Nonpharmacological Interventions to Mitigate Procedural Pain in the NICU: An Integrative Review.

Small infants experience a myriad of stimuli while in the Neonatal Intensive Care Unit (NICU), with many being painful or stressful experiences, although medically necessary. To determine what is known about nonpharmacological developmental care interventions used in the NICU to mitigate procedural pain of infants born under 32 weeks gestation. Five electronic databases were searched: Medline, CINAHL, Scopus, Embase and the Cochrane Library. The inclusion criteria were as follows: experimental and nonexperimental studies from all publication years with infants born at less than 32 weeks gestational age; peer-reviewed research articles studying nonpharmacological interventions such as skin-to-skin care, facilitated tucking, nonnutritive sucking, hand hugs, and swaddling; and English language articles. Our search yielded 1435 articles. After the elimination of 736 duplicates, a further 570 were deemed irrelevant based on their abstract/titles. Then, 124 full-text articles were analyzed with our inclusion and exclusion criteria. Twenty-seven studies were reviewed. Sucrose, facilitated tucking, pacifier, skin-to-skin care, and human milk appeared to lessen pain experienced during heel sticks, suctioning, nasogastric tube insertions, and echocardiograms. All nonpharmacological interventions failed to prove efficacious to adequately manage pain during retinopathy of prematurity (ROP) examinations. Evidence review demonstrates that healthcare practitioners should use nonpharmacological measures to help prevent pain from day-to-day procedures in the NICU including heel sticks, nasogastric tube insertions, suctioning, echocardiograms, and subcutaneous injections. Future research is necessary to better understand and measure how pain is manifested by very small premature infants. Specific research on mitigating the pain of examinations for retinopathy of prematurity is also needed.

Sutton R ，Lemermeyer G 《-》

Facilitated tucking to reduce pain in neonates: evidence for best practice.

Hartley KA ，Miller CS ，Gephart SM 《-》

The effect of expressed breast milk, swaddling and facilitated tucking methods in reducing the pain caused by orogastric tube insertion in preterm infants: A randomized controlled trial.

Orogastric tube feeding is used to support the nutrition of preterm infants. Although nonpharmacological methods are effective in reducing the pain caused by orogastric tube insertion, only limited studies have been found addressing this pain. No study has used combined nonpharmacological methods to reduce this orogastric tube insertion pain. This randomized controlled study aims to compare the effects of expressed breast milk, swaddling, facilitated tucking, expressed breast milk+swaddling, expressed breast milk+facilitated tucking and routine care methods on preterm infant pain and the physiological parameters (i.e., heart rate, oxygen saturation) before, during and after orogastric tube insertion procedures. Randomised controlled trial. Three level III neonatal intensive care units in Turkey. Preterm infants born at 32-34 weeks gestation were randomly assigned to six groups: routine care (n = 33), swaddling (n = 30), facilitated tucking (n = 32), expressed breast milk (n = 31), swaddling+expressed breast milk group (n = 30), and facilitated tucking+expressed breast milk group (n = 31). Orogastric tube insertion included four phases: baseline (the last one minute of 30 min without stimuli), the insertion, recovery (one minute after insertion), and recovery (two minutes after insertion). The four phases were videotaped. Premature infant pain profile score, heart rate and oxygen saturation were assessed by two independent evaluators who were blinded to the purpose of the study. Data were assessed by analysis of variance for the multiple repeated measurements, bonferroni and generalised estimating equation logistic regression. There was a significant main effect of the intervention groups for all the pain and physiological parameters (heart rate: F = 3.99, p = 0.001; oxygen saturation: F = 5.22, p<0.001; pain profile 1 score: F = 9.55, p<0.001; pain profile 2 score: F = 9.74, p<0.001). The use of the nonpharmacological methods combined or alone was more effective in reducing infants' pain profile score and physiological variables than routine care. Infants receiving swaddling+expressed breast milk had significantly lower pain profile scores during the insertion (phase2) (5.2 ± 1.7) than those receiving routine care (9.5 ± 3.6), swaddling (8.8 ± 2.9), facilitated tucking (7.2 ± 3.2), expressed breast milk (7.9 ± 2.6), facilitated tucking+expressed breast milk (6.6 ± 2.3) (p<0.001). The breast milk group had 6.195 times more pain than the swaddling+expressed breast milk, while the facilitated tucking group had 6.301, the facilitated tucking+expressed breast milk group had 3.107, the control group had 13.015, and the swaddling group had 7.892 times more pain. The swaddling+expressed breast milk method is clinically better pain relief nonpharmalogical option and is the recommended method to nurses for the orogastric tube insertion procedures, preterm infants.

Apaydin Cirik V ，Efe E 《-》

A Systematic Review of Behavioral and Environmental Interventions for Procedural Pain Management in Preterm Infants.

Current research suggests behavioral and environmental interventions to prevent neonatal pain prior to an invasive procedure are rarely administered and seldom documented. The aim of this study was to systematically review findings from published randomized controlled trials that tested the effects of behavioral and environmental procedural pain management interventions on behavioral pain response in preterm infants. Randomized controlled trials examining the effects of behavioral and environmental pain management interventions on behavioral pain response in preterm infants were identified. Articles accepted for inclusion met the following criteria: English language, original, peer refereed, randomized controlled clinical trials published within the past 5 years, study sample: preterm infants, setting: neonatal intensive care units, study intervention behavioral and environmental, outcome pain measurement score from valid and reliable pain scale. Fourteen randomized controlled trials from a literature search of PubMed and Medline databases were included in this review. Across all age groups, facilitated tucking, oral sucrose, and kangaroo care decreased behavioral and physiologic pain response alone and in combination with other behavioral and environmental interventions. Among preterm infants, facilitated tucking, oral sucrose, and kangaroo care significantly mitigates biobehavioral pain response associated with acutely painful procedures. Evidence suggests that behavioral and environmental interventions can decrease biobehavioral pain response associated with acutely painful procedures in preterm infants. This review highlights the need for rigorous studies to help healthcare providers to build a tailored pain treatment plan for preterm infants.

Hatfield LA ，Murphy N ，Karp K ，Polomano RC ... -  《-》

Development of atraumatic heel-stick procedures by combined treatment with non-nutritive sucking, oral sucrose, and facilitated tucking: a randomised, controlled trial.

Preterm infants manifest pain and stress by behavioural agitation and state change. Few studies have explored the effects of combining nonpharmacological interventions, i.e. non-nutritive sucking, oral sucrose, and facilitated tucking, on infants' behaviours across painful procedures. To explore the effects of combined use of three nonpharmacological interventions (non-nutritive sucking, oral sucrose, and facilitated tucking) on infants' pain- and stress-related behaviours during four assessment phases: baseline, intervention, heel stick, and recovery. Prospective, randomised controlled trial. Level III neonatal intensive care unit in Taipei. A convenience sample of 110 infants (gestational age 27-37 weeks) needing heel sticks was randomly assigned to five combinations of nonpharmacological treatments: (1) routine care, (2) non-nutritive sucking+facilitated tucking, (3) oral sucrose+facilitated tucking, (4) non-nutritive sucking+oral sucrose, and (5) non-nutritive sucking+oral sucrose+facilitated tucking. Outcomes were infants' withdrawal or stress (grimace, limb and trunk extension or squirming) and approach or self-soothing (sucking, sucking search, or mouthing; hand holding or grasping; and hand to mouth, face) behaviours. The frequency of infants' withdrawal behaviours decreased significantly when they received combinations of nonpharmacological interventions before heel stick. Specifically, grimace frequency decreased by 32.2%, 30.6%, 19.7%, and 13.8% in infants receiving oral sucrose+non-nutritive sucking+facilitated tucking, non-nutritive sucking+oral sucrose, oral sucrose+facilitated tucking, and non-nutritive sucking+facilitated tucking, respectively, compared to those receiving routine care across assessment phases. Furthermore, infants' frequency of limb and trunk extension or squirming decreased by 24.0% when they received non-nutritive sucking+oral sucrose+facilitated tucking compared to those receiving routine care. Infants' frequency of approach behaviours did not change significantly across all phases when they received non-nutritive sucking+oral sucrose+facilitated tucking, non-nutritive sucking+oral sucrose, and oral sucrose+facilitated tucking compared to those receiving routine care. The combined use of nonpharmacological interventions (non-nutritive sucking+oral sucrose+facilitated tucking) effectively reduced the frequencies of infants' withdrawal behaviours, i.e. grimace and limb and trunk extension or squirming. Our results provide evidence supporting clinicians' incorporation of the combined use of facilitated tucking, oral sucrose, and non-nutritive sucking into clinical practice during painful procedures. Heel-stick procedures can be atraumatic when conducted while infants are stable and quiet, appropriately positioned, and stabilised and by offering facilitated tucking, oral sucrose, and non-nutritive sucking before gently sticking the heel and squeezing blood.

Yin T ，Yang L ，Lee TY ，Li CC ，Hua YM ，Liaw JJ ... -  《-》