Non-pharmacological management of infant and young child procedural pain.

BACKGROUND: Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title. OBJECTIVES: To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music. SEARCH METHODS: For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements. AUTHORS' CONCLUSIONS: Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Effectiveness of technology-based interventions compared with other non-pharmacological interventions for relieving procedural pain in hospitalized neonates: a systematic review.

OBJECTIVE: The objective of this review was to evaluate the effectiveness of technology-based interventions for relieving procedural pain among hospitalized neonates compared with other non-pharmacological interventions. INTRODUCTION: Neonates who require hospital care often experience acute pain during medical procedures. The current best practice for relieving pain in neonates is the use of non-pharmacological interventions, such as oral solutions or intervention-based human touch. Technological solutions (eg, games, eHealth applications, mechanical vibrators) have become more commonplace in pediatric pain management over recent years; however, there is a sizeable knowledge gap around how effective technology-based interventions are for relieving pain in neonates. INCLUSION CRITERIA: This review considered experimental trials that include technology-based, non-pharmacological interventions for relieving procedural pain among hospitalized neonates. The primary outcomes of interest include pain response to a procedure measured by a pain assessment scale validated for neonates, behavioral indicators, and changes in physiological indicators. METHODS: The search strategy aimed to identify both published and unpublished studies. MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Cochrane Central Register of Controlled Trials, MedNar, and EBSCO Open Dissertations databases were searched for studies published in English, Finnish, or Swedish. Critical appraisal and data extraction were conducted by 2 independent researchers who adhered to JBI methodology. Meta-analysis could not be performed due to considerable heterogeneity in the studies; as a result, the findings are presented narratively. RESULTS: A total of 10 randomized controlled trials involving 618 children were included in the review. The staff members delivering the interventions and the outcome assessors were not blinded in all of the studies, which introduced a potential risk of bias. The presented technology-based interventions were diverse, including laser acupuncture, noninvasive electrical stimulation of acupuncture points, robot platform, vibratory stimulation, recorded maternal voice, and recorded intrauterine voice. In the studies, pain was measured using validated pain scales, behavioral indicators, and physiological variables. In the studies in which pain was assessed with a validated pain measure (N=8), technology-based pain relief was significantly more effective than the comparator in 2 studies, whereas no statistically significant differences were observed in 4 studies and the technology-based intervention was less effective than the comparator in 2 studies. CONCLUSIONS: The effectiveness of technology-based interventions in relieving neonatal pain, either as a standalone method or in combination with another non-pharmacological method, was mixed. Further research is needed to provide reliable evidence on which technology-based, non-pharmacological pain relief intervention is most effective for hospitalized neonates. SUPPLEMENTAL DIGITAL CONTENT: A Finnish-language version of the abstract of this review is available as supplemental digital content [ http://links.lww.com/SRX/A19 ]. REVIEW REGISTRATION: PROSPERO CRD42021254218.

Virtually Augmented Self-Hypnosis in Peripheral Vascular Intervention: A Randomized Controlled Trial.

PURPOSE: Hypnosis is useful for diminishing distress during medical procedures. This study investigated the efficacy of virtually augmented self-hypnosis as an adjunctive non-pharmacological method for procedural pain and anxiety relief during endovascular interventions (EVI). METHODS: We compared an immersive distraction experience (clinicaltrials.gov identifier NCT04561596) featuring virtual reality (VR) using a head-mounted display versus treatment as usual (TAU). Patients followed the "Aqua" module (Oncomfort™) consisting of a scuba dive and breathing exercises. They experienced a self-induced dissociative state similar to clinical hypnosis without direct intervention of a professional. Enrollment followed a 1:1 randomized open study (VR or TAU). Patients' feelings were evaluated just before and after the procedure, and 3 months following intervention. Anxiety was evaluated using the State Trait Anxiety Inventory (STAI) and pain (sensory, emotional, and memory) with a visual analogue scale (VAS). RESULTS: This study included 100 patients. Mean anxiety (pre-post) was significantly reduced within groups and between groups (difference of 4.2 points, p = 0.016). The percentage of responders to anxiety lowering were 76 and 46% for VR and TAU, respectively (p = 0.004). The two groups did not significantly differ in mean sensory-intensity and affective emotional pain (pre-post) using VAS, in negative memories concerning remembered pain at 3 months (difference > 1 from immediate post-procedural reported pain intensity), mean procedural time, or the need for analgesic or sedative drugs. CONCLUSIONS: VR self-hypnosis has the potential to improve the management of patients' distress during radiological procedures. It is safe and effective for reducing anxiety during EVI.

Clinical Hypnosis for Procedural Pain and Distress in Children: A Scoping Review.

OBJECTIVE: Pain and distress are common in children undergoing medical procedures, exposing them to acute and chronic biopsychosocial impairments if inadequately treated. Clinical hypnosis has emerged as a potentially beneficial treatment for children's procedural pain and distress due to evidence of effectiveness and potential superiority to other psychological interventions. However, systematic reviews of clinical hypnosis for children's procedural pain and distress have been predominantly conducted in children undergoing oncology and needle procedures and are lacking in broader pediatric contexts. This scoping review maps the evidence of clinical hypnosis for children's procedural pain and distress across broad pediatric contexts while highlighting knowledge gaps and areas requiring further investigation. METHODS: Published databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus, and Web of Science) and grey literature were searched in addition to hand-searching reference lists and key journals (up to May 2022). Two independent reviewers screened the titles and abstracts of search results followed by a full-text review against eligibility criteria. Articles were included if they involved a clinical hypnosis intervention comprising an induction followed by therapeutic suggestions for pain and distress in children undergoing medical procedures. This review followed the Arksey and O'Malley (2005) methodology and incorporated additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: A total of 38 eligible studies involving 2,205 children were included after 4,775 articles were screened. Research on clinical hypnosis for children's procedural pain and distress was marked by a lack of fidelity measures and qualitative data as well as by inadequate intervention reporting and high attrition rates. Evidence regarding the safety of clinical hypnosis, pain unpleasantness outcomes, factors influencing outcomes, as well as barriers and facilitators to implementing hypnosis and study procedures was also lacking. Clinical hypnosis has potential benefits for children's procedural pain and distress based on evidence of superiority to control conditions and nonpharmacological interventions (e.g., distraction, acupressure) with moderate to large effect sizes as reported in 76% of studies. However, heterogeneous interventions, contexts, study designs, and populations were identified, and the certainty of the evidence was not evaluated. CONCLUSIONS: The review suggests potential benefits of clinical hypnosis for children's procedural pain and distress and thus provides a precursor for further systematic reviews and trials investigating the effectiveness of clinical hypnosis. The review also indicates the need to further explore the feasibility, acceptability, implementation, and safety of clinical hypnosis in children undergoing painful procedures. Based on the review, researchers implementing clinical hypnosis should adequately report interventions or use treatment manuals, follow recommended research guidelines, and assess the fidelity of intervention delivery to promote replicating and comparing interventions. The review also highlights common methodological shortcomings of published trials to avoid, such as the lack of implementation frameworks, small sample sizes, inadequate reporting of standard care or control conditions, and limited evidence on pain unpleasantness outcomes.

The effectiveness of massage interventions on procedural pain in neonates: A systematic review and meta-analysis.

BACKGROUND: The painful procedures experienced by neonates during hospitalization have short-term or long-term effects on neonates. While the limitations of previous interventions make it imperative to explore effective interventions that are readily available. This systematic review and meta-analysis was conducted to evaluate the safety and effectiveness of massage for pain management in neonates. METHODS: This systematic review was registered in PROSPER. PubMed, Embase, Cochrane Library, and the Clinical Trials Registry were searched to December 2021. Two reviewers independently carried out study selection, data extraction, bias risk assessment. Continuous data were analyzed by mean differences (MD). Dichotomous data were reported using relative risk. If at least two studies reported identical results by the same pain assessment tool, a meta-analysis was conducted using random effect model and inverse variance. RESULTS: Total 11 included studies involving 755 neonates investigated the effects of massage on neonatal pain response compared to standard care. The meta-analysis showed that massage could effectively improve pain response in neonates compared to standard care no matter whether neonatal infant pain scale (NIPS) or premature infant pain profile (PIPP) was used as an assessment tool. Besides, massage was also effective for crying duration, blood oxygen saturation both during and after the procedure, but non-effective for the variation of respiratory rate after the procedure, and heart rate both during and after the procedure. CONCLUSIONS: Massage may have a positive effect on pain relief of neonate, and rigorous trials are needed in the future to determine the most effective massage method.

Virtually Augmented Self-Hypnosis applied to endovascular interventions (VA-HYPO): Randomized Controlled Trial Protocol.

Endovascular interventions (EVI) are increasingly performed as minimally-invasive alternatives to surgery and have many advantages, including a decreased need for general anesthesia. However, EVI can be stressful for patients and often lead to anxiety and pain related to the procedure. The use of local anesthetics, anxiolytics, and analgesic drugs can help avoid general anesthesia. Nevertheless, these drugs have potential side effects. Alternative nonpharmacological therapies can improve patients' experience during conscious interventions and reduce the need for additional medications. The added value of virtually augmented self-hypnosis (VA-HYPO) and its potential to reduce pain and anxiety during peripheral and visceral arterial and venous EVI is unknown. This is a prospective two-arm trial designed to randomize 100 patients in two groups according to the use or not of VA-HYPO during peripheral EVI as a complementary nonpharmacological technique to improve patient comfort. The main objective is to compare per-procedural anxiety, and the secondary aim is to compare the rated per-procedural pain in both groups. The potential significance is that VA-HYPO may improve patients' experience during peripheral and visceral arterial and venous EVI and other minimally invasive interventions performed under local anesthesia. Trial registration: Our study is registered on clinicaltrials.gov, with trial registration number: NCT04561596.

Music Therapy in Dialysis Access Procedures With Moderate Sedation.

BACKGROUND: The aim was to evaluate the effects of music on patients' anxiety and satisfaction after undergoing dialysis access procedures under moderate sedation. METHODS: Patients (n = 30) undergoing moderate sedation for dialysis access procedures were evaluated at a single institution. Each patient filled out a survey preoperatively and postoperatively using the short form State-Trait Anxiety Inventory (STAI-6). Patient-selected music was provided by using a MP3 player with noise canceling headphones. RESULTS: Postoperatively, 77% of patients perceived music intervention as very or extremely helpful in decreasing anxiety during the procedure. Further, 93% of patients were somewhat or very satisfied with their procedure. The average pain rating was 3.1 on a scale of 0-10, in which 70% of patients had no to mild pain and 30% of patients rated moderate to severe pain. In comparison to prior procedures without music, 63% of patients rated better experience with the music intervention, 37% rated a similar experience, and 3.7% rated having a worse experience. Approximately, 93% of patients were willing to repeat procedure with music and would recommend it to other patients. Preoperative anxiety average score was 35.6 ± 13 and was reduced postoperatively to 28.9 ± 12.9 (P = .006). Preoperatively, 23% of patients rated high anxiety and postoperatively only 6.7% of patients rated high anxiety (P = .016). CONCLUSION: Music is an easy, feasible, inexpensive intervention that may reduce patients' anxiety and improve satisfaction during moderate sedation procedures and in the postoperative period.

Techniques to Relieve Pain Associated With Botulinum Injections for Palmar and Plantar Hyperhidrosis.

BACKGROUND: Palmar and plantar hyperhidrosis (HH) is a common condition characterized by excessive sweating of the palms and soles. Botulinum neurotoxin (BTX) is a very effective and safe treatment. However, the associated intense injection pain is a major limiting factor deterring patients from selecting this treatment. OBJECTIVE: The aim of this study was to review the numerous techniques used to minimize pain accompanying injections for palmoplantar HH. Additionally, the advantages and limitations of each modality will be discussed. MATERIALS AND METHODS: The authors performed a comprehensive literature search in PubMed/MEDLINE, Embase, Cochrane Central, and Google Scholar on randomized controlled trials, cohort studies, and case series on techniques to relieve pain of BTX injections for treatment of palmar and plantar HH. RESULTS: Current available techniques in reducing botulinum injection with merits and drawbacks are nerve blocks, Bier blocks, cryoanalgesia, needle-free anesthesia, topical anesthetics, and vibration anesthesia. CONCLUSION: Topical anesthesia, ice, and vibration are the safest and most convenient noninvasive available methods to relieve pain associated with botulinum injection. Nerve blocks, Bier block, and needle-free anesthesia provide better anesthesia but are limited by the need for training and equipment.

A Randomized Controlled Trial of Virtual Reality in Awake Minor Pediatric Plastic Surgery Procedures.

BACKGROUND: Virtual reality has been used to alleviate pain and anxiety in a variety of medical procedures. The authors sought to explore the effects of virtual reality in common awake minor plastic surgery procedures where children may experience discomfort. METHODS: A randomized controlled trial compared virtual reality to standard-of-care distraction among children aged 6 to 16 years undergoing awake minor plastic surgery procedures at a quaternary children's hospital. Primary outcome was change in Faces Pain Scale-Revised pain score, and secondary outcomes included change in Venham Situational Anxiety Scale score, procedure duration, administration of local anesthetic, and pain/anxiety management satisfaction. RESULTS: Mean pain and anxiety scores were similar in both groups (p = 0.60 and p = 0.18, respectively), and procedure duration was shorter with virtual reality (22 minutes versus 29 minutes; p = 0.002). Duration remained shorter in a linear regression model accounting for procedure type (p = 0.01). Similar proportions of children received additional local anesthetic after the initial dose (virtual reality, n = 6; standard of care, n = 9; p = 0.19) and median pain management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.41). Median anxiety management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.05). Younger children reported more "fun" than older children with virtual reality (p = 0.02). Surgeons reported interest "using virtual reality again" in 83 percent of cases. CONCLUSIONS: The use of virtual reality for awake pediatric plastic surgery reduced procedure time but not pain or anxiety compared to standard of care in children aged 6 to 16 years. Virtual reality was safe and well-liked and should be considered as an additional tool. Increased efficiency may allow more cases to be performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Effectiveness of technology-based interventions compared with other non-pharmacological interventions for relieving procedural pain in hospitalized neonates: a systematic review protocol.

OBJECTIVE: The objective of this review is to evaluate the effectiveness of technology-based interventions in relieving procedural pain in hospitalized neonates compared with other non-pharmacological interventions. INTRODUCTION: Neonates requiring hospital care often experience acute pain during medical procedures. The current best practice for relieving pain in neonates is the use of non-pharmacological interventions, such as oral solutions or intervention-based human touch. Technological solutions (such as games, eHealth applications, and mechanical vibrators) have become more commonplace in pediatric pain management over recent years. However, there is a knowledge gap about how effective technology-based interventions are at relieving pain in neonates. INCLUSION CRITERIA: This review will consider experimental trials that include technology-based non-pharmacological interventions for relieving procedural pain in hospitalized neonates. Primary outcomes of interest include pain response to a procedure measured by a validated pain assessment scale for neonates, behavioral indicators, and/or changes in physiological indicators. METHODS: MEDLINE (Ovid), CINAHL (EBSCO), Scopus (Elsevier), Cochrane Central Register of Controlled Trials, and the MEDIC databases will be searched for studies published in English, Finnish, and Swedish. Critical appraisal and data extraction will be conducted by two independent researchers following JBI methodology. Quantitative data will be pooled in statistical meta-analyses. If statistical analysis is not possible, the findings will be reported narratively. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021254218.

Skin Closure Technique and Postprocedural Pain after Spinal Cord Stimulator Implantation: A Retrospective Review.

Spinal cord and dorsal root ganglion stimulation are minimally invasive surgical techniques used to treat an array of chronic pain disorders. There is a paucity of data related to defining best practices in these specific patient populations, and historically, providers have relied on consensus committees to opine on the best techniques for patient safety and experience. The most efficacious mechanism of surgical closure-specifically a running suture closure compared to a surgical staple closure-is debated. A retrospective review of 155 patients implanted with either a spinal cord or dorsal root ganglion stimulator between 2017 and 2019 was undertaken to determine if the type of surgical closure was related to degree of postoperative surgical site discomfort. The primary outcome showed no statistically significant difference on postoperative pain scores between the suture (6.0 (IQR 5.0-8.0)) and staple (7.0 (IQR 5.0-8.0)) cohorts at postoperative day (POD) #1 (adjusted ß 0.17 (95% CI -0.61 to 0.95), P=0.670). This finding held for postoperative pain scores at POD #10 as well (staples (1.0 (IQR 0.0-4.0)) and suture (2.0 (IQR 0.0-5.0), adjusted ß -0.39 (95% CI -1.35 to 0.58), P=0.432)). A regression analysis was performed to identify secondary factors impacting postoperative pain scores. Higher preoperative pain score (ß 0.50 (95% CI 0.09 to 0.92), P=0.019) and female gender (ß 1.09 (95% CI 0.15 to 2.02), P=0.023) were predictive of higher incisional pain scores at POD#10. Increasing age was associated with decreased incisional pain scores at POD#10 (ß -0.06 (95% CI -0.09 to -0.03), P < 0.001). These findings are of interest to the pain practitioner and may be valuable in preoperative discussions with prospective patients.

Interest of a standardized hypnotic message for the reduction of pain and anxiety in cancer patients treated by capsaicin patch for neuropathic pain: a randomized controlled trial.

BACKGROUND: Neuropathic pain is characterized by spontaneous painful symptoms. Medical therapies include the use of a capsaicin 8% patch (Qutenza®, Grünenthal Gmbh, Germany), and patients may experience a sharp burning sensation at application and removal of the patch. This study aimed to evaluate the impact of playing a standardized hypnosis recording during application, on the pain and anxiety induced by capsaicin treatment. METHODS: In a randomized, controlled trial, we assessed the benefits of the intervention firstly on pain and secondly on anxiety, as measured using numerical rating scales. All patients had application of the capsaicin patch, including the possibility for the patient to apply a cold patch. Participants were randomly assigned to one of 3 groups, namely the "Standard group" (no intervention), "Hypnosis group", in which a standardized hypnotic message was played during application, or the "Music group" in which relaxing music was played during application of the patch. RESULTS: Sixty-nine patients were included. Overall, there was no significant difference in pain scores between groups (p = 0.355). Compared to standard application, anxiety was significantly lower in the hypnosis group after application (p = 0.007), with no significant difference between the standard and music arms (p = 0.271), or between the hypnosis and music arms (p = 0.423). CONCLUSIONS: Listening to a standardized hypnotic message during application of a capsaicin patch was found to significantly lower anxiety. These findings indicate that the use of a hypnotic message can reduce discomfort and warrant its evaluation in other indications of pain or anxiety during treatment procedures. TRIAL REGISTRATION: NCT02822625 .

Massage therapy as a non-pharmacological analgesia for procedural pain in neonates: A scoping review.

INTRODUCTION: Neonates who undergo painful medical procedures should be given analgesics to reduce future adverse risks. The evidence for massage therapy (MT) as an analgesic method still varies, both in its terminology and implementation. Only a few studies on this topic have been conducted using a standardised trial approach. This review can thus become the basis for better future research. OBJECTIVE: This review aims to identify literature on MT practices as a method to manage or control pain in neonates undergoing painful procedures. METHODS: The methodology for this review followed the JBI scoping review methodology guidelines. Searches were performed in several databases: MEDLINE (PubMed), CINAHL (EBSCO), Scopus (Elsevier) and EMBASE. Data collected were then extracted by two independent reviewers, synthesised and presented in the form of tables and narratives. RESULTS: Fifteen studies involving a total of 1,058 neonates in nine countries were identified in the search as meeting the criteria set for this review. One study was a comparative study, five were quasi-experiment studies and nine were randomised control trials (RCT). CONCLUSION: The implementation of massage as a non-pharmacological analgesic method for neonates undergoing painful procedures varied among the reviewed studies. Differences were identified in terms of the body part massaged, the duration and intensity of the massage, the level of pressure and the combination of massage with other methods. All studies presented positive results for reducing pain intensity in neonates undergoing procedural pain. Therefore, it is crucial that the method used for giving massage should be practical, accurate and safe.

Effect of acupressure on procedural pain before heel lancing in neonates.

OBJECTIVE: To investigate the effect of acupressure applied to UB60 and K3 acupuncture points in order to relieve the procedural pain caused by heel lancing blood sampling process in the term newborns. METHODS: The data were collected by using the Information Form and the Neonatal Infant Pain Scale. Acupressure applied for 3 min before heel lancing blood sampling in the newborns in the experimental group (n = 31). No intervention was applied to newborns in the control group (n = 32). RESULTS: A significant difference was found between mean scores of the newborns in the control and acupressure group in favor of the acupressure group in terms of heart rate during and after the procedure, oxygen saturation before, during and after the procedure, duration of crying during and after the procedure (P < 0.05). It was found that there was a significant difference between groups in terms of Neonatal Infant Pain Scale mean scores during (P = 0.001) and after the procedure (P < 0.05), and the difference was found to be in favor of the acupressure group. CONCLUSION: As a result, acupressure was found to be an effective method in relieving pain caused by heel lancing blood sampling in newborns.

Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era.

OBJECTIVE: Since minimally invasive surgery and general anesthesia are both aerosol-generating procedures, their use became controversial during the outbreak of coronavirus disease 2019 (COVID-19). Moreover, social distancing resulted in serious psychological consequences for inpatients. This case report investigates pain distraction during awake laparotomy, as well as new possibilities for emotional postoperative support to inpatients. PATIENTS AND METHODS: A 72-year-old man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total mesorectal excision under combined spinal-epidural anesthesia. A 3D mobile theatre (3DMT) was intraoperatively used for pain distraction. A postoperative "Cuddle delivery" service was instituted: video-messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were investigated through a clinical interview by the psychologist of our Hospital. RESULTS: Intraoperative, as well as postoperative pain, resulted well-controlled: visual analogue scale (VAS) ≤3. Conversion to general anesthesia and postoperative intensive support/monitoring were unnecessary. The "Cuddle delivery" initiative positively fed our patient's mood and attitude, strengthening his bond to life. CONCLUSIONS: During pandemic, awake laparotomy under loco-regional anesthesia may be a crucial option in delivering acute care surgery to selected patients when intensive care beds are unavailable. Our procedure introduces potential ways to optimize this approach.

Management of Procedural Pain in Children.

In recent years, there has been increased interest in the study of pain in children and its treatment. It is known that when facing diagnostic and therapeutic procedures similar to those performed on adults, children either do not receive specific pain treatment or receive it on a significantly lower scale. However, recent research suggests a change in attitude and an improvement in the current treatment of children's pain. Although current knowledge demonstrates the falsity of many preconceived ideas about pain and its management, our results suggest that attitudinal change towards childhood pain remains slow and that real improvement in the training and practical application of the pediatrician who has to treat childhood pain is urgently needed. In this context, this manuscript has prepared standards and guidelines to improve pain management practices in a large number of national and international professional settings.

Improving the discomfort and satisfaction of colonoscopy by distraction with smartphones: A prospective randomized controlled study.

BACKGROUND: Colonoscopy is an uncomfortable procedure. Distraction is thought to reduce pain by decreasing the amount of attention a person spends on a painful stimulus. We aimed to assess the usefulness of smartphones on discomfort associated with the colonoscopy. METHODS: We designated 360 enrolled patients according to prospective randomized controlled study into two groups, including smartphone (SP) group (Relaxation by smartphones) and Control group (No relaxation). Measured outcomes included the discomfort, satisfaction, polyp detection rate and the willingness to repeat colonoscopy were analyzed between groups. RESULTS: The pain and distension scores of SP group patients were significantly lower than those of the Control group (2.18 ±â€Š2.80 vs 3.55 ±â€Š3.07, P < .001; 4.15 ±â€Š2.35 vs 4.79 ±â€Š2.36, P = .011, respectively). Importantly, patient-reported satisfaction scores of the SP group were significantly higher than those of the Control group (96.45 ±â€Š7.17 vs 91.12 ±â€Š10.49, respectively; P < .001). Moreover, although there were no statistical differences, patients using smartphones were more likely to have shorter reach cecum times (09m:11 s vs 07m:37 s, P = .116) and more polyp detection rate (13.3% vs 9.4%, P = .246). In addition, more patients using smartphones were willing to repeat colonoscopy but no statistical difference (85.0% vs 81.7%, P = .396). CONCLUSION: Patient using smartphone is a special manner to increase satisfaction during colonoscopy with a less discomfort and is more likely to be polyp detection rate.

Impact of music on anxiety and pain control during extracorporeal shockwave lithotripsy: A protocol for systematic review and meta-analysis.

BACKGROUND: The present evidence is insufficient for evaluating the impact of exclusive music therapy on anxiety and pain control in extracorporeal shock wave lithotripsy (ESWL). METHODS: A systematic review and meta-analysis was conducted to explore the efficacy of music therapy in reducing pain and anxiety in patients undergoing ESWL. PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases (updated March 2020) were searched for randomized controlled trials assessing music therapy in reducing pain and anxiety in patients undergoing ESWL. The search strategy and study selection process were managed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. RESULTS: Five randomized controlled trials were included in the meta-analysis. Overall, music intervention groups experienced significant reductions in pain (risk ratios = -1.20, 95% confidence intervals = -1.95 to -0.45, P = .002) and anxiety (risk ratios = -3.31, 95% confidence intervals = -4.97 to -1.84, P < .0001) compared with control groups during ESWL. Music therapy gave patient more satisfaction with the treatment and a willingness to repeat the therapy was reported. However, there was no significant difference in the stone clearance rate. CONCLUSIONS: Listening to music can reduce patient's pain and anxiety significantly with increased therapy satisfaction and willingness to repeat.

Recent Applications of Virtual Reality for the Management of Pain in Burn and Pediatric Patients.

PURPOSE OF REVIEW: Virtual reality, via integration of immersive visual and auditory modalities, offers an innovative approach to pain management. The purpose of this review is to investigate the clinical application of virutal reality as an adjunct analgesic to standard of care, particularly in pediatric and burn patients. RECENT FINDINGS: Although relatively new, virtual reality has been successfully implemented in a wide range of clinical scenarios for educational, diagnostic, and therapeutic purposes. Most recent literature supports the use of this adjunct analgesic in reducing pain intensity for pediatric and burn patients undergoing acute, painful procedures. This summative review demonstrates the efficacy of virtual reality in altering pain perception by decreasing pain and increasing functionality among pediatric and burn patients. However, large, multi-center randomized controlled trials are still warranted to generalize these findings to more diverse patient demographics and medical scenarios.

Effect of combined pharmacological, behavioral, and physical interventions for procedural pain on salivary cortisol and neurobehavioral development in preterm infants: a randomized controlled trial.

Repeated procedural pain may lead to increased secretion of cortisol and future neurobehavioral development disorders in preterm infants. Changes in the cortisol level may mediate the effect of neonatal repetitive procedural pain on altered childhood neurobehavioral development in preterm infants. However, few studies have investigated the effect of combined pharmacological, behavioral, and physical interventions over repeated painful procedures on pain response, cortisol level, and neurobehavioral development. This study examined (1) the efficacy and safety of sucrose combined with massage, music, non-nutritive sucking, and gentle human touch to treat preterm infants with repeated procedural pain; (2) the cortisol level at discharge from the neonatal intensive care unit (NICU); (3) neurobehavioral development at 40 weeks' corrected gestational age; and (4) the potential mediating effect of the cortisol level in the combined interventions on neurobehavioral development. Stable preterm infants (n = 76) were randomized to receive routine care or combined interventions across repeated painful procedures throughout their NICU stay. The Premature Infant Pain Profile scores in the early, middle, and late periods of the NICU stay were measured, as were the basal salivary cortisol level at admission and discharge, the Neonatal Behavioral Neurological Assessment score at 40 weeks' corrected gestational age, and the incidence of adverse effects during the study period. Our findings indicated that the combined interventions remained efficacious and safe for reducing repeated procedural pain, decreased the cortisol level at discharge, and promoted early neurobehavioral development in preterm infants. This effect may have been mediated through decreased cortisol levels and reduced repeated procedural pain.