Denise Harrison

Epidemiology and management of painful procedures in children in Canadian hospitals

Background Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management. Methods We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ2) analyses. Results Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered. Interpretation For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

Pain assessment and procedural pain management practices in neonatal units in Australia

Objective: To identify current pain assessment and procedural pain management practices in neonatal units in Australia.

A systematic review and meta-analyses of nonsucrose sweet solutions for pain relief in neonates.

BACKGROUND Sucrose has been demonstrated to provide analgesia for minor painful procedures in infants. However, results of trials investigating other sweet solutions for neonatal pain relief have not yet been synthesized. OBJECTIVE To establish the efficacy of nonsucrose sweet-tasting solutions for pain relief during painful procedures in neonates. METHOD The present article is a systematic review and meta-analyses of the literature. Standard methods of the Cochrane Neonatal Collaborative Review Group were used. Literature searches were reviewed for randomized controlled trials investigating the use of sweet solutions, except sucrose, for procedural pain management in neonates. Outcomes assessed included validated pain measures and behavioural and physiological indicators. RESULTS Thirty-eight studies (3785 neonates) were included, 35 of which investigated glucose. Heel lancing was performed in 21⁄38 studies and venipuncture in 11⁄38 studies. A 3.6-point reduction in Premature Infant Pain Profile scores during heel lances was observed in studies comparing 20% to 30% glucose with no intervention (two studies, 124 neonates; mean difference -3.6 [95% CI -4.6 to -2.6]; P<0.001; I2=54%). A significant reduction in the incidence of cry after venipuncture for infants receiving 25% to 30% glucose versus water or no intervention was observed (three studies, 130 infants; risk difference -0.18 [95% CI -0.31 to -0.05]; P=0.008, number needed to treat = 6 [95% CI 3 to 20]; I2=63%). CONCLUSIONS The present systematic review and meta-analyses demonstrate that glucose reduces pain scores and crying during single heel lances and venipunctures. Results indicate that 20% to 30% glucose solutions have analgesic effects and can be recommended as an alternative to sucrose for procedural pain reduction in healthy term and preterm neonates.

Analgesic Effects of Sweet-Tasting Solutions for Infants: Current State of Equipoise

OBJECTIVE: The goal was to review published studies of analgesic effects of sweet solutions, to ascertain areas with sufficient evidence of effectiveness and areas of uncertainty. METHODS: Databases searched included Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and PsycINFO, using the terms pain*, infant*, neonat*, newborn*, sucrose, glucose, and alternative sugars. Publications were sorted according to type, year, painful procedure studied, placebo/no-treatment groups, population studied, and country of publication. RESULTS: A total of 298 relevant unique publications involving human infants were identified; 125 (42%) were primary research studies, of which 116 (93%) were randomized controlled trials. Healthy preterm or term newborns were included in 82 studies (65%), and sick or very low birth weight infants were included in 22 (18%). Most studies included single episodes of painful procedures, with only 3 (2%) conducted over long periods. Procedures investigated most frequently were heel lance (49%), venipuncture (14%), and intramuscular injection (14%). Placebo or no-treatment groups were included in 111 studies (89%); in 103 (93%) of those studies, sweet solutions reduced behavioral responses, compared with placebo/ no treatment. CONCLUSION: Clinical equipoise relating to analgesic effects of sweet solutions no longer exists for single episodes of procedures for healthy preterm and term newborn infants. Uncertainties include outcomes after prolonged use of sweet solutions, concomitant use of other analgesics, and effectiveness beyond the newborn period. Future research should focus on addressing these knowledge and research gaps.

Sucrose for Procedural Pain Management in Infants

The use of oral sucrose has been the most extensively studied pain intervention in newborn care to date. More than 150 published studies relating to sweet-taste-induced calming and analgesia in human infants have been identified, of which 100 (65%) include sucrose. With only a few exceptions, sucrose, glucose, or other sweet solutions reduced pain responses during commonly performed painful procedures in diverse populations of infants up to 12 months of age. Sucrose has been widely recommended for routine use during painful procedures in newborn and young infants, yet these recommendations have not been translated into consistent use in clinical practice. One reason may be related to important knowledge and research gaps concerning analgesic effects of sucrose. Notably, the mechanism of sweet-taste-induced analgesia is still not precisely understood, which has implications for using research evidence in practice. The aim of this article is to review what is known about the mechanisms of sucrose-induced analgesia; highlight existing evidence, knowledge gaps, and current controversies; and provide directions for future research and practice.

Oral sucrose for procedural pain in sick hospitalized infants: A randomized-controlled trial

Objective:  To determine the efficacy of 25% oral sucrose in the reduction of pain during a heel lance procedure in sick hospitalized infants.

Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use?

Abstract The Face, Legs, Activity, Cry and Consolability (FLACC) scale is one of the most widely used behavioural observation pain scales. However, the psychometrics of the scale have not been adequately summarised and evaluated to provide clear recommendations regarding its use. The aim of this study was to rigorously evaluate the reliability, validity, feasibility, and utility of the scale for clinical and research purposes and provide recommendations regarding appropriate use of the scale. Databases searched were MEDLINE, CINAHL, Embase, PsycINFO (using the Ovid, PubMed, and Ebscohost platforms), The Cochrane Database of Systematic reviews and Cochrane Controlled Trials, and Google Scholar. Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the FLACC scale applied to children (birth to 18 years) and randomised controlled trials (RCT) using the FLACC scale to measure a study outcome in infants and children. Data extraction included study design, population demographics, and psychometric data. Analysis involved in this study are quality assessment of the psychometric evaluation studies and the RCTs using the COSMIN checklist and the Jadad scale, respectively, and narrative synthesis of all results. Twenty-five psychometric evaluations studies and 52 RCTs were included. The study population, circumstances, and quality of the studies varied greatly. Sufficient data addressing postoperative pain assessment in infants and children exist. Some positive data support the psychometrics of the scale used to assess postoperative pain in children with cognitive impairment. Limited and conflicting data addressing procedural pain assessment exist. Content validity and scale feasibility have had limited psychometric evaluation. There are insufficient data to support the FLACC scale for use in all circumstances and populations to which is currently applied.

Skin conductance variability between and within hospitalised infants at rest.

BACKGROUND Various methods of pain assessment in infants have been trialled in the search for objective, specific, physiologic measures of responses to pain. Skin conductance (SC) measured in the palm of the hand or on the plantar aspect of the foot may be one such measure. SC in these sites reflects the emotional sweating due to sympathetic nerve activity. The skin conductance response (SCR), which results from filling and reabsorption of sweat in the sweat glands, has previously been suggested to be the most sensitive SC parameter of sympathetic nerve activity in response to painful stimulation. AIM To study SCRs within and between medically stable hospitalised infants while at rest. METHODS SCRs were measured in infants during at least six periods of monitoring in a maximum 48-h period. Behavioural state was recorded throughout the data collection periods. RESULTS SC recordings (n=91) from 15 infants during sleep showed that frequency of SCRs varied between 0 and 0.04 SCRs per second (SCRs/s), median 0.002 SCRs/s. 73% of the total variation was within-infant variation, with the remaining 27% of variation due to variation between the mean SCR values of different infants. CONCLUSION This pilot study contributes to establishing baseline phasic SC activity in hospitalised infants at rest by measuring SCRs. These data can be used as a reference for future studies to determine the validity and reliability of SC measurement in infants exposed to painful or stressful interventions within a neonatal unit.

Procedural pain in neonates in Australian hospitals: A survey update of practices

The study aims to determine whether there has been improved uptake of the evidence for the management of procedural pain in neonates throughout Australia.

Analgesics administered during minor painful procedures in a cohort of hospitalized infants: a prospective clinical audit.

UNLABELLED A number of evidence-based consensus statements relating to pain in infants include recommendations concerning effective pain management during painful procedures. Yet numerous studies have shown that procedural pain remains poorly managed in neonatal intensive care units. The aim of this prospective clinical audit was to ascertain analgesics administered during skin-breaking, minor painful procedures occurring over the entire course of a hospitalization in a cohort of infants with a length of stay of 28 days or more. Data were collected on aspects relating to utilization of oral sucrose specifically for minor painful procedures as well as administration of opioid analgesics or other strong analgesics on the day the procedures were performed. A total of 3605 minor painful procedures were recorded for 55 infants during the study period, a mean of 65 minor procedures per infant. The majority of procedures recorded were heel lance (71%), followed by intravenous catheter insertion or venepuncture (14%). Either oral sucrose was specifically administered or background opioid analgesics were being administered during 85% of all minor painful procedures. These results show considerably higher frequency of analgesic use during acute minor painful procedures compared with similar studies of pain management practices in neonatal intensive care units. PERSPECTIVE This study ascertained analgesics administered to sick infants during minor painful procedures during a prolonged hospitalization. Oral sucrose or morphine was administered during the most painful procedures, whereas 15% of procedures were performed with no analgesics. This illustrates a vast improvement compared with similar studies.