the same incubator or crib) or a standard care group (cared for in separate incubators or cribs). Pain response (determined by the Premature Infant Pain Profile [PIPP]) and time to return to physiologic baseline parameters were compared between groups with adjustment for the nonindependence of twin infants. RESULTS: Maternal and infant characteristics were not significantly different between twin infants in the cobedding and standard care groups except for 5-minute Apgar <7 and postnatal age and corrected gestational age on the day of the heel lance. Mean PIPP scores were not different between groups at 30, 60, or 120 seconds. At 90 seconds, mean PIPP scores were higher in the cobedding group (6.0 vs 5.0, P = .04). Recovery time was shorter in the cobedding group compared with the standard care group, (mean = 75.6 seconds versus 142.1 seconds, P = .001). No significant adverse events were associated with cobedding. Adjustment for nonindependence between twins and differences in baseline characteristics did not change the results. CONCLUSIONS: Cobedding enhanced the physiologic recovery of preterm twins undergoing heel lance, but did not lead to lower pain scores.

Maternal touch and talk for invasive procedures in infants and toddlers in the pediatric intensive care unit.

The aim of this single-blind, randomized, crossover trial was to test the effect of Touch & Talk (T&T) for infants and toddlers less than 36 months of age (N = 65) in the pediatric intensive care unit on their physiological stability and recovery to an invasive procedure. In the T&T condition, mothers touched, sang, or told stories or rhymes to their child during an invasive procedure. In the control condition, the mothers did not have contact with their child. Physiological measures included heart rate, heart rate variability, and oxygen saturation range during the procedure and change from baseline. Time from the end of the procedure until the heart rate returned to baseline levels gave the recovery time. Analysis was conducted using repeated-measures analysis of covariance. There were no significant differences on any of the physiological parameters by condition during the procedure. However, when controlling for severity of illness, recovery was faster with mothers.

Procedural pain management for neonates using nonpharmacological strategies: Part 1: sensorial interventions.

Neonates who are born preterm and are admitted to neonatal intensive care units endure frequent procedures that may be painful. Nonpharmacological interventions that have been studied to relieve their pain may be categorized in 2 main groups according to their nature: interventions that focus on creating a favorable environment and offering pleasant sensorial stimuli and interventions that are centered on maternal care. These interventions may be considered within the philosophy of developmental care, since they are aimed at adjusting the environment to the needs of the neonate and involve family-centered care. In this article, the first of a 2-part series, we will synthesize the evidence from experimental studies of interventions that focus on the environment and on tactile and gustatory stimulation. The mechanisms suggested by researchers as possible explanations for the efficacy of these interventions are pointed, and the implications for procedural pain management in neonatal care are drawn.

Paternal vs maternal kangaroo care for procedural pain in preterm neonates: a randomized crossover trial.

OBJECTIVE: To test paternal vs maternal kangaroo care (KC) to reduce pain from heel lance. DESIGN: Randomized crossover design. SETTING: Three university-affiliated level III neonatal intensive care units. PATIENTS: Sixty-two preterm neonates at 28 to 36 weeks' gestational age who were expected to stay in the neonatal intensive care unit for at least 2 blood sampling procedures, without major congenital anomalies, grade III or IV intraventricular hemorrhage, or periventricular leukomalacia; without surgical interventions; not receiving parenteral analgesics or sedatives within 72 hours; and with parental consent. INTERVENTION: During 2 separate medically ordered heel lance procedures at least 24 hours apart, infants were held in KC for 30 minutes before and during the procedure with the mother or with the father, and with the other parent in the subsequent session. Which parent came first was randomized. MAIN OUTCOME MEASURES: The Premature Infant Pain Profile and time for heart rate to return to baseline were the primary outcomes. RESULTS: At 30 and 60 seconds after the heel lance, infants in maternal KC displayed significantly lower scores on the Premature Infant Pain Profile than when in paternal KC (30 seconds mean difference, 1.435 [95% confidence interval, 0.232-2.632]); 60 seconds mean difference, 1.548 [95% confidence interval, 0.069-3.027]). At 90 and 120 seconds, there were no differences. The difference in time to return to KC heart rate before the heel lance was significant, with the time in maternal KC being 204 seconds and in paternal KC, 246 seconds (mean difference, 42 seconds [95% confidence interval, 5.16-81.06 seconds]). CONCLUSIONS: Mothers were marginally more effective than fathers in decreasing pain response. Future research should address feasibility issues and nonparent providers of KC during painful procedures. TRIAL REGISTRATION: clinicaltrials.gov Identifier: ISRCTN51481987.

Measuring psychological outcomes following pediatric intensive care unit hospitalization: psychometric analysis of the Children's Critical Illness Impact Scale.

OBJECTIVE: Critically ill children are at risk for psychological sequelae following pediatric intensive care unit hospitalization. This article reports on the psychometric testing of the first self-report measure of psychological distress for 6-12-yr-old children post-pediatric intensive care unit hospitalization: The Children's Critical Illness Impact Scale. This 23-item scale takes approximately 15 mins for children to complete. DESIGN: Psychometric testing based on Classic Test Theory and guidelines for health measurement scale development. SETTING: The pediatric intensive care units of four Canadian pediatric hospitals and the ear, nose, and throat clinic of one participating hospital. PATIENTS: A total of 172 children (pediatric intensive care unit group, n = 84; ear, nose, and throat group, n = 88) aged 6-12 yrs and their parents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed the factor structure, internal consistency, and test-retest reliability of the Children's Critical Illness Impact Scale and conducted contrasted group comparisons and convergent and concurrent validation testing. Fit indices and internal consistency were best for a three-factor solution, suggesting three dimensions of psychological distress: 1) worries about getting sick again, 2) feeling things have changed, and 3) feeling anxious and fearful about hospitalization. As expected, Children's Critical Illness Impact Scale scores were positively correlated with child anxiety and medical fear scores. The ear, nose, and throat group scores were higher than expected. Higher Children's Critical Illness Impact Scale scores in older children may reflect a better understanding of the situation and its complexity and meaning, and younger children's tendency to provide more positive self-evaluation. CONCLUSIONS: The Children's Critical Illness Impact Scale is a promising new self-report measure of psychological distress with demonstrated reliability and validation testing in 6-12-yr-old children post-pediatric intensive care unit hospitalization. This new measure has potential to advance the evidence base for pediatric intensive care unit and post-pediatric intensive care unit health promotion interventions.

Mothers' experiences of a Touch and Talk nursing intervention to optimise pain management in the PICU: a qualitative descriptive study.

BACKGROUND: Parents consistently express a desire to support their child and retain a care-giving role in the paediatric intensive care unit (PICU). Qualitative data gathered as part of a PICU intervention study were analysed to explore mothers' experiences using a Touch and Talk intervention to comfort their children during invasive procedures. OBJECTIVES: To describe how mothers experienced involvement in their children's care through a Touch and Talk intervention and whether they would participate in a similar intervention again. RESEARCH METHODOLOGY AND SETTING: A qualitative descriptive design was used and semi-structured interviews conducted with 65 mothers in three Canadian PICUs. Data were subjected to thematic analysis. RESULTS: The overarching theme centred on the importance of comforting the critically ill child. This included being there for the child (the importance of parental presence); making a difference in the child's pain experience; and feeling comfortable and confident about participating in care. All but two mothers would participate in the intervention again and all would recommend it to others. CONCLUSIONS: Giving parents the choice of being involved in their child's care using touch and distraction techniques during painful procedures can provide an invaluable opportunity to foster parenting and support the child during a difficult PICU experience.

Co-bedding as a Comfort measure For Twins undergoing painful procedures (CComForT Trial).

BACKGROUND: Co-bedding, a developmental care strategy, is the practice of caring for diaper clad twins in one incubator (versus separating and caring for each infant in separate incubators), thus creating the opportunity for skin-to-skin contact and touch between the twins. In studies of mothers and their infants, maternal skin-to-skin contact has been shown to decrease procedural pain response according to both behavioral and physiological indicators in very preterm neonates. It is uncertain if this comfort is derived solely from maternal presence or from stabilization of regulatory processes from direct skin contact. The intent of this study is to compare the comfort effect of co-bedding (between twin infants who are co-bedding and those who are not) on infant pain response and physiologic stability during a tissue breaking procedure (heelstick). METHODS/DESIGN: Medically stable preterm twin infants admitted to the Neonatal Intensive Care Unit will be randomly assigned to a co-bedding group or a standard care group. Pain response will be measured by physiological and videotaped facial reaction using the Premature Infant Pain Profile scale (PIPP). Recovery from the tissue breaking procedure will be determined by the length of time for heart rate and oxygen saturation to return to baseline. Sixty four sets of twins (n = 128) will be recruited into the study. Analysis and inference will be based on the intention-to-treat principle. DISCUSSION: If twin contact while co-bedding is determined to have a comforting effect for painful procedures, then changes in current neonatal care practices to include co-bedding may be an inexpensive, non invasive method to help maintain physiologic stability and decrease the long term psychological impact of procedural pain in this high risk population. Knowledge obtained from this study will also add to existing theoretical models with respect to the exact mechanism of comfort through touch. TRIAL REGISTRATION: NCT00917631.

Pain Management Practices in a Pediatric Emergency Room (PAMPER) Study: interventions with nurses.

BACKGROUND AND AIM: Children's pain in emergency departments (EDs) is poorly managed by nurses, despite evidence that pain is one of the most commonly presenting complaints of children attending the ED. Our objectives were 2-fold: to verify if tailored educational interventions with emergency pediatric nurses would improve nurses' knowledge of pain management and nurses' pain management practices (documentation of pain, administration of analgesics, nonpharmacological interventions). METHODS: This intervention study with a pre-post design (baseline, immediately after the intervention [T-2], and 6 months after intervention [T-3]) used a sample of nurses (N = 50) and retrospective chart reviews of children (N = 450; 150 charts reviewed each at baseline, T-2, and T-3) who presented themselves in the ED with a diagnosis known to generate moderate to severe pain (burns, acute abdominal pain, deep lacerations, fracture, sprain). Principal outcomes: nurses' knowledge of pain management (Pediatric Nurses Knowledge and Attitudes Survey [PNKAS] on pain) and nurses' clinical practices of pain management (Pain Management Experience Evaluation [PMEE]). RESULTS: Response rate on the PNKAS was 84% (42/50) at baseline and 50% (21/42) at T-2. Mean scores on PNKAS were 28.2 (SD, 4.9; max, 42.0) at baseline and 31.0 (SD, 4.6) at T-2. Results from paired t test showed significant difference between both times (t = -3.129, P = 0.005). Nurses who participated in the capsules improved their documentation of pain from baseline (59.3%) to T-2 (80.8%; chi = 12.993, P < 0.001) as well as from baseline (59.3%) to T-3 (89.1%; chi = 29.436, P < 0.001). In addition, nurses increased their nonpharmacological interventions from baseline (16.7%) to T-3 (31.9%; chi = 8.623, P = 0.003). Finally, we obtained significant differences on pain documentation between the group of nurses who attended at least 1 capsule and the group of nurses who did not attend any capsule at both times (T-2 and T-3; chi = 20.424, P < 0.001; chi = 33.333, P < 0.001, respectively). CONCLUSIONS: The interventions contributed to the improvement of the nurses' knowledge of pain management and some of the practices over time. We believe that an intervention tailored to nurses' needs and schedule has more impact than just passive diffusion of educational content.

Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery.

A repeated measure design was used to evaluate additional psychometric qualities (sensitivity and specificity) of the Critical-Care Pain Observation Tool (CPOT), a previously validated tool, in intubated intensive care unit (ICU) adults after cardiac surgery recruited in a university cardiology health center in Canada. Patients were evaluated while conscious and intubated (n=99/105), and extubated (n=105). For each of these two testing periods, patients were evaluated using the CPOT at rest (pre-exposure), during a nociceptive procedure-turning (exposure), and 20 minutes after the procedure (postexposure). The patients' self-reports of pain were obtained while intubated and extubated. During the nociceptive exposure, the CPOT had a sensitivity of 86%, a specificity of 78%, a positive likelihood ratio (LR(+)) of 3.87 (1.63-9.23), and a negative LR (LR(-)) of 0.18 (0.09-0.33) and was effective for the screening of pain. It also showed good specificity (83% and 97%) but lower sensitivity (47% and 63%) during nonexposure conditions. The CPOT cutoff score was >2 during the nociceptive exposure. After extubation, patients' self-reports of pain intensity were associated with the positive CPOT cutoff score previously determined. The CPOT adequately classified most of the patients with severe pain. The CPOT seems to be a useful tool to detect pain in intubated postoperative ICU adults, especially during a nociceptive procedure. Sensitivity and specificity of the CPOT need to be further explored during other nociceptive procedures and with different critically ill populations.

Developing the Children's Critical Illness Impact Scale: capturing stories from children, parents, and staff.

OBJECTIVE: With the evolution of pediatric critical care medicine has come an awareness of the ethical imperative of healthcare professionals to attend to the psychological sequelae of technologically intensive care. Recent attempts to measure psychological outcomes in these children have been limited. The purpose of this study was to develop a measure of posthospitalization distress, the Children's Critical Illness Impact Scale (CCIIS), for children aged 6-12 yrs following pediatric intensive care unit hospitalization. DESIGN: A measurement development study consisting of two phases: 1) item generation and scale formatting; and 2) item reduction and scale revisions. Items were generated following thematic analysis of qualitative data from focus groups and individual interviews with children, parents, and healthcare professionals. Children reviewed items for interpretability and importance and assessed scaling technique and item presentation; healthcare professionals further evaluated item relevance. SETTING: The pediatric intensive care units of three quaternary care, Canadian pediatric teaching hospitals. PATIENTS: Phase 1 included 18 children, 22 parents, and 12 healthcare professionals (n = 52). Phase 2 included eight children and four healthcare professionals (n = 12). MEASUREMENTS AND MAIN RESULTS: Five key domains were identified in the thematic analyses: worries, fears, friends and family, sense of self, and behaviors. Thirty-six items were initially generated, and subsequent item reduction resulted in 23 items that were retained on the final scale. Items were generally rated extremely relevant and were judged to capture the content area (content validity index = 0.87). The CCIIS was easily understood, and the scaling format worked well. Older children preferred written items, while younger children will require a modified, pictorial version. CONCLUSIONS: The CCIIS is a new self-report measure with demonstrated content validity and specific relevance for young school-aged children following pediatric intensive care unit hospitalization. Valid, accessible, and developmentally appropriate measures are essential to identify high-risk children and, ultimately, promote healthy growth and development.

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 < .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.

Recorded maternal voice for preterm neonates undergoing heel lance.

PURPOSE: To determine if a recording of a mother's voice talking soothingly to her baby is useful in diminishing pain in newborns born between 32 and 36 weeks' gestational age (GA) during routine painful procedures. BACKGROUND: While maternal skin-to-skin contact has been proven efficacious for diminishing procedural pain in both full-term and preterm neonates, it is often not possible for mothers to be present during a painful procedure. Because auditory development occurs before the third trimester of gestation, it was hypothesized that maternal voice could substitute for maternal presence and be effective in diminishing pain response. SUBJECTS: Preterm infants between 32 and 36 weeks' GA (n = 20) in the first 10 days of life admitted to 2 urban university-affiliated neonatal intensive care units. DESIGN AND METHODS: Crossover design with random ordering of condition. Following informed consent, an audio recording of the mother talking soothingly to her baby was filtered to simulate the mother's voice traveling through amniotic fluid. A final 10-minute recording of repetition of mothers' talking was recorded with maximum peaks of 70 decibels (dB) and played at levels ranging between 60 and 70 ambient decibels (dbA), selected above recommendations of the American Academy of Pediatrics in order to be heard over high ambient noise in the settings. This was played to her infant by a portable cassette tape player 3 times daily during a 48-hour period after feedings (gavage, bottle, or breast). At the end of 48 hours when blood work was required for clinical purposes, using a crossover design, the infant underwent the heel lancing with or without the recording being played. The order of condition was randomized, and the second condition was within 10 days. The Premature Infant Pain Profile (PIPP) was used as primary outcome. This is a composite measure using heart rate, oxygen saturation, 3 facial actions, behavioral state, and gestational age. This measure has demonstrated reliability and validity indexes. RESULTS: There were no significant differences between groups on the PIPP or any of the individual components of the PIPP except a lower oxygen saturation level in the voice condition following the procedure. The second condition, regardless of whether it was voice or control, had higher heart rate scores and lower oxygen saturation scores even in the prelance baseline and warming phases. Order did not affect PIPP scores or facial actions. CONCLUSIONS: Different modalities of maternal presence would appear to be necessary to blunt pain response in infants, and recorded maternal voice alone is not sufficient. The loudness of the recording may have obliterated the infant's ability to discern the mother's voice and may even have been aversive, reflected in decreased oxygen saturation levels in the voice condition. Preterm neonates of 32 to 36 weeks' gestation may become sensitized to painful experiences and show anticipatory physiological response.

One-on-one coaching to improve pain assessment and management practices of pediatric nurses.

Pain in children is infrequently assessed and managed by nurses. One-on-one coaching based on audit with feedback and the use of opinion leaders have been effective in changing professional health care practices. Coaching by an opinion leader for changing pediatric nurses' pain practices was tested in a clustered randomized trial in six Canadian pediatric hospitals. The rate of pain assessments, nurses' knowledge, and nonpharmacological interventions increased in the coaching group. However, there were significant site differences that could not be attributed to the coaching but to factors inherent in the sites. The context in which interventions are implemented will influence the effectiveness of individualized interventions.