Current pain management practices for preterm infants with necrotizing enterocolitis: a European survey.

BACKGROUND: Necrotizing enterocolitis (NEC) is a highly painful intestinal complication in preterm infants that requires adequate pain management to prevent short- and long-term effects of neonatal pain. There is a lack of international guidelines for pain management in NEC patients. Therefore, this study aims to describe current pain management for NEC patients in European neonatal intensive care units (NICUs). METHODS: An online survey was designed and conducted to assess current practices in pain management for NEC patients in European NICUs. The survey was distributed via neonatal societies, digital platforms, and professional contacts. RESULTS: Out of the 259 responding unique European NICUs from 36 countries, 61% had a standard protocol for analgesic therapy, 73% assessed pain during NEC, and 92% treated NEC patients with intravenous analgosedatives. There was strong heterogeneity in the used pain scales and initial analgesic therapy, which mainly included acetaminophen (70%), fentanyl (56%), and/or morphine (49%). A third of NICU representatives considered their pain assessment adequate, and half considered their analgesic therapy adequate for NEC patients. CONCLUSIONS: Various pain scales and analgesics are used to treat NEC patients in European NICUs. Our results provide the first step towards an international guideline to improve pain management for NEC patients. IMPACT: This study provides an overview of current pain management practices for infants with necrotizing enterocolitis (NEC) in European neonatal intensive care units. Choice of pain assessment tools, analgosedatives, and dosages vary considerably among NICUs and countries. A third of NICU representatives were satisfied with their current pain assessment practices and half of NICU representatives with their analgesic therapy practices in NEC patients in their NICU. The results of this survey may provide a first step towards developing a European pain management consensus guideline for patients with NEC.

COVID-19 lockdown impacts the wellbeing of parents with infants on a Dutch neonatal intensive care unit.

PURPOSE: Parents of infants admitted to a neonatal intensive care unit (NICU) experience additional stress due to restrictions on their presence and visits by other family members during the COVID-19 pandemic. Our study aims to describe how this impacted parents and how NICU staff could support them. DESIGN AND METHODS: This was a cross-sectional study in which 25 parents (16 mothers, 9 fathers) of infants admitted to our NICU during the first COVID-19 lockdown completed online questionnaires with socio-demographic questions, the Parental Stressor Scale:NICU (PSS:NICU) and questions related to COVID-19. RESULTS: Being separated from, and not being able to hold their infant at all times were among the most important PSS:NICU stressors. Parents experienced additional stress because other family members were not allowed to visit. They indicated that NICU staff could support them by clearly explaining the reasons for visitor restrictions and by ensuring that they felt heard. Most parents supported the restrictions, but also mentioned that less strict measures would really help them. CONCLUSIONS: Parents who participated in this study found it very stressful that they could not be with their infant together with their partner and other family members. Furthermore, parents recommended the hospital management to continuously reconsider whether particular restrictions could be lifted in case of a new lockdown. Together with clear communication, this would result in less parenteral stress. PRACTICE IMPLICATIONS: Hospital management should be cautious on restricting the presence of parents and other family members and scale restrictions back whenever possible.

Retrospective study shows that doxapram therapy avoided the need for endotracheal intubation in most premature neonates.

AIM: Using doxapram to treat neonates with apnoea of prematurity might avoid the need for endotracheal intubation and invasive ventilation. We studied whether doxapram prevented the need for intubation and identified the predictors of the success. METHODS: This was a retrospective study of preterm infants born from January 2006 to August 2014 who received oral or intravenous doxapram. Success was defined as no need for endotracheal intubation, due to apnoea, during doxapram therapy. Univariable and multivariable logistic regression analyses identified predictors of success during the first 48 hours of doxapram therapy. RESULTS: Data on 203 patients with a median gestational age of 26.1 (interquartile range 25.1-27.4) weeks were analysed. During the first 48 hours of doxapram therapy, 157 (77%) patients did not need endotracheal intubation and 127 (63%) patients were successfully treated over the entire treatment course. The median postnatal age at the start of doxapram therapy was 20 days (interquartile range 12-30). Postnatal age and a lower fraction of inspired oxygen at the start of doxapram therapy were significant predictors of success (odds ratio 0.964, 95% confidence interval 0.938-0.991, p = 0.001). CONCLUSION: Oral and intravenous doxapram effectively treated most cases of apnoea in preterm infants, avoiding the need for intubation.

Biomarkers for assessing pain and pain relief in the neonatal intensive care unit.

Newborns admitted to the neonatal intensive care unit (NICU) regularly undergo painful procedures and may face various painful conditions such as postoperative pain. Optimal management of pain in these vulnerable preterm and term born neonates is crucial to ensure their comfort and prevent negative consequences of neonatal pain. This entails accurate and timely identification of pain, non-pharmacological pain treatment and if needed administration of analgesic therapy, evaluation of treatment effectiveness, and monitoring of adverse effects. Despite the widely recognized importance of pain management, pain assessment in neonates has thus far proven to be a challenge. As self-report, the gold standard for pain assessment, is not possible in neonates, other methods are needed. Several observational pain scales have been developed, but these often rely on snapshot and largely subjective observations and may fail to capture pain in certain conditions. Incorporation of biomarkers alongside observational pain scores holds promise in enhancing pain assessment and, by extension, optimizing pain treatment and neonatal outcomes. This review explores the possibilities of integrating biomarkers in pain assessment in the NICU.

COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates?

OBJECTIVE: We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain. STUDY DESIGN: This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity. RESULT: Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively. CONCLUSION: The COMFORTneo can be used to reliably and validly assess pain in NICU patients.

Do Pain Measurement Instruments Detect the Effect of Pain-Reducing Interventions in Neonates? A Systematic Review on Responsiveness.

The effectiveness of pain-reducing interventions in newborns can only be determined if pain measurement instruments are responsive; that is, able to detect a decrease in pain intensity after the pain-reducing intervention. This review assesses the methodologic quality of studies on this measurement property-the responsiveness. We searched the literature published until January 2018 for validation studies of pain measurement instruments focusing on responsiveness to pain-reducing treatment in neonates. The methodologic quality of the included studies was rated using the COnsensus-based Standards for the selection of health Measurement INstruments checklist. Nine studies were included involving 10 pain measurement instruments. These studies differed with respect to the population, setting and type of pain-reducing intervention. In all studies, pain scores were significantly lower after a pain-reducing intervention and the instrument used was therefore considered responsive. We rated 4 studies as having poor methodologic quality, 5 as fair quality, and none as good quality. In conclusion, the responsiveness was studied for only 10 of the 43 existing pain measurement instruments for the use in neonates. Because this is an important property of a pain instrument, more research on this topic is needed, with attention for blinding and formulating a specific hypothesis before start of data collection. PERSPECTIVE: This review focuses on the property of measurement instruments to detect changes in pain intensity after a pain-reducing intervention in neonates. We concluded that this property-the responsiveness-is under studied and that the methodologic quality of the included studies was low. Future high-quality validation studies should focus on responsiveness.

Acute Pain Assessment in Prematurely Born Infants Below 29 Weeks: A Long Way to Go.

OBJECTIVES: Neonates born extremely prematurely are at high risk of acute and prolonged pain. Effective treatment requires reliable pain assessment, which is currently missing. Our study explored whether existing pain assessment tools and physiological indicators measure pain and comfort accurately in this population. MATERIALS AND METHODS: We prospectively collected data in 16 neonates born at less than 29 weeks' gestational age during 3 conditions: skin-to-skin care, rest, and heelstick procedure for capillary blood sampling in the incubator. The neonates were video recorded in these situations, and recordings were coded using 5 observational pain assessment tools and numeric rating scales for pain and distress. We simultaneously collected heart rate, respiratory rate, arterial oxygen saturation, regional cerebral oxygenation, and the number of skin conductance peaks. All measures across the 3 conditions were compared using general linear modeling. RESULTS: The median gestational age was 27.1 weeks (range: 24.1 to 28.7). Forty measurement periods across the 3 conditions were analyzed. Heart rate was significantly higher during heelstick procedures compared with during rest, with a mean difference of 10.7 beats/min (95% confidence interval [CI]: 2.7-18.6). Oxygen saturation was significantly higher during skin-to-skin care compared with during heelstick procedures with a mean difference of 5.5% (95% CI: 0.2-10.8). The Premature Infant Pain Profile-revised (PIPP-R) score was significantly higher during heelstick procedures compared with skin-to-skin care with a mean difference of 3.2 points (95% CI: 1.6-5.0). DISCUSSION: Pain measurement in clinical practice in prematurely born infants below 29 weeks remains challenging. The included behavioral and physiological indicators did not adequately distinguish between a painful situation, rest, and skin-to-skin care in premature neonates.

Waiting 2†minutes after sucrose administration-unnecessary?

BACKGROUND: Worldwide, oral sucrose is standard of care in many neonatal intensive care units to relieve procedural pain in neonates. This study aims to determine if time interval between sucrose administration and heelstick correlates with pain scores. METHODS: Neonates were prospectively studied with variable time intervals and assessed with the Premature Infant Pain Profile-Revised (PIPP-R). RESULTS: 150 neonates were included with a median gestational age of 30+6 (IQR 27+6-33+2) weeks and a median time interval of 72 (IQR 39-115) seconds between sucrose administration and heelstick. In multiple regression analysis, this time interval was not significantly related to the PIPP-R (B=0.004, 95% CI -0.005 to 0.013, p=0.37). Providing non-nutritive sucking combined with sucrose was significantly related to lower PIPP-R scores (B=-3.50, 95% CI -4.7 to -2.3, p<0.001). CONCLUSIONS: Our study suggests that there is no need to wait 2 min after sucrose administration before a painful procedure. Sucrose-induced non-nutritive sucking shows a fast pain-relieving effect in neonates.

Infants Operated on for Necrotizing Enterocolitis: Towards Evidence-Based Pain Guidelines.

BACKGROUND: Necrotizing enterocolitis (NEC) is known as an extremely painful childhood condition. OBJECTIVES: The objective of this study was to explore pain management around NEC-related surgery in our neonatal intensive care unit (NICU) from a chart review of prospectively collected data on 60 operated NEC patients admitted between 2008 and 2013 with a median (IQR) gestational age of 28.3 (25.5-31.6) weeks. METHODS: Pain medication data and pain scores (i.e. COMFORTneo and Numerical Rating Scale pain and distress scores) from 72 h before until 72 h after surgery were collected. RESULTS: Preoperatively, 95% of the patients received morphine versus 100% postoperatively, with a median dosage of 10.0 (IQR 9.7-14.5) and 16.9 (IQR 10.1-20.0) µg/kg/h, respectively. Postoperatively, 28 patients (46.7%) received additional fentanyl intermittently and 14 (23.3%) received midazolam, which was part of palliative treatment for 6 patients (42.9%). In patients receiving pain medication, median COMFORTneo scores were 10 (IQR 10-11) preoperatively and 11 (10-12) postoperatively. The pain scores were comparable with those of other patients admitted to the NICU in the same time period. CONCLUSIONS: Continuous morphine of 10 µg/kg/h preoperatively, with an increase to 15 µg/kg/h postoperatively, seems to constitute a good starting dose for further individualized pain management guided by pain scores.