Francoise Filion

Kangaroo mother care diminishes pain from heel lance in very preterm neonates: a crossover trial.

BackgroundSkin-to-skin contact, or kangaroo mother care (KMC) has been shown to be efficacious in diminishing pain response to heel lance in full term and moderately preterm neonates. The purpose of this study was to determine if KMC would also be efficacious in very preterm neonates.MethodsPreterm neonates (n = 61) between 28 0/7 and 31 6/7 weeks gestational age in three Level III NICUs in Canada comprised the sample. A single-blind randomized crossover design was employed. In the experimental condition, the infant was held in KMC for 15 minutes prior to and throughout heel lance procedure. In the control condition, the infant was in prone position swaddled in a blanket in the incubator. The primary outcome was the Premature Infant Pain Profile (PIPP), which is comprised of three facial actions, maximum heart rate, minimum oxygen saturation levels from baseline in 30-second blocks from heel lance. The secondary outcome was time to recover, defined as heart rate return to baseline. Continuous video, heart rate and oxygen saturation monitoring were recorded with event markers during the procedure and were subsequently analyzed. Repeated measures analysis-of-variance was employed to generate results.ResultsPIPP scores at 90 seconds post lance were significantly lower in the KMC condition (8.871 (95%CI 7.852–9.889) versus 10.677 (95%CI 9.563–11.792) p < .001) and non-significant mean differences ranging from 1.2 to1.8. favoring KMC condition at 30, 60 and 120 seconds. Time to recovery was significantly shorter, by a minute(123 seconds (95%CI 103–142) versus 193 seconds (95%CI 158–227). Facial actions were highly significantly lower across all points in time reaching a two-fold difference by 120 seconds post-lance and heart rate was significantly lower across the first 90 seconds in the KMC condition.ConclusionVery preterm neonates appear to have endogenous mechanisms elicited through skin-to-skin maternal contact that decrease pain response, but not as powerfully as in older preterm neonates. The shorter recovery time in KMC is clinically important in helping maintain homeostasis.Trial Registration(Current Controlled Trials) ISRCTN63551708

Pain in Canadian NICUs: have we improved over the past 12 years?

ObjectivesTo determine the incidence of and factors predicting management strategies used for procedural pain in Canadian neonatal intensive care units and to determine whether the incidence of procedures and their management has changed since our 1997 study. PatientsFive hundred eighty-two neonates who were hospitalized in any of the participating study centers were included. MethodsA prospective observational study was conducted in 14 Canadian neonatal intensive care units (level III A and III B). Infants were followed for 1 week regarding all invasive procedures. Data were collected prospectively by unit staff using a checklist and verified by research assistants. ResultsA total of 3508 tissue damaging (mean=5.8, SD=15) and 14,085 (mean=25.6, SD=15) nontissue damaging procedures were recorded. Half of procedures (46% tissue damaging and 57% nontissue damaging) had no analgesic interventions. Opiates were used for 14.5% of tissue-damaging procedures and sweet taste was used for 14.3% of the tissue-damaging procedures. Factors predicting use of pharmacologic management of tissue-damaging procedures were being less ill at birth, receiving high frequency ventilatory support, and being transferred to the study center. Parental presence predicted use of sweet taste or nonpharmacologic analgesia for tissue-damaging procedures. Study site practices varied widely with 1 unit providing analgesia for 90% of tissue-damaging procedures. InterpretationAlthough the number of tissue-damaging procedures has decreased from 1997 and the use of analgesics has increased, the management of these procedures falls far below the recommended guidelines of the Canadian Pediatric Society. That 1 unit reached a high level of analgesic use suggests that it is possible to achieve this goal. That parental presence had a positive influence on comfort strategies supports offering encouragement and support for parents to remain with their infant during procedures.

Intrauterine Growth Restriction and the Fetal Programming of the Hedonic Response to Sweet Taste in Newborn Infants

Intrauterine growth restriction is associated with increased risk for adult metabolic syndrome and cardiovascular disease, which seems to be related to altered food preferences in these individuals later in life. In this study, we sought to understand whether intrauterine growth leads to fetal programming of the hedonic responses to sweet. Sixteen 1-day-old preterm infants received 24% sucrose solution or water and the taste reactivity was filmed and analyzed. Spearman correlation demonstrated a positive correlation between fetal growth and the hedonic response to the sweet solution in the first 15 seconds after the offer (r = 0.864, P = 0.001), without correlation when the solution given is water (r = 0.314, P = 0.455). In fact, the more intense the intrauterine growth restriction, the lower the frequency of the hedonic response observed. IUGR is strongly correlated with the hedonic response to a sweet solution in the first day of life in preterm infants. This is the first evidence in humans to demonstrate that the hedonic response to sweet taste is programmed very early during the fetal life by the degree of intrauterine growth. The altered hedonic response at birth and subsequent differential food preference may contribute to the increased risk of obesity and related disorders in adulthood in intrauterine growth-restricted individuals.

Does sucrose analgesia promote physiologic stability in preterm neonates

A double-blind, randomized controlled trial was conducted with infants born <31 weeks of gestational age and recruited within 48 h of life. The infants were randomized to receive up to three doses of 0.1 ml of either 24% sucrose or sterile water (placebo) for every painful procedure during the 1st week of life. The purpose of this study was to test the efficacy of treating all procedural pain with sucrose on overall physiological stability. The hypotheses were that infants who received 24% sucrose for all painful procedures would be less stressed as measured by salivary cortisol, and more physiologically stable as measured by pulse rate variability than those who received placebo. Salivary cortisol was measured before and 30 min after a painful procedure, whereas the pulse rate was continuously recorded, from second to second, from a pulse oximeter. There were no group differences in the cortisol response to a painful stimulus or in pulse rate variability over time. There was, however, a significant correlation between standard deviation of pulse rate and number of doses of sucrose only in the group who received high doses of sucrose.

Construct validity of the Neurobehavioral Assessment of Preterm Infants.

In this nonrandomized, prospective cohort study, the construct validity of the Neurobehavioral Assessment of the Preterm Infant (NAPI) was examined by comparing it with measures of neonatal physiological status. A cohort of preterm infants (n = 37) was tested repetitively at 32 and 36 weeks post-conceptional age (PCA) to determine whether there was a correlation between physiological status and NAPI scores at these ages. We anticipated fair, clinically significant correlations (r = 0.25–0.50) between physiological and neurobehavioral status. This was found using Pearson Product Moment correlational analysis between components of the neurobehavioral performance repertoire at 32 weeks PCA, the degree of medical intervention and the early biological risks that contribute to developmental status. The finding was less marked at 36 weeks PCA when the subjects were physiologically more stable.

Alternative female kangaroo care for procedural pain in preterm neonates: a pilot study.

Aim:  To determine the feasibility and effect size of kangaroo care (KC) for pain from heel lance in preterm neonates provided by either the infant’s mother (MKC) or an unrelated alternate female (AFKC).

Maternal touch and talk for invasive procedures in infants and toddlers in the pediatric intensive care unit.

The aim of this single-blind, randomized, crossover trial was to test the effect of Touch & Talk (T&T) for infants and toddlers less than 36 months of age (N = 65) in the pediatric intensive care unit on their physiological stability and recovery to an invasive procedure. In the T&T condition, mothers touched, sang, or told stories or rhymes to their child during an invasive procedure. In the control condition, the mothers did not have contact with their child. Physiological measures included heart rate, heart rate variability, and oxygen saturation range during the procedure and change from baseline. Time from the end of the procedure until the heart rate returned to baseline levels gave the recovery time. Analysis was conducted using repeated-measures analysis of covariance. There were no significant differences on any of the physiological parameters by condition during the procedure. However, when controlling for severity of illness, recovery was faster with mothers.

Therapeutic touch is not therapeutic for procedural pain in very preterm neonates: a randomized trial.

Background:Preterm neonates below 30 weeks’ gestational age undergo numerous painful procedures. Many management approaches are not appropriate for this population. Therapeutic Touch, an alternative approach based on the theory of energy medicine, has been shown to promote physiological stability in preterm neonates and reduce pain in some adult studies. The objective was to determine whether Therapeutic Touch is efficacious in decreasing pain in preterm neonates. Methods:Infants <30 weeks’ gestational age participated in a randomized control trial in 2 level III neonatal intensive care units. All evaluations, analyses, and heel lance procedure were conducted with only the therapist knowing the group assignment. Immediately before and after the heel lance procedure, the therapist performed nontactile Therapeutic Touch (n=27) with infant behind curtains, leaving the curtained area for the heel lance, performed by another. In the sham condition (n=28), the therapist stood by the incubator with hands by her side. The Premature Infant Pain Profile was used for pain response and time for heart rate to return to baseline for recovery. Heart rate variability and stress response were secondary outcomes. Results:There were no group differences in any of the outcomes. Mean Premature Infant Pain Profile scores across 2 minutes of heel lance procedure in 30-second blocks ranged from 7.92 to 8.98 in the Therapeutic Touch group and 7.64 to 8.46 in the sham group. Interpretation:Therapeutic Touch given immediately before and after heel lance has no comforting effect in preterm neonates. Other effective strategies involving actual touch should be considered.