ALPS-Neo pain and stress assessment scale for neonates-A measure for procedural pain.

AIM: The aim of this study was to investigate psychometric properties, reliability and validity, of Astrid Lindgren and Lund Children's Hospitals Pain and Stress Assessment Scale for Preterm and Sick Newborn Infants (ALPS-Neo), as a measure for procedural pain. METHODS: This observational, prospective study with a repeated measures design, explored inter-rater reliability by two raters assessing 21 neonates during non-pain and pain events. Construct validity was explored, that is, ability to discriminate between non-pain and pain, and criterion validity by correlating ALPS-Neo with Premature Infant Pain Profile-Revised (PIPP-R) and Skin Conductance Algesimeter (SCA) in 54 neonates without ventilator support and sedation undergoing routine heel-stick procedure in a tertiary neonatal intensive care unit. RESULTS: Mean gestational and assessment age of 54 infants was 33.8 weeks and 12.7 days respectively. Inter-rater reliability from baseline, skin wiping, heel-stick events for 21 infants demonstrated intraclass correlations with 95% confidence intervals (CI) of 0.49 (-0.27 to 0.79), 0.86 (0.65-0.94) and 0.73 (0.34-0.89) respectively. ALPS-Neo discriminated significantly between baseline, non-pain and heel-stick (mean differences from pain event -2.3 and -1.0 respectively) and correlated during heel-stick with PIPP-R (r = 0.56, 95% CI: 0.34-0.72), not with SCA. CONCLUSION: ALPS-Neo may be used as a measure for procedural pain.

Iatrogenic Flexion-Related Classic Metaphyseal Lesion of the Distal Tibia: Three Cases.

BACKGROUND: Classic metaphyseal lesions (CMLs) should raise concern for nonaccidental trauma. However, iatrogenic causes for CMLs have increasingly been described and warrant close consideration. Increasing the clinical understanding of CML mechanics and their relation to often routine medical procedures will enhance provider awareness and expand the differential diagnosis when these otherwise highly concerning injuries are identified. CASE REPORTS: We describe three clinical cases where suspected iatrogenic dorsiflexion or plantar flexion resulted in an isolated distal tibia CML. Respectively, we present heel-stick testing and i.v. line placement as clinical correlates of these two mechanisms. Although prior reports have aimed to describe iatrogenic CML etiologies, they have not focused on dorsiflexion or plantar flexion as predominant mechanisms of injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are critical to the surveillance and identification of nonaccidental trauma. Given that children oftentimes present to the emergency department with subtle yet concerning signs of maltreatment, an emergency physician must be aware of the potential causes of injury as well as the recommended response. Although avoiding missed cases of abuse and improving the detection of injuries is crucial for child health and well-being, failing to consider or recognize alternative explanations could also have serious implications for a child and their caregivers.

Effectiveness of maternal-targeted training on nonpharmacologic pain management on heel stick sampling: A randomized controlled trial.

BACKGROUND: Heel stick sampling, which is a common procedure in newborns, causes acute pain, and parents are aware of this. AIM: The current study aimed to investigate the effectiveness of maternal-targeted training on newborn pain management, addressing the use of nonpharmacological methods and anxiety. METHODS: The study is 2-arm, parallel-group randomized controlled trial. A total of 64 mothers were included in this study. Mothers were randomly allocated to each group; intervention (n:32) and control (n=:32). Training on nonpharmacological pain management in newborns was given to the mothers in the intervention group. Data were collected with an Introductory Information Form, Nonpharmacological Pain Management Use Checklist, and State-Trait Anxiety Inventory. RESULTS: Nonpharmacological methods were used for the procedures in the control group and the intervention group, with an absolute difference of 68.8% between groups. The difference was statistically significant (p < 0.001) and had a large effect (d = -79.222; 95% CI, -9.365 to 670.143. There was no significant difference between the groups in terms of anxiety score (p = 0.558). CONCLUSION: Demonstrates the clinical relevance and feasibility of training targeting maternal on neonatal pain management during the heel stick sampling procedure. PRACTICE IMPLICATIONS: When non-pharmacological methods in pain management of newborns were recommended by the nurse, maternal involvement in pain management increased significantly, suggesting that nurses have a key role in ensuring parental involvement. CLINICAL TRIAL REGISTRATION: NCT05173662.

Antinociceptive effect of vapocoolant medium stream spray on hotplate latency in rat pups.

BACKGROUND: Heel sticks account for most blood tests performed in neonates without analgesia because topical local anesthetics are ineffective on heel glabrous skin. We investigated the antinociceptive effect of an alternative topical analgesic, a vapocoolant spray, on hind paw glabrous skin of rat pups. The spray was applied by two methods: method 1 for 4 s at a distance of 8 cm and method 2 for 10 s at a distance of 18 cm. METHODS: The rat pups were randomized to either method 1 (n = 32) or method 2 (n = 31). Vapocoolant spray was applied to one hind paw randomly, and saline spray was applied to the contralateral paw. The paws were exposed to a hotplate test to measure withdrawal latency time before and 30 s after the spray applications. Additionally, rat pups were tested for tissue toxicity in method 1 (n = 20) and method 2 (n = 20) after application of the vapocoolant spray before heel sticks three times a day for two consecutive days. Analyses of spray and method effects on hotplate withdrawal latency time were determined by nonparametric Wilcoxon tests to assess paired difference between vapocoolant spray and saline spray and to compare difference in medians between the two methods. RESULTS: Method 1 and method 2 vapocoolant spray applications significantly prolonged the withdrawal latency time compared with saline, a median difference of 0.6 s (IQR 0.1-1.2) for method 1 and 9.5 s (IQR 5.5-10.7) for method 2 (a 15-fold longer latency time with method 2). Method-2 produced significantly longer withdrawal latency time than method 1 with a difference in median time of 8.9 s (CI: 95% 7.3-10.4 s, P < .0001). No histopathological changes were detected. CONCLUSIONS: Compared with method- 1, the vapocoolant spray in method 2 produced significantly longer withdrawal latency time that is clinically applicable to collecting blood samples after a heel stick.

The Effect of Breastfeeding, Kangaroo Care, and Facilitated Tucking Positioning in Reducing the Pain During Heel Stick in Neonates.

PURPOSE: Invasive intervention can negatively affect prognosis, behavior, environmental adaptation in neonates. Some nonpharmacological pain management methods are used for effective pain treatment. This study investigated the effect of breastfeeding, kangaroo care, and facilitated tucking positioning on heel-stick pain in neonates. DESIGN: A quasi-experimental design was employed. The study was conducted in three family health centers in Kütahya/Turkey. The sample consisted of 140 healthy neonates with the gestational age of 37 weeks or more, birth weight greater than 2500 g, and no sucking problems. The sample was divided into four groups (breastfeeding, kangaroo care, facilitated tucking position, and control). Data were collected using a Baby-Mother Characteristics Questionnaire, a Physiological Parameter Follow-up Form, and the Neonatal Infant Pain Scale. Data were analyzed using chi-square, the one-way analysis of variance (ANOVA), Kruskal-Wallis, Student t-test, and Mann-Whitney U tests. The research adhered to ethical principles. RESULTS: The facilitated tucking position group cried less and experienced less pain during heel stick than the other groups (p < 0.05). Breastfeeding, kangaroo care, and facilitating tucking help reduce heel-stick pain but facilitating tucking causes less crying and imposes less pain on neonates than the other methods. CONCLUSION: Facilitated tucking position may be preferred to reduce pain during heel stick. PRACTICE IMPLICATIONS: Using facilitated tucking positions and breastfeeding methods can assist healthcare professionals as supportive methods in pain management.

Effects of breastfeeding and heel warming on pain levels during heel stick in neonates.

AIM: To determine the effects of two different methods, breastfeeding and heel warming, during heel stick procedures on pain levels in healthy term neonates. METHODS: This study was a prospective, randomized controlled trial. The sample of the study consisted of 150 healthy newborns who matched the case selection criteria and were brought to the nursery for the heel stick procedure. Fifty neonates were randomly assigned to each group: breastfeeding (n = 50), heel warming (n = 50), and control (n = 50), using computer-based randomization. The study data were obtained using an Information Form and the Neonatal Infant Pain Scale (NIPS). RESULTS: The pre-procedural pain scores of the breastfeeding group (mean 4.44 SD 1.21 seconds) were lower than in the heel warming (mean 6.10 SD 1.07 seconds) and the control group (mean 6.42 SD 0.91 seconds) (P < 0.01). Both the total crying time and the first calming time of the breastfeeding group were shorter than the heel warming and control group. The first calming time of the heel warming group was shorter than in the control group. CONCLUSIONS: Both breastfeeding and heel warming are effective in reducing the calming time during heel stick procedures. However, breastfeeding is more effective than heel warming in reducing pain during heel stick and should be preferred as the first choice.

Validation of Heel Stick Microsampling To Optimize Micafungin Doses in Neonates and Young Infants.

Major gaps exist in our knowledge of antimicrobial pharmacokinetics in critically ill neonates and infants that require validated microsampling and bioanalysis methods to support therapeutic drug monitoring. We compared serially collected intravenous (i.v.) and heel stick capillary (HSC)-sampled plasma concentrations of micafungin (8 mg/kg) in eight infants born preterm with systemic candidiasis. The mean (standard deviation) micafungin area under the plasma concentration-time curve to infinity (AUCinf) was 316 (65.0) h · mg/liter based on HSC concentrations that strongly correlated (R2 = 0.92) with i.v. values to support dose adjustment.

Effects of Kangaroo Care on Neonatal Pain in South Korea.

Blood sampling for a newborn screening test is necessary for all neonates in South Korea. During the heel stick, an appropriate intervention should be implemented to reduce neonatal pain. This study was conducted to identify the effectiveness of kangaroo care (KC), skin contact with the mother, on pain relief during the neonatal heel stick. Twenty-six neonates undergoing KC and 30 control neonates at a university hospital participated in this study. Physiological responses of neonates, including heart rate, oxygen saturation, duration of crying and Premature Infant Pain Profile (PIPP) scores were measured and compared before, during and 1 min and 2 min after heel sticks. The heart rate of KC neonates was lower at both 1 and 2 min after sampling than those of the control group. Also, PIPP scores of KC neonates were significantly lower both during and after sampling. The duration of crying for KC neonates was around 10% of the duration of the control group. In conclusion, KC might be an effective intervention in a full-term nursery for neonatal pain management.

Efficacy of swaddling and heel warming on pain response to heel stick in neonates: a randomised control trial.

AIMS AND OBJECTIVES: To determine the efficacy of swaddling and heel warming on pain response in neonates following heel stick. BACKGROUND: Swaddling has been suggested to reduce pain response in neonates during heel stick. Heel warming is also often performed for drawing blood easily before heel stick. However, the efficacy of both on pain response is unclear. DESIGN: A randomised controlled study was used. METHODS: Twenty-five neonates were randomly assigned to each of the control, swaddling and heel-warming groups. Heart rate, oxygen saturation Neonatal Infant Pain Scale and duration of crying were used to assess pain reactivity and pain recovery. A greater heart rate and Neonatal Infant Pain Scale increase, or oxygen saturation decrease, indicated higher pain reactivity. A longer duration of heart rate and oxygen saturation changes after heel stick back to baseline indicated a longer pain recovery. RESULTS: The decrease in oxygen saturation in swaddling group was significantly greater than that in heel-warming group. The increase in the Neonatal Infant Pain Scale in control group was significantly higher than that in swaddling group. The heart rate recovery time in control group and swaddling group was significantly longer than that in heel-warming group. The oxygen saturation recovery time in control group was significantly longer than that in heel-warming group. The duration of crying in control group was significantly longer than those in swaddling group and heel-warming group. CONCLUSION: Both swaddling and heel warming decreased the pain response of neonates during heel stick. Heel warming resulted in a lower pain response than did swaddling for neonates, particularly in terms of pain recovery. RELEVANCE TO CLINICAL PRACTICE: Heel warming could become a routine practice to decrease the pain response of neonates during heel stick.

Effectiveness of facilitated tucking on reducing pain during heel stick in neonates: a randomized controlled experimental study.

Background: Pain in neonates is associated with adverse neurodevelopmental outcomes in the later days of life. Facilitated tucking is a nonpharmacological method of pain relief. The study aims to compare the effect of facilitated tucking in pain reduction in neonates. Materials and methods: This was a randomized controlled experimental study conducted in the neonatal ward of a tertiary care center. There were 25 neonates randomized each in the experimental and control groups (total of 50), based on computer-generated random tables. The experimental group was placed in a facilitated tucking position during heel stick, while the control group was kept in the usual position, as done routinely. A self-structured questionnaire and Neonatal Infant Pain Scale were used. The main outcome measures were the mean Neonatal Infant Pain Scale score, and change in preprocedure and postprocedure heart rate and oxygen saturation in the two groups. Ethical clearance and informed written consent were sought. Results: Neonates in the experimental group had significantly lesser pain (less Neonatal Infant Pain Scale score) than the neonates in the control group (P<0.001). There was also a significant increment in the mean heart rate and a decrease in the oxygen saturation after the procedure in the control group, indicating significantly more pain perception (P<0.001) in the control group. Conclusions: Facilitated tucking was found to be effective in reducing the pain during heel stick procedures in neonates.

Effect of Non-nutritive Sucking during Heel-stick Procedure in Pain Management of Term Infants in the Neonatal Intensive Care Unit: A Systematic Review and Meta-analysis.

BACKGROUND: This study aimed to evaluate the efficacy of non-nutritive sucking for analgesia in term infants undergoing heel-stick procedures. METHODS: Randomized controlled trials and non-randomized studies based on the PICO framework were included in the study. Review articles, commentary, pilot, and non-English articles were excluded. Databases, such as PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane, were searched until January 31st, 2021, using the keywords "Pain management", 'Non-nutritive sucking", and "Heel stick". All studies were reviewed and retrieved by two authors independently using a standardized form according to the inclusion criteria, and any disagreements were examined by a third scholar. Quality assessment was evaluated by using the ROB-2 tool. Data were analyzed using Stata version 12.0 software, and a random-effects model was used for analysis. RESULTS: A total of 5,629 articles were retrieved from all databases, and after the screening, finally, 6 relevant articles were included in the analysis. The tools used to control pain in infants in the articles included PIPP, NFCS, NIPS, and NPASS. The results showed that the pain scores were significantly lower in the NNS group compared to the control group (MD, -1.05; 95% CI, -1.53 to -0.57) and NNS had a significant effect on oxygen saturation (O2 Sat) increasing in newborns compared to the control group, but no significant reduction in the heart rate (HR) between two groups was observed. CONCLUSION: NNS effectively provides analgesia in full-term neonates undergoing heel-stick procedures; however, its effects on the long-term outcomes of infants are unclear. The results showed that NNS was effective in improving heel-stick pain in infants.

Breastmilk as a Multisensory Intervention for Relieving Pain during Newborn Screening Procedures: A Randomized Control Trial.

The study aim was to explore the effects of multisensory breastmilk interventions on short-term pain of infants during newborn screening. This is a randomized controlled trial. A total of 120 newborns were recruited and assigned by randomization to one of three treatment conditions: Condition 1 = routine care (gentle touch + verbal comfort); Condition 2 = breastmilk odor + routine care; or Condition 3 = breastmilk odor + taste + routine care. Pain was scored with the Neonatal Infant Pain Scale (NIPS). Data were collected from video recordings at 1 min intervals over the 11 phases of heel sticks: phase 1, 5 min before heel stick without stimuli (baseline); phase 2 to phase 6 (during heel stick); and phase 7 to phase 11 (recovery). Generalized estimating equations compared differences in pain scores for newborns over phases among the three conditions. Compared with the routine care, provision of the odor and taste of breastmilk reduce NIPS scores during heel sticks (B = -4.36, SE = 0.45, p < 0.001 [phase6]), and during recovery (B = -3.29, SE = 0.42, p < 0.001 [phase7]). Our findings provide new data, which supports the use of multisensory interventions that include breastmilk odor and taste in combination with gentle touch and verbal comfort to relieve pain in infants undergoing newborn screening.

Suitability of Placental Blood Samples of Newborns for Pre-Transfusion Testing.

Objective: To show concordance between heel stick and placental blood sample pairs for newborns' pre-transfusion testing and to validate placental blood's tube and gel methodology. Methods: Placental samples were collected for pre-transfusion testing at birth from 78 singleton and twin newborns admitted to our Mother-Baby Unit to compare with the results of heel stick samples taken from same newborns. Gestational age ≥35 weeks, weight ≥2,000 g. The study was approved by the Institutional Review Board (IRB). Informed consent was obtained from newborn parents. ABO blood group, Rhesus factor (Rh), direct antiglobulin test (DAT), and antibody screen were performed. Ortho ProVue Analyzer was used for tube and gel methods. McNemar's test for paired categorical data was performed. Results: One hundred percent concordance in 78 pairs for ABO and Rh. Seventy-four pairs were tested for antibodies, 72 were both negative, 1 was both positive, and 1 gave discordant result. Ninety-nine percent concordance, p = 0.999. Sixty-five pairs were both DAT negative, seven were both DAT positive, and six gave discordant results. Ninety-two percent concordance, p = 0.68. Placental blood gave identical results comparing tube with gel methods. Conclusions: Placental blood is suitable for pre-transfusion testing and can replace heel sticks. Placental blood tube and gel methods are validated.

Non-nutritive sucking, oral breast milk, and facilitated tucking relieve preterm infant pain during heel-stick procedures: A prospective, randomized controlled trial.

BACKGROUND: Preterm infant pain can be relieved by combining non-nutritive sucking (sucking), oral sucrose, and facilitated tucking (tucking), but the pain-relief effects of oral expressed breast milk (breast milk) are ambiguous. AIMS: We compared the effects of combined sucking+ breast milk, sucking+breast milk+tucking, and routine care on preterm infant pain during and after heel-stick procedures. DESIGN: A prospective, randomized controlled trial. SETTINGS: Level III neonatal intensive care unit and a neonatal unit at a medical center in Taipei. PARTICIPANTS/SUBJECTS: Preterm infants (N=109, gestational age 29-37 weeks, stable disease condition) needing procedural heel sticks were recruited by convenience sampling and randomly assigned to three treatment conditions: routine care, sucking+ breast milk, and sucking+breast milk+ tucking. METHODS: Pain was measured by watching video recordings of infants undergoing heel-stick procedures and scoring pain at 1-min intervals with the Premature Infant Pain Profile. Data were collected over eight phases: baseline (phase 1, 10min without stimuli before heel stick), during heel stick (phases 2 and 3), and a 10-min recovery (phases 4-8). RESULTS: For infants receiving sucking+ breast milk, pain-score changes from baseline across phases 2-8 were 2.634, 4.303, 2.812, 2.271, 1.465, 0.704, and 1.452 units lower than corresponding pain-score changes of infants receiving routine care (all p-values <0.05 except for phases 6 and 7). Similarly, for infants receiving sucking +breast milk+ tucking, pain-score changes from baseline were 2.652, 3.644, 1.686, 1.770, 1.409, 1.165, and 2.210 units lower than corresponding pain-score changes in infants receiving routine care across phases 2-8 (all p-values <0.05 except for phase 4). After receiving sucking +breast milk +tucking and sucking +breast milk, infants' risk of mild pain (pain score ≥6) significantly decreased 67.0% and 70.1%, respectively, compared to infants receiving routine care. After receiving sucking +breast milk +tucking and sucking +breast milk, infants' risk of moderate-to-severe pain (pain score ≥12) decreased 87.4% and 95.7%, respectively, compared to infants receiving routine care. CONCLUSION: The combined use of sucking+breast milk +tucking and sucking+breast milk effectively reduced preterm infants' mild pain and moderate-to-severe pain during heel-stick procedures. Adding facilitated tucking helped infants recover from pain across eight phases of heel-stick procedures. Our findings advance knowledge on the effects of combining expressed breast milk, sucking, and tucking on preterm infants' procedural pain.