Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors.

BACKGROUND: Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered. OBJECTIVES: We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN. METHODS: We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14 days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models. RESULTS: Premature birth (b = -0.721), caffeine (b = -0.302), and the behavioural states quiet and awake (b = -0.283), active and asleep (b = -0.158), and quiet and asleep (b = -0.498) were associated with changes in behavioural pain scores. Premature birth (b = -0.232), mechanical ventilation (b = -0.196), and duration of the heel stick procedure (b = 0.0004) were associated with changes in physiological pain scores. Premature birth (b = -0.907), Caffeine (b = -0.402), the behavioural states quiet and awake (b = -0.274), and quiet and asleep (b = -0.459), and duration of the heel stick procedure (b = 0.001) were associated with changes in the modified BPSN total scores. CONCLUSIONS: Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs. SIGNIFICANCE: We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.

Patterns of paediatric end-of-life care: a chart review across different care settings in Switzerland.

BACKGROUND: Paediatric end-of-life care is challenging and requires a high level of professional expertise. It is important that healthcare teams have a thorough understanding of paediatric subspecialties and related knowledge of disease-specific aspects of paediatric end-of-life care. The aim of this study was to comprehensively describe, explore and compare current practices in paediatric end-of-life care in four distinct diagnostic groups across healthcare settings including all relevant levels of healthcare providers in Switzerland. METHODS: In this nationwide retrospective chart review study, data from paediatric patients who died in the years 2011 or 2012 due to a cardiac, neurological or oncological condition, or during the neonatal period were collected in 13 hospitals, two long-term institutions and 10 community-based healthcare service providers throughout Switzerland. RESULTS: Ninety-three (62%) of the 149 reviewed patients died in intensive care units, 78 (84%) of them following withdrawal of life-sustaining treatment. Reliance on invasive medical interventions was prevalent, and the use of medication was high, with a median count of 12 different drugs during the last week of life. Patients experienced an average number of 6.42 symptoms. The prevalence of various types of symptoms differed significantly among the four diagnostic groups. Overall, our study patients stayed in the hospital for a median of six days during their last four weeks of life. Seventy-two patients (48%) stayed at home for at least one day and only half of those received community-based healthcare. CONCLUSIONS: The study provides a wide-ranging overview of current end-of-life care practices in a real-life setting of different healthcare providers. The inclusion of patients with all major diagnoses leading to disease- and prematurity-related childhood deaths, as well as comparisons across the diagnostic groups, provides additional insight and understanding for healthcare professionals. The provision of specialised palliative and end-of-life care services in Switzerland, including the capacity of community healthcare services, need to be expanded to meet the specific needs of seriously ill children and their families.

[Skin care and skin protection in preterm babies]. / Hautpflege und Hautschutz beim unreifen Frühgeborenen. Eine systematische Literaturübersicht.

UNLABELLED: The skin of preterm infants is anatomically and physiologically premature. This quality of the skin as well as the need for intensive monitoring and treatment/care represent additional stress factors for the integrity of the babies' skin. The babies have an increased vulnerability and risk of skin injuries. Therefore, during the first two to three weeks of life observation of the premature skin is of utmost importance. Ritualistic activities have to be questioned. This is particularly true for infants who are born before 28 weeks of pregnancy. This systematic literature review investigates the effectiveness of nursing interventions in the skin care and protection of the premature infants born earlier than the 32nd week of pregnancy. A systematic literature-search in different databases addressed the following topics: Skin-assessment, selection and use of adhesives, skin care with emollients, and body cleaning (wash interval). Despite certain methodological problems with some of the studies included in this review the following results can be formulated: Based on altered infant behaviour and the skin's continuously high population of germs the interval of bathing should be enhanced to four days. During the first two to four weeks of life the application of sun flower oil is recommended. It has a disinfecting effect and is relatively cheap. Potential preventive or protective dressings of the skin are recommended. Similarly both the utilisation of a valid skin assessment instrument and of preventive measures are inevitable. CONCLUSION: Evidence-based knowledge of the needs and care of premature skin could reduce complications during the neonatal phase and therefore health care costs. The implementation of a standardised, evidence-based skin care guideline could raise the health professionals' awareness in of skin care needs in this vulnerable patient group.

Routine procedures in NICUs: factors influencing pain assessment and ranking by pain intensity.

BACKGROUND: Pain associated with routine procedures in NICUs is often inadequately managed. Barriers to more appropriate pain management are nurses' and physicians' knowledge and the challenges of collaborative decision-making. Few studies describe the differing perceptions of procedural pain intensity among nurses and physicians in NICUs which could complicate common decision-making. This study set out to explore the factors influencing pain intensity assessment and to gain insight into a possible pain intensity classification of routine procedures in the NICU. METHOD: A survey was conducted among 431 neonatal health care professionals from 4 tertiary level NICUs. Each routine procedure was assessed on a 10-point visual analogue scale (VAS) assuming absence of analgesia. RESULTS: Multiple ANCOVA models showed that nurses rated 19 of the 27 procedures as significantly more painful than did physicians (p<0.05). We found no differences in pain assessment based on professional experience, gender or age. Of the 27 procedures listed, 70% were rated as painful and 44% were judged very painful. Ranking and classification of the pain intensity of routine procedures were drawn up. The general ranking of the median across all procedures shows that "insertion of a thoracic drain" is assessed as the most painful procedure. CONCLUSIONS: The majority of routine procedures in an NICU are considered to be painful. Nurses generally rate procedures as more painful than do physicians. This difference in assessment deserves exploration in regard to its impact on collaborative decision-making in neonate pain management.

The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systematic literature review.

BACKGROUND: Neonates in a neonatal intensive care unit are exposed to a high number of painful procedures. Since repeated and sustained pain can have consequences for the neurological and behaviour-oriented development of the newborn, the greatest attention needs to be paid to systematic pain management in neonatology. Non-pharmacological treatment methods are being increasingly discussed with regard to pain prevention and relief either alone or in combination with pharmacological treatment. AIMS: To identify effective non-pharmacological interventions with regard to procedural pain in neonates. METHODS: A literature search was conducted via the MedLine, CINAHL, Cochrane Library databases and complemented by a handsearch. The literature search covered the period from 1984 to 2004. Data were extracted according to pre-defined criteria by two independent reviewers and methodological quality was assessed. RESULTS: 13 randomised controlled studies and two meta-analyses were taken into consideration with regard to the question of current nursing practice of non-pharmacological pain management methods. The selected interventions were "non-nutritive sucking", "music", "swaddling", "positioning", "olfactory and multisensorial stimulation", "kangaroo care" and "maternal touch". There is evidence that the methods of "non-nutritive sucking", "swaddling" and "facilitated tucking" do have a pain-alleviating effect on neonates. CONCLUSIONS: Some of the non-pharmacological interventions have an evident favourable effect on pulse rate, respiration and oxygen saturation, on the reduction of motor activity, and on the excitation states after invasive measures. However, unambiguous evidence of this still remains to be presented. Further research should emphasise the use of validated pain assessment instruments for the evaluation of the pain-alleviating effect of non-pharmacological interventions.

[The efficacy of non-pharmacological interventions in the management of pain in preterm and term neonates. A systematic literature review]. / Die Effektivität nicht-medikamentöser Interventionen in der Schmerzbehandlung von Früh- und Termingeborenen. Eine systematische Literaturübersicht.

Many diagnostic and therapeutic procedures performed in the neonatal intensive care unit are painful for the preterm or term infant. Pain is therefore a central issue in neonatal intensive care nursing. As significant side effects are associated with analgesics, non-pharmacological methods of pain prevention and relief are being favoured over pharmacological therapy. This development is very important for the nursing profession since non-pharmacological interventions are determined and carried out without an order from a physician. This review of the current literature investigates the efficacy of non-pharmacological nursing interventions in the management of pain in the neonatal intensive care unit. Despite certain methodological problems with some of the studies included in this review, the trend favours non-pharmacological interventions. Modulation of arousal and excitability during and after a painful stimulus as well as an effect on physiological and behavioural parameters have been described following non-pharmacological interventions. The studies reviewed suggest that neonates show fewer signs of pain and stress after non-pharmacological interventions for prevention and relief of pain.