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Support during painful procedures and pain assessment

Authors 

Oude-Reimer M, Frauenfelder O, Binter J, Cámba F, Ceccatelli M, Hankes-Drielsma I, Jørgensen E, Silva E

© Christian Klant Photography

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

All infants in neonatal and paediatric units receive optimal comfort to minimise stress and pain, supported by their parents.

Rationale

Provision of optimal comfort, recognition, and treatment of pain are core skills underpinning all clinical care. Infants may be subjected to a large number of painful and stressful, although necessary, procedures during their care. (1,2) Infants depend on others to recognise, to assess and to treat pain and discomfort. (3–9) The situation for the preterm infant is more complex than that of the full term infant, since they often require intensive or high dependency care for many weeks, and their immature stage of neuromotor development may minimise the external manifestations of distress. Compared to older children and adults, infants are less able to communicate their pain and discomfort and are at greater risk for inadequate analgesia. Although awareness of symptoms of pain and stress is increasing, they are still often underestimated. (10)

Pain and stress may be minimised by regular expert prospective observation, respect for the infant’s behavioural cues of pain and discomfort, attention to positioning, the immediate environment and timing of intervention, and appropriate use of pain relief strategies, including non-pharmacological strategies (5) (e.g. tuck, wrap, giving individualised supportive care and use of pacifiers) and analgesics. For some non-urgent procedures, you can expect the parents of the infant in the NICU and apply with them the non-pharmacological pain relief procedures, programming the timing of the intervention. (11)

Benefits

Short-term benefits

  • Improved sleep (12)
  • Improved digest of feeding (13)
  • Improved weight gain (13)
  • Improved cortisol levels (13)
  • Improved physiologic stability (14)

Long-term benefits

  • Improved brain structure and development (6)
  • Improved behaviour (6,12)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about strategies to optimise comfort, minimise painful stimuli and manage unavoidable pain during care. A (High quality)
B (High quality)
Patient information sheet
       
2. Parents are informed by healthcare professionals about and offered the opportunity to be present and assist during procedures, when appropriate. (10) A (High quality)
B (High quality)
Audit report, patient information sheet
       
3. Parents are educated by healthcare professionals to recognise pain and discomfort signals in their infant and how to comfort the infant. (15) A (High quality)
B (High quality)
Patient information sheet, training documentation
       
For healthcare professionals    
4. A unit guideline on the importance of appropriate pharmacologic and non-pharmacologic pain relief strategies during care and procedures is adhered to by all healthcare professionals. B (High quality) Audit report, guideline
       
5. Training to recognise pain and distress in term and preterm infants is attended by all responsible healthcare professionals. (3) A (High quality)
B (High quality)
Audit report, training documentation
       
6. Training to avoid any non-essential painful and discomfort procedures is attended by all healthcare professionals. (3) A (High quality)
B (High quality)
Training documentation
       
7. Pain and stress are assessed using validated tools. (6,9) A (High quality)
B (High quality)
Assessment tools
       
8. All infants receive appropriate pharmacological and non-pharmacological pain relief. (3,15–21) A (High quality)
B (High quality)
Audit report, guideline
       
For neonatal unit    
9. A unit guideline for maintaining comfort, avoiding unnecessary pain and discomfort and use of appropriate pharmacological and non-pharmacological pain relief is available and regularly updated. (4,6,9) A (High quality)
B (High quality)
Guideline
       
10. Each unit recognises and utilises an individualised developmental care approach when reducing and avoiding pain and discomfort experiences during infants stay in the hospital. (22) A (High quality)
B (High quality)
Audit report
       
For hospital    
11. Training to recognise pain and distress in term and preterm infants and to avoid any non-essential painful and discomfort procedures is ensured. (4,6,9) A (High quality)
B (High quality)
Training documentation
       
For health service    
N/A      
       

Where to go

Further development Grading of evidence
For parents and family  
  • Psychological support is offered to parents to cope with a stressful experience of their infant pain. (23,24)
A (Moderate quality)
For healthcare professionals  
N/A  
For neonatal unit  
N/A  
For hospital  
N/A  
For health service  
  • Promote strategies to license new preparations of pharmacological agents to relieve pain in infants. (14,25)
A (Moderate quality)
  • Promote research into new approaches to pharmacological and non-pharmacological support during painful procedures in infants.
B (High quality)
   

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about strategies to optimise comfort, minimise painful stimuli and manage unavoidable pain during care.
  • Planned procedures are verbally discussed with parents.
For healthcare professionals
  • Attend training to recognise pain and distress and to avoid any non-essential painful and discomfort procedures in infants.
For neonatal unit
  • Develop and implement a unit guideline on pain assessment and treatment
  • Develop information material on strategies to optimise comfort, minimise painful stimuli and manage unavoidable pain during care for parents.
  • Use a validated pain assessment tool and a flowchart.
For hospital
  • Support healthcare professionals to participate in training on pain management.
For health service
N/A
 

Sources

  1. Roofthooft DWE, Simons SHP, Anand KJS, Tibboel D, van Dijk M. Eight years later, are we still hurting newborn infants? Neonatology. 2014;105(3):218–26.
  2. Simons SHP, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003 Nov;157(11):1058–64.
  3. Pillai Riddell RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2015 Dec 2;(12):CD006275.
  4. Stevens BJ, Gibbins S, Yamada J, Dionne K, Lee G, Johnston C, et al. The premature infant pain profile-revised (PIPP-R): initial validation and feasibility. Clin J Pain. 2014 Mar;30(3):238–43.
  5. Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. In: The Cochrane Collaboration, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2014 [cited 2016 Jul 27]. Available from: http://doi.wiley.com/10.1002/14651858.CD008435.pub2
  6. Gibbins S, Stevens BJ, Yamada J, Dionne K, Campbell-Yeo M, Lee G, et al. Validation of the Premature Infant Pain Profile-Revised (PIPP-R). Early Hum Dev. 2014 Apr;90(4):189–93.
  7. Holsti L, Grunau RE, Oberlander TF, Osiovich H. Is it painful or not? Discriminant validity of the Behavioral Indicators of Infant Pain (BIIP) scale. Clin J Pain. 2008 Jan;24(1):83–8.
  8. Smith GC, Gutovich J, Smyser C, Pineda R, Newnham C, Tjoeng TH, et al. Neonatal intensive care unit stress is associated with brain development in preterm infants. Ann Neurol. 2011 Oct;70(4):541–9.
  9. van Dijk M, Roofthooft DWE, Anand KJS, Guldemond F, de Graaf J, Simons S, et al. Taking up the challenge of measuring prolonged pain in (premature) neonates: the COMFORTneo scale seems promising. Clin J Pain. 2009 Sep;25(7):607–16.
  10. van Ganzewinkel C, Anand KJS, Kramer BW, Andriessen P. Chronic pain in the newborn: toward a definition. Clin J Pain. 2014 Nov;30(11):970–7.
  11. Skene C, Franck L, Curtis P, Gerrish K. Parental involvement in neonatal comfort care. J Obstet Gynecol Neonatal Nurs JOGNN. 2012 Dec;41(6):786–97.
  12. Vinall J, Miller SP, Bjornson BH, Fitzpatrick KPV, Poskitt KJ, Brant R, et al. Invasive Procedures in Preterm Children: Brain and Cognitive Development at School Age. PEDIATRICS. 2014 Mar 1;133(3):412–21.
  13. Stevens B, Gibbins S, Franck LS. Treatment of pain in the neonatal intensive care unit. Pediatr Clin North Am. 2000 Jun;47(3):633–50.
  14. Neubert A, Lukas K, Leis T, Dormann H, Brune K, Rascher W. Drug utilisation on a preterm and neonatal intensive care unit in Germany: a prospective, cohort-based analysis. Eur J Clin Pharmacol. 2010 Jan;66(1):87–95.
  15. Lago P, Garetti E, Merazzi D, Pieragostini L, Ancora G, Pirelli A, et al. Guidelines for procedural pain in the newborn. Acta Paediatr Oslo Nor 1992. 2009 Jun;98(6):932–9.
  16. Harrison D, Loughnan P, Manias E, Gordon I, Johnston L. Repeated doses of sucrose in infants continue to reduce procedural pain during prolonged hospitalizations. Nurs Res. 2009 Dec;58(6):427–34.
  17. Bellieni CV, Tei M, Buonocore G. Should we assess pain in newborn infants using a scoring system or just a detection method? Acta Paediatr Oslo Nor 1992. 2015 Mar;104(3):221–4.
  18. Kleberg A, Warren I, Norman E, Morelius E, Berg A-C, Mat-Ali E, et al. Lower Stress Responses After Newborn Individualized Developmental Care and Assessment Program Care During Eye Screening Examinations for Retinopathy of Prematurity: A Randomized Study. PEDIATRICS. 2008 May 1;121(5):e1267–78.
  19. Harrison DM. Oral sucrose for pain management in infants: Myths and misconceptions. J Neonatal Nurs. 2008 Apr 1;14(2):39–46.
  20. Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Neonatal Group, editor. Cochrane Database Syst Rev [Internet]. 2016 Jul 15 [cited 2018 May 8]; Available from: http://doi.wiley.com/10.1002/14651858.CD001069.pub5
  21. Menon G, Anand KJ, McIntosh N. Practical approach to analgesia and sedation in the neonatal intensive care unit. Semin Perinatol. 1998 Oct;22(5):417–24.
  22. Als H, Duffy FH, McAnulty GB, Rivkin MJ, Vajapeyam S, Mulkern RV, et al. Early experience alters brain function and structure. Pediatrics. 2004 Apr;113(4):846–57.
  23. Simons LE, Goubert L, Vervoort T, Borsook D. Circles of engagement: Childhood pain and parent brain. Neurosci Biobehav Rev. 2016;68:537–46.
  24. Pomicino L, Maccacari E, Buchini S. Levels of anxiety in parents in the 24 hr before and after their child’s surgery: A descriptive study. J Clin Nurs. 2018 Jan;27(1–2):278–87.
  25. Carbajal R, Eriksson M, Courtois E, Boyle E, Avila-Alvarez A, Andersen RD, et al. Sedation and analgesia practices in neonatal intensive care units (EUROPAIN): results from a prospective cohort study. Lancet Respir Med. 2015 Oct;3(10):796–812.

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Oude-Reimer M, Frauenfelder O et al., European Standards of Care for Newborn Health: Support during painful procedures and pain assessment. 2018.

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