Marilyn Ballantyne

Validation of the premature infant pain profile in the clinical setting.

OBJECTIVE The Premature Infant Pain Profile (PIPP) is a 7-indicator composite measure developed to assess acute pain in preterm and term neonates. It has been validated in studies using synchronized videotaping of infants undergoing procedures. The purpose of this study was to establish (a) construct validity of the PIPP and (b) inter- and intrarater reliability of the PIPP prospectively in the clinical environment. DESIGN A randomized, crossover design was used. SETTING The study was conducted in a Level III outborn neonatal intensive care unit. PARTICIPANTS A convenience sample of 43 neonates, stratified by gestational age, was studied. INTERVENTIONS Each infant experienced three separate, randomly ordered events: baseline, a painful event, and a nonpain event. Infants were videotaped and scored at the bedside using the PIPP by the nurse caring for the infant and the clinical nurse specialist who bad expertise in infant pain. The videotapes were later reviewed by two additional experts; one in real time and one using a second-to-second stop frame technique. RESULTS Repeated-measures analysis of the main effects and interactions yielded a statistically significant main effect for event (pain, nonpain, baseline), thus differentiating pain from nonpain and baseline events (F = 48, p = 0.0001) and establishing construct validity. Interrater reliability analysis of individual event scores of the PIPP yielded reliability coefficients of 0.93-0.96. Intrarater reliability coefficients analysis for individual events were equally high at 0.94-0.98. CONCLUSIONS This study demonstrates that the PIPP is a pain measure with good construct validity and excellent inter- and intrarater reliability for the assessment of procedural pain of preterm and term infants in clinical settings.

Determinants of developmental outcomes in a very preterm Canadian cohort

Objectives Identify determinants of neurodevelopmental outcome in preterm children. Methods Prospective national cohort study of children born between 2009 and 2011 at <29 weeks gestational age, admitted to one of 28 Canadian neonatal intensive care units and assessed at a Canadian Neonatal Follow-up Network site at 21 months corrected age for cerebral palsy (CP), visual, hearing and developmental status using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). Stepwise regression analyses evaluated the effect of (1) prenatal and neonatal characteristics, (2) admission severity of illness, (3) major neonatal morbidities, (4) neonatal neuroimaging abnormalities, and (5) site on neurodevelopmental impairment (NDI) (Bayley-III score < 85, any CP, visual or hearing impairment), significant neurodevelopmental impairment (sNDI) (Bayley-III < 70, severe CP, blind or hearing aided and sNDI or death. Results Of the 3700 admissions without severe congenital anomalies, 84% survived to discharge and of the 2340 admissions, 46% (IQR site variation 38%–51%) had a NDI, 17% (11%–23%) had a sNDI, 6.4% (3.1%–8.6%) had CP, 2.6% (2.5%–13.3%) had hearing aids or cochlear implants and 1.6% (0%–3.1%) had a bilateral visual impairment. Bayley-III composite scores of <70 for cognitive, language and motor domains were 3.3%, 10.9% and 6.7%, respectively. Gestational age, sex, outborn, illness severity, bronchopulmonary dysplasia, necrotising enterocolitis, late-onset sepsis, retinopathy of prematurity, abnormal neuroimaging and site were significantly associated with NDI or sNDI. Site variation ORs for NDI, sNDI and sNDI/death ranged from 0.3–4.3, 0.04–3.5 and 0.12–1.96, respectively. Conclusion Most preterm survivors are free of sNDI. The risk factors, including site, associated with neurodevelopmental status suggest opportunities for improving outcomes.

The Influence of Context on Pain Practices in the NICU: Perceptions of Health Care Professionals

In this qualitative descriptive study, we explored health care professionals’ perceptions of the influence of context (i.e., organizational culture, structure, resources, capabilities/competencies, and politics) on evidence-based pain practices. A total of 16 focus groups with 147 health care professionals were conducted in three neonatal intensive care units (NICUs) in central and eastern Canada. Three overarching themes emerged from the data, which captured influences on optimal pain practices in the NICU, including (a) a culture of collaboration and support for evidence-based practice, (b) threats to autonomous decision making, and (c) complexities in care delivery. These results were consistent with theoretical conceptualizations of how context influences practice, as well as recent empirical research findings. This study supports the importance of context in shaping evidence-based practices by health care professionals in the management of pain in the NICU.

A randomized controlled trial evaluating the efficacy of tetracaine gel for pain relief from peripherally inserted central catheters in infants.

BACKGROUNDInsertion of peripherally inserted central catheters (PICC) is a commonly performed procedure in both preterm and term infants. Tetracaine 4% gel (Ametop; Smith & Nephew Inc, St. Laurent, Quebec), a topical anesthetic, although reported to be effective for reducing the pain of venipuncture in neonates, has not been investigated for the management of pain associated with the PICC procedure. PURPOSETo determine the efficacy of tetracaine gel for managing the pain associated with the PICC procedure in preterm and term infants. METHODSA double-blind, placebo-controlled, randomized controlled trial (RCT) design was used. Infants undergoing nonurgent PICC insertion were randomized to receive either the treatment (1.0 g of tetracaine 4% gel) or placebo control (1.0 g of eucerin-plus cream) applied to the skin under occlusion for 30 minutes before the procedure. Data on the behavioral (facial expression) and physiologic (heart rate and oxygen saturation) indicators of pain were collected via videotaping and computer monitoring throughout the procedure. Data then were coded and measured by independent observers using the Premature Infant Pain Profile (PIPP; Stevens et al, 1996), and analyzed using descriptive statistics and repeated-measures analyses of variance. RESULTSForty-nine infants, gestational age 27 to 41 weeks (mean = 33; SD = 4.2) and age at time of insertion 2 to 85 days (mean = 18; SD = 22.5) participated. No differences were found between the groups at the time of randomization. There were no adverse cardiorespiratory events or local skin reactions in either group. There was a significant within-subjects main effect of time across the procedure (F[48,3] = 11.03; P < 0.0001). There was no significant between-subjects main effect of group (F[48,1] = 0.11; P = 0.74) and no (group × time) interaction (F[48,3] = 0.45; P = 0.72). CONCLUSIONTetracaine gel was not effective for pain relief for PICC insertion in infants. Its use for pain relief cannot be recommended based on the results of this study. Other pharmacologic, behavioral, and physical interventions should be investigated for safety and relief of procedural pain in this population of infants.

Transition to neonatal follow-up programs: is attendance a problem?

Neonatal follow-up (NFU) programs provide health services for infants at high risk for developmental problems after they transition home from the neonatal intensive care unit (NICU). The purpose of the study was to assess current patterns of NFU attendance and explore time points when mothers and infants withdrew from NFU programs during the infants first year of life. The study was conducted in 3 Canadian tertiary-level NICUs that referred to 2 affiliated, regional NFU programs. A total of 357 mothers and 400 infants were consecutively recruited during NICU hospitalization. Attendance at NFU programs was tracked at each of the 3 scheduled appointments from existing NFU databases. Attendance at NFU decreased over time from 84% at the first appointment to 74% by 12 months, with the highest withdrawal from NFU after NICU discharge, followed by withdrawal after the first NFU appointment. Nonattendance at NFU results in less access to required services and underreporting of the developmental outcomes of these infants. Given these findings, mothers should be screened earlier in the NICU to identify those at greatest risk of not attending NFU. Strategies should be implemented to address potential barriers and provide effective transition and access to the NFU program.

Indwelling Versus Intermittent Feeding Tubes in Premature Neonates

OBJECTIVE To determine the effect of indwelling versus intermittent feeding tube placement on weight gain, apnea, and bradycardia in premature neonates. DESIGN Eligible subjects were assigned randomly to either feeding tube method. Each subject was followed for 6 days. SETTING The study was conducted in a secondary level neonatal intensive-care unit (NICU), a tertiary level NICU in a perinatal center, and a tertiary level NICU in a referral center. PATIENTS/PARTICIPANTS Neonates who were 24-34 weeks gestational age, developmentally appropriate for gestational age, medically stable, on full enteral feedings through an orogastric or a nasogastric tube, and not fluid restricted. Ninety-three neonates were enrolled--49 indwelling group and 44 in the intermittent group. Nine neonates did not complete the study. INTERVENTIONS Nasogastric indwelling feeding tubes were placed and left in site for up to 3 days. Orogastric intermittent feeding tubes were placed for each feeding and removed at completion of the feeding. MAIN OUTCOME MEASURES Weight gain, apnea, and bradycardia. RESULTS Members of both groups had similar demographic characteristics, clinical problems, and nutritional intake. No statistical differences were found between the two groups in weight gain or episodes of apnea and bradycardia. CONCLUSIONS There were no statistically or clinically significant differences between the two groups. The intermittent method of feeding is more expensive. Because no clinical differences were found, the type of tube placement chosen for feeding the premature infant may be based on economics.Objective: To determine the effect of indwelling versus intermittent feeding tube placement on weight gain, apnea, and bradycardia in premature neonates. Design: Eligible subjects were assigned randomly to either feeding tube method. Each subject was followed for 6 days. Setting: The study was conducted in a secondary level neonatal intensive-care unit (NICU), a tertiary level NICU in a perinatal center, and a tertiary level NICU in a referral center. Patients/Participants: Neonates who were 24–34 weeks gestational age, developmentally appropriate for gestational age, medically stable, on full enteral feedings through an orogastric or a nasogastric tube, and not fluid restricted. Ninety-three neonates were enrolled-49 in the indwelling group and 44 in the intermittent group. Nine neonates did not complete the study. Interventions: Nasogastric indwelling feeding tubes were placed and left in site for up to 3 days. Orogastric intermittent feeding tubes were placed for each feeding and removed at completion of the feeding. Main outcome measures: Weight gain, apnea, and bradycardia. Results: Members of both groups had similar demographic characteristics, clinical problems, and nutritional intake. No statistical differences were found between the two groups in weight gain or episodes of apnea and bradycardia. Conclusions: There were no statistically or clinically significant differences between the two groups. The intermittent method of feeding is more expensive. Because no clinical differences were found, the type of tube placement chosen for feeding the premature infant may be based on economics.

Influence of risk of neurological impairment and procedure invasiveness on health professionals’ management of procedural pain in neonates

Objectives: To describe how (i) risk of neurological impairment (NI) and (ii) procedure invasiveness influence health professionals’ assessment and management of procedural pain in neonates in the Neonatal Intensive Care Unit (NICU).

Long-term home visiting with vulnerable young mothers: an interpretive description of the impact on public health nurses

BackgroundThe Nurse-Family Partnership (NFP) is a targeted, nurse home visitation program for young, low-income, first-time mothers. While the effectiveness of the NFP has been established in the United States, and is currently being evaluated in the Canadian public health care system, we have minimal understanding of how work of this nature impacts public health nurses (PHNs), an essential component of this program delivery model, on both professional and personal levels.MethodsThis two-phase study consisted of a qualitative secondary analysis of data from five focus groups conducted with PHNs (N = 6) who delivered the NFP intervention as part of a pilot study assessing feasibility and acceptability conducted in Hamilton, Ontario. The second phase, an interpretive description of individual interviews with the PHNs (N = 10) who have delivered the NFP in this context, further explored themes identified in the first phase. A practice, problem and needs analysis was conducted to describe and understand the phenomenon and promote sustainability of PHNs in this practice environment. Conventional content analysis was used to code and categorize data in the two datasets.ResultsThe nurse-client relationship, the core elements and structure of the NFP program and support of NFP colleagues were described as rewarding factors, while workload and workplace factors were identified as significant contributors to stress. PHNs described transforming their nursing practice through redefining success and shifting to a philosophy where the client is the expert of her own life. PHNs described the personal impact of worry about clients and doubt about their effectiveness in addressing client concerns. High levels of satisfaction were described in relation to the depth and intensity of relationships with clients and seeing them succeed over time.ConclusionsPHNs are impacted in multiple ways by their work with vulnerable, young mothers. The study findings have implications for identification of strategies to support PHNs in reducing staff turnover, PHN burnout, secondary traumatic stress and compassion fatigue, and improving program delivery.

Risk of developmental delay: Comparison of late preterm and full term Canadian infants at age 12 months.

BACKGROUND Late preterm (34(0/7) to 36(6/7)weeks gestation) infants may experience developmental delays greater than those found in term (≥ 37(0/7)weeks gestation) infants. AIM The aim of this study was to compare the risk of developmental delay between late preterm and full-term Canadian born infants at age 12months, and to determine infant and maternal factors associated with risk of delay. METHODS A descriptive comparative study was conducted from data available from the All Our Babies community-based, prospective, pregnancy cohort in Calgary, Alberta. Participants were a sample of mothers of 52 infants born late preterm and 156 randomly selected mothers of term infants, matched for infant sex; eligible infants were singleton births. Mothers completed a developmental screening tool, the Ages and Stages Questionnaire, version 3 (ASQ-3), when their infant was age 12months. Corrected age (CA) was used for preterm infants. RESULTS Both late preterm and term infants who required neonatal intensive care (NICU) were more likely to demonstrate risk of developmental delay. Compared to term infants, there was a trend for late preterm infants to be at risk of communication and gross motor delay at age 12months CA that was attenuated to the null when adjustments were made for NICU admission and other covariates. CONCLUSIONS Infants born between 34 and 41weeks who are admitted to NICU are at increased risk of developmental delay. Early identification of risk provides an opportunity for referral for developmental assessment and early intervention programming.

Longitudinal patterns of early development in Canadian late preterm infants: A prospective cohort study

This prospective, longitudinal cohort study examined longitudinal patterns of early development in Canadian children born late preterm. A convenience sample of 82 mothers and their healthy, singleton, late preterm children participated. Mothers completed the Ages and Stages Questionnaires at 4, 8, and 18 months corrected age. Concerns were most commonly reported in the communication and gross motor domains, especially early in development. The proportion of children scoring below the referral cut-off in at least one domain at 4, 8, and 18 months was, respectively, 25.6, 25.6, and 14.6%. Only two children (2.4%) scored below referral cut-off in at least one domain at all three time points. At ages four and eight months, the late preterm sample had significantly lower communication and gross motor scores than the Ages and Stages Questionnaires normative sample. At age four months, there was also a significant difference on the fine motor domain. There were no significant differences at age 18 months. Healthy late preterm children appear to catch up to population norms by age 18 months corrected age. Longer term studies are needed to further clarify early indicators of delay in late preterm children and identity those who require close developmental monitoring.