Douleur et inconfort en periode périnatal Pijn en discomfort

Transcription

service public fésiéial
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Douleur et inconfort en periode périnatal
Pijn en discomfort in de perinatale periode
08.30-09.00
09. 00-09.30
Registration Pacheco Brussels
Impactdesstimulations environnementales sur Iebien-êtredunouveau-néhospitalisé.
Pr. Dr. Pierre Kuhn
09.30-10.00
Douïeur liée auxsoins chez l'enfant premature: I'impact des soins de développement.
Pr. Dr. Pierre Kuhn,
Médecine et réanimation du nouveau-né, CHU Strasbourg
Laboratoire de Neurosciences Cognitives et Adaptatives CNRS/UdS Strasbourg
10. 00-11. 00
Psychology of pain: fust 'thinking' about pain makes you want to scream sometimes...
Prof. ErikFranck. Antwerpen
Hoofd Expertise centrum Psychisch Welzijn in Patiëntenzorg
Kareï de Grote Honeschool
11. 00-11. 30
11. 30-12. 30
12. 30-13.30
Pauze
Analgosedatie voor neonaten: wat weten we en hoe handelen we?
Prof. Dr. Kareï Allegaert
Neonatoïoog. UZLeuven
La gestion de la douleur dans Ie décours de I'allaitemenL
Mme. Christeï Jouret, IBCLC
13. 30-14.30
14. 30-15. 15
Broodjes lunch
Résultatsdel'étudeEPIPAGE2 : étudeépldémiologiquedesgestesdouloureuxchezles
nouveau-nés.
Emilie Courtois
Infirmière puéricultrice, doctorante
Coordinatrice de l'étude EPIPAGE 2
Service des urgences pédiatriques - Hópital Trousseau, AP-HP, Paris. Inserm U1153
15. 15-16.00
Moedermelkals pijnbestrijding.
Dr. Philippe AIliet,
Kinderarts Jessaziekenhuis Hasselt
Staftraining FOD-SPF: SDE15mcF029 7 u
RIZIV INAMI: 15002319 (5, 5 u) rubriek 6
Cerps IBCLC : 315012K (3 L + l E]
25 03 2015
"Douleur et inconfort en periode périnatal "
F
Impact des stimulations environnementales sur
Ie bien-être du nouveau-né hospitalisé
Pr Pierre Kuhn,
Médecine et Réanimation du Nouveau-né. CHU Strasbourg, France
Lesnouveau-nésprématuréssont confrontésen neonatologiea un environnementatypiqueet
technique, différant par bien des aspects de l'environnement utérin dont ils ont étéextraits précocement.
Leurs systèmes sensoriels bien qu'immatures leur permettent de détecter et discriminer nombre des
stimulations issues de leur nouvelle « niche écologique » hospitalière, et d'y réagir de fayon plus ou moins
adaptée.En effet, les systèmessensoriels se développentselon un continuümtrans-natalet une
chronologie propre a chaque sens, en debutant par Ie système du tact et de la douleur, puis les systèmes
chémo-sensoriels[odorat et gustation), auditifset finalementvisuels. Lesprincipales étapesde leur
développementsont présentéesdansIetableau l qui synthétiseles résultatsdesrecherches,
fondamentaleset appliquées,menéesdansles dernièresdécennieschezIe foetuset Ie nouveau-né.
L'ensembledes systèmessensoriels partidpent a l'émergenced'une consciencede soi et de son
environnement qui peut atteindre un niveau minimal chez Ie premature.
Principaiesétap««,ri»!'or!0togia.! idu<;it:'\'('loppem«:n( desi.ystèmes,sensotl.'lsrtt'z te feetusrtft»u if nowaau-nfpremature.
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g sem
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15-17 sem
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25 sem
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25 03 2015
(d'après Kuhn P et al. Développement des systèmes sensoriels et environnement physique hospitalier des
nouveau-nésgrandsprématurés.Arch Pediatr.2011Jul;18:S92-102.)
Nous détaillons un peu plus avant Ie développement du système olfactif tres impliqué dans
l'adaptation postnatale de l'enfant et dans les processus d'attachement. Beaucoup d'études ont mis en
évidence les capacités de détection, de discrimination, d'expression de préférenceet de mémorisation
d odeurs chez Ie nouveau-né a terme. Il apparait que les principaux systèmes chimiorécepteurs Colfactif
principal, trigéminalj atteignent une maturité dés Ie second trimestre de gestation. Le premier est
impliqué dans la perception [détection, discrimination et identification) d'une large palette d'odeurs
même de faible intensité. Le second est sensible a des odeurs de plus forte intensité ou des odeurs
porteuses d'une composante tactile (la fraïcheur de la menthe. Iepiquant du piment, l'irritant duchlore) et
aurait surtout pour fonction de défendre l'organisme en l'informant de la présence de molécules
potentiellement toxiques. Cette perception est intégrée au niveau cortical comme en témoigne les
activations cérébralesmesuréesau niveau du cortex orbito-frontal du nouveau-népar destechniques de
spectrométrie dans Ie proche infra-rouge. Ces activations cérébralesont étéobservées pour des odeurs
agréables.Ie laitdemèreet desodeursd'originehospitalière.Sipeudechosessontencore connuessurles
aptitudes perceptives ou encore les effets physiologiques et comportementaux de la perception des
odeurs chez Ie nouveau-né grand premature, ceux-ci sont déjè doués d'une sensibilité olfactive
remarquable. Des travaux ont révélé que l'exposition de l'enfant premature a des odeurs agréables ou
familièress'estmontréebénéfiquepour diminuersaréponsea Iadouleurou encore améliorersastabilité
respiratoire. A l'inverse des odeurs irritantes peuvent altérer son bien être physiologique et
comportemental.
A l'hópital, dans eet environnement « nosocomial», les enfants prématurés sont privés a des degrés
variables, dépendant des stratégies de soins de développement mises en place (peau a peau, accueil et
participation des parents aux soins), de nombreuses stimulations biologiquement signifiantesprovenant
de leur mère (odeurs, bruits physiologiques digestifs et cardio-respiratoires de fréquences basses, voix
douces utilisant Ie langage « motherese »] souvent congruentes et multimodales. En revanche, ils y sant
exposésa demultiples stimuli accompagnantles soinsqui leurs sontprodigués: bruitsartificiels,lumière,
stimulations tactiles voire nociceptives, odeurs souvent irritantes libéréespar les produits d'hygiène et de
soins. Pour ces dernièrespar exemple, on a pu estimer que l'exposition d'enfants de 24 et 28 semaines
d'AG, a ces odeurs majoritairement irritantes, peut atteindre 4200 et 3500 fois respectivement pendant
l'hospitalisation.
Ces stimulations different qualitativement et quantitativement des stimulations chémo-sensorielles
foetales. Tous les stimuli rencontrés dans les différentes modalités sensorielles sont intenses et de
survenue souvent chaotique et imprédictible. lis sant souvent source de stress, d'inconfort ou de douleur
et de rupture des états de veille sommeil. Le premature détecte et discrimine nombre de ces stimulations
environnementales. Après une stimulation auditive, il augmente sa frequence cardiaque
proportionnellement a l'intensité du stimulus, diminue sa fréquence respiratoire et sa saturation
25 03 2015
systémiqueen oxygène.Un niveaude bruit > 70 dBApeutaltérersa stabilitéphysiologique (hypoxémie,
tachycardie) ou comportementale (rupture de sommeil). Des pics sonores pius modérés, dintensité
maximale <70 dBA, sontaussi en mesure d'altérer Ie bien-être physiologique, l'oxygénation cerebrale et Ie
sommeil de ces enfants. Des données attestent de la forte réactivité physiologique de grands prématurés a
des odeurs émanantde leurs produits de soins ou d'hygiène, et vectrices de stimulations trigéminales
pouvant altérer leur bien-être. Il en va de même pour une exposition excessive a une lumière intense au
cours des soins.
Les conséquencessur Ie développementneuro-cognitifa long terme de ce milieu potentiellement
dystimulant sont mieux connues et documentées. On sait aujourd'hui que cette exposition atypique,
répétée,etintensepeutmodifierl'architectureetla fonctionnalitédu cerveaudecesenfantsvulnérables.
Un des enjeux essentiels de la prise en soins de ces enfants est donc d'ajuster au mieux leur
environnement en milieu hospitalier a leurs capacités et attentes sensorielles. Les équipes soignantes
prenantenchargeles nouveau-néssontmisesaudéfide concilierd'unepartdesimpératifsde sécuritéet
de soins et d'autre part d'adapter l'environnement hospitalier a leurs besoins. Le respect de ces deux
objectifs est nécessaire pour prodiguer des soins de qualité. Le but n'est pas de mimer forcément
l'environnementutérinpources enfantsqui ne santplus desfoetusdepuisleur naissanceet évoluentdans
un milieu different. L'implantationde programmes formalisésde soins de développementet l utilisation
d'interventions précoces validées scientifiquement sont les meilleurs moyens pour minorer les effets
délétèrespossibles de l'environnement hospitalieret favoriserl'accèsde l'enfantauxsignauxsensoriels
d'origine maternelle [paternelle et familiale). Cet engagement pour une bientraitance hospitalière et une
meilleure qualité des soins est au mieux complete par des réïïexions ou des actions menées è I'échelle d un
hopital, d'un réseau régional de soins, et des sociétéssavantes au niveau national ou international. Toutes
ces démarchessontutiles a l'adaptationde l'environnementhospitalierauxexigencesdéveloppementales
des plus petits de nos patients et a une plus grande humanisation des soins qui leurs sont prodigués.
En guise d'exemple nous présentons ci-dessous les recommandations pouvant être formulées pour
l'environnement olfactifdes enfants prématurés.Lesrecommandationsspécifiquespourl'environnement
olfactif visent a offrir nouveau-nés prématorés une expérience sensorielle, sans sur-sollicitations ni
privations, favorisant leur développement au niveau physiologique, relationnel et comportemental.
L'exposition aux odeurs hospitalières devrait être minimisée, notamment pour les produits vecteurs de
stimulation du système trigéminal qui entravent l'accès a la « signature olfactive» de la mère:
suppression de l'utilisation des produits odorants dont l'utilité n'est pas prouvée, choix è efficacité egale
des produits les moins odorants pour des substances jugées essentielles pour les soins, respect d un temps
de séchage suffisant pour les solutions hydro-alcooliques qui sant la principale source d'odeur
nosocomiale.Lapratique dupeaua peaudevraitêtreencouragéeetsoutenuedésquepossible.
25 03 2015
"Douleur et inconfort en periode périnatal
Biblioeraphieoour en savoir plus :
Lecanuet JP,Schaal B (1996) Fetal sensory competencies. Eur J Obstet Gynecol Reprod Biol 68:1-23
LagercrantzH [2010] The NewbornBrain, Neuroscienceand clinicalapplication. 2nd Edition. Cambridge
University Press, Cambridge
Kuhn P, Zores-Koenig C, Astruc D, Dufour A, Casper Ch. Développement des systèmes sensoriels et
environnementphysique hospitalierdesnouveau-nésgrandsprématurés.Arch Pediaü-.2011Jul;18:S92102.
DeCasperAJ, FiferWP (1980) Ofhumanbonding:newbornsprefertheir mothers' voices. Sdence
208:1174-6
Varend! H, Porter RH, Winberg J [1994] Does the newborn baby fmd the nipple by smell? Lancet 344:98990
WidströmAM, Lilja G, DahllöfA,et al [2011). Newbornbehaviourto locate the breastwhenskin-to-skin: a
possible method for enablingearly self-regulation.Acta Paediatr100:79-85.
Schaal B, Hummel T, Soussignan R. Olfaction in the fetal and premature infant: functional status and
clinicalimplications. Clin Perinatol 2004;31:261-85.
Marlier L, Gaugler C,Astruc D, Messer J.La sensibilité olfactive du nouveau-né premature. Arch Pediatr
2007;14:45-53.
Kuhn P, Astruc D, Messer J, Marlier L. Exploring the olfactory environment ofpreterm infants: a French
survey ofhealthcare and cleaning products used in neonatal units. Acta Paediatr 2011;100(3):334-9
Kuhn P, Zores C, Pebayle T et al. [2012) Infants bom very preterm react to variations ofthe acoustic
environment in theirincubatorfrom a minimum signal-to-noiseratio threshold of5 to 10 dBA. Pediatr
Res 71:386-92
AAP (1997) Noise: a hazard for the fetus and newborn. American Academy of Pediatrics. Committee on
Environmental Health. Pediatrics 100:724-7
Doheny L, Morey JA, Ringer SA, LahavA (2011] Reduced frequency ofapnea and bradycardia episodes
causedby exposureto biologicalmaternal sounds. PediatrInt 54:el-3
KuhnP,ZoresC,LangletC etal. (2013) Moderateacousticchangescandisruptthe sleep ofverypreterm
infants in their incubators. Acta Paediatr 102:949-54
Kuhn P, Pebayle T, Langlet C et al. [2011) Do infants bom very preterm reactto nosocomial odors present
in their incubator?Evidencefrom physiologicdataPediatrRes 70:663
Levin A (1999) Humane Neonatal Care Initiative. Acta Paediatr 88:353-5
Haumont D, AmieI-Tison C, Casper C, Conneman N, Ferrari F, Huppi P, Kuhn P, Lagercrantz H, Moen A,
Pallas-Alonso C, PierratV, Poets C, Sizun J,Valls Y SolerA, Westrup B. Nidcap and developmental care:a
european perspective Pediatrics.2013Aug;132[2]:e551-2.doi: 10.1542/peds.2013-1447C.
Sizun J, Guillois B, Casper C, Thiriez G, Kuhn P. [2014] Soins de développement: de la recherche a la
pratique. EditionsSpringer,Paris,p 1-350.
25 03 2015
l
Douleur liée aux soins chez l'enfant premature:
Impact des soins de développement.
Pr Pierre Kuhn,
Médecine et Réanimation du Nouveau-né. CHU Strasbourg, France
Depuislestravauxd'Anand,la sensibilitédunouveau-néa la douleurnefaitplusaucundoute. La
capacité dunouveau-né, même tres immature a réagirphysiologiquement et au niveau comportemental a
la douleur est aussi evidente. Cependant l'évaluation de la douleur qui atteint l'enfant premature est plus
difficilecarl'informationnociceptiveesttraitéeparunsystèmeencoreimmature et endéveloppement
constant. L'expérience douloureuse pleinement vécuenécessite destraitements corticaux supérieurs
impliquant aussi les voies de l'émotion et de la motivation. Une activation du cortex somato-sensoriel
primaire a étémise en évidence [par technique de NearInfra-Red Spectroscopy, NIRS), lors d'un
prélèvement veineux chez des nouveau-nés désun age post-conceptionnel de 25 SA. Ces résultats
témoignentainsid'unepossibleperception« consciente» de la douleurmêmeen casdeprématurité
extreme. Pour autant l'évaluation de la douleur chez eet être préverbal, qui n'est pas capable de décrire
par la parole la sensation ressentie est un défipour les équipes soignantes. L'observation du
comportement des enfants et I'utilisation de plusieurs échelles validées, préférentiellement multidimensionnelles, permettent cependant généralement d'appréhender Ievécudouloureux des enfants.
Au cours de leurs soins, les nouveau-nés grands prématurés, font face a de nombreuses
stimulationstactilesdontlaplus grandepartestdenaturedouloureuse.Leurfréquencea étéévaluéedans
l'étude EPIPPAIN a un niveau médian de 16 [0-62]/jours dont 10[0-51] de nature nociceptive. L'absence
detraitement antalgique y étaitrelevée pour quasiment 4/5ème d'entre elles. L'ensemble de ces données
témoigne desactivations répétéesdu système nociceptifqu'elies peuvent induire. Lesprématurés et les
nouveau-nésa terme avecatteinte cerebralesontparticulièrementexposésetvulnérablesa ces
stimulationsatypiques,différentesenquantitéeten qualitédecelles présentesin utero. Maiscelan'est
pastoutcardufaitdesonimmaturitéautonomique,toutevenementstressantpeutinduireuneinstabilité
physiologique. Deplus, un inconfort et un sü-esslies auxinterventions humaines pendant dessoins
courants« standard»,mêmesupposésnondouloureux[changementdecouche,prise detempérature,
soinsdebouche) ontétésoulignésparplusieursauteurs.Demêmecesinterventions « banales» peuvent
même potentialiser la douleur liéeè des gestes reconnus comme douloureux si elles les precedent. Ainsi
des prélèvements sanguins réalisésimmédiatement aprèsdes soins courants entrainent une réponse
douloureuseexacerbéeet supérieurea celle observéelors d'unprélèvementveineuxréaliséen débutde
soinsaprèsuneperiodederepos.Ladistinctionentre stressetdouleurn'estpastoujours aiséemais
certainstypes deréponsespermettentde distinguerstress etdouleür.Lesdonnéesissuesdel observation
comportementale NIDCAPIe permettent aussi. Ainsi des mouvements d'extension des membres,
d'écartements des doigts, de baillements sont plus ft-équemment observés au décours d'un « soin
stressant» que « douloureux ».A l'inverse des mimiques fadales de douleurs, des changements d'étatde
vigilance sont plus fréquemment observés aprèsun geste douloureux qu'un soin courant«inconfortable».
25 03 2015
"Douleur et inconfort en periode périnatal
Cette distinction ne doit pas faire oublier que des stimulations répétéespeuvent réellement aboutir a une
hypersensibilitévoire a une allodynie [sensationde douleur liéea une stimulation normalementnon
douloureuse).
Laréalisationdessoins en utilisantdesstratégiesnon médicamenteusesde lutte contre la
douleurminoreles comportements dedouleuret/ou d'inconfortliesauxsoins.C'estIecaspourles
sü-atégiesdesoinsde développementutilisantdestechniquesd'enveloppementet deregroupement, de
succionnon nutritive, d'offre d'opportunitésd'agrippementou d'interactionsmains-bouche,de succion de
sirop de glucose. Des bénéfices identiques sont aussi apportés par des stimulations biologiquement
signifiantes [d'origine matemelle), concomitantes aux soins : voix maternelle parlée ou chantée,
stimulations olfactives de support. Lamajoritéde ces stimulations sontau mieuxdélivréesau cours du
peaua peau. Lesbénéficesphysiologiqueset comportementaux de cette expériencemulti-sensorielle
uniquesont largement reconnus.
L'évaluation fine et individuelle des signes de retrait et d'approche de chaque enfant par
l'observation NIDCAP permet de guider au mieux la réalisation des soins pour les individualiser. Elle
permet aussi d'ajuster au mieux leur durée a la capacité de tolérance de chaque enfant.
Laréductiondesévènementsstressants que subissentles enfants en unitéde réanimation
néonatale lors des soins apparait primordiale car une exposition a un nombre élevé de stimulations
stressantespeutaltérerIe développementcérébral[structure anatomiqueetfonction)du cerveaudes
enfantsgrandsprématurés.
Biblioeraphie cour en savoir plus :
CarbajalR,RoussetA, DananC etal. C2008]Epidemiologyandtreatmentofpainfulproceduresin
neonates in intensive care units. JAMA300:60-70
Sizun J,Ansquer H, Browne J, et al. [2002] Developmental care decreases physiologic and behavioral pain
expression in preterm neonates. J Pain 3:446-50
CatelinC,TordjmanS,MorinV etal. [2005) Clinical,physiologic,andbiologieimpactofenvironmentaland
behavioralinterventions in neonatesduringa routine nursingprocedure. J Pain 6:791-7
Holsti L, Grunau RE, Oberlander TF, Whitfield MF [2004). Specific Newborn Individualized Developmental
Care and Assessment Program movements are associated with acute pain in preterm infants in the
neonatal intensive care unit. Pediatrics 114(1):65-72.
Holsti L, Grunau RE, Oberlander TF, et al [2005) Body movements: an important additional factor in
discriminatingpain from stress in preterm infants. ClinJ Pain21:491-8
Holsti L, GrunauRE,WhifieldMF,et al (2006).Behaviouralresponsesto painareheightenedafter
clusteredcarein preterm infantsbombetween30and32 weeksgestationalage.ClinJ Pain22:757-64
Bellieni CV, lantorno L, Perrone S, et al [2009). Even routine painful procedures can be harmful for the
newborn. Pain 147:128-31.
Bellieni CV,CordelliDM,MarchiS,etal (2007).Sensorialsaturationfor neonatalanalgesia
din J Pain. 23:219-21.
JohnstonC, Campbell-YeoM, FernandesA, etal (2014J.Skin-to-skincarefor proceduralpainin neonates.
CochraneDatabaseSystRev. 2014Jan23;1:CD008435
Smith GC1,GutovichJ, Smyser C, et al (2011). Neonatalintensive care unit stress is associatedwith brain
developmentin preterm infants.Ann Neurol. 70[4):541-9.
PCS
The Pain Catastrophizing Scale
Naam:.. ...... ........................... Leeftijd:..... Geslacht:..... Datum:
Iedereen ervaart wel eens pijn in zijn leven, zoals hoofdpijn, tandpijn, gewrichts- ofspierpijn.
Mensen komen ook vaak in situaties terecht die pijn veroorzaken zoals een behandeling bij de
tandarts of een chirurgische ingreep.
Wij zijn geïnteresseerd in de soort gedachtenen gevoelens die u ervaartals u pijn hebt. In de
onderstaande lijst staan dertien beweringen die verschillende gedachten en gevoelens
beschrijven die mogelijk met pijn te maken hebben. Probeer aan te geven in welke mate deze
gedachten en gevoelens ook voor u van toepassing zijn. Maak daarbij gebruik van de
volgende puntenschaal.
O - helemaal niet
l - in lichte mate
2 - in zekere mate
3 - in grote mate
4-altijd
Als ik pijn heb...
1.
vraagik mij voortdurendafofdepijn wel zal ophouden.
2.
voel ik dat ik zo niet verder kan.
3.
is dat verschrikkelijk en denk ik dat het nooit beter zal worden.
4.
is datafschuwelijkenvoel ik datdepijn mij overweldigt.
5.
voel ik dat ik het niet meer uithoud.
6.
word ik bang dat de pijn erger zal worden.
7.
blijfik denkenaananderepijnlijke gebeurtenissen.
8.
verlangikhevigdatdepijn weggaat.
9.
kan ik de pijn niet uit mijn gedachten zetten.
10.
blijfik eraandenkenhoeveel pijn hetwel doet.
11.
blijf ik denken hoe graag ik zou willen dat depijn ophoudt.
12.
is er nietsdat ik kandoenom de intensiteitvan depijn te verminderen.
13.
vraagik mij afofer iets ernstigkangebeuren.
.....
Totaal
¥
DroilsRiiscTrós®199i
MichidJLSullhmi
PCS-CF
Nom:
Age:
Date:
Sexe:
Chacund'entrenousauraè subirdesexpériencesctouloureuses Celapeutêtrela douleurassociée
aux mauxdetête, è un mal de dent, ouencore la douleurmusculalre ou auxarticulatbns. IInous
arrive souvent d'avoir è subir des expériences douloureuses telles que la maladie, une blessure, un
traitementdentaireou une interventionchirurgicale.
DansIeprésentquestionnaire,nousmusöemandonsdedécrireIegenredepenséesetd'émotions
que vous avez quandvous avezde la douleur. Voustrouverezci-dessoustreize énoncésdécrivant
différentespenséesetémotionsquipeuventêtreassociéesè ladouteur. Veuillezindiquerè quel
point vous avez ces pensées et émotions, selon l'échelle ci<lessous. quand vous avezde la douleur.
0-pasdutout
1-quefquepeu
2 - defa?onmodérè
3-beaucoup
4-touttetemps
Quandj 'm de la douleur ...
11-!
j'ai peur qu'il n'y aura pas de fin a la douleur.
11_I je sensqueje nepeuxpascontinuer.
3\- i
c'estterrible etje penseque (a ne s'améliorerajamais.
4\-!
c'est affreuxetje sensque c'estplus fort quemoi.
"}
si-i
je sens queje ne peux plus supporter la doulêur.
si-i
j ai peur que la douteur s'empire.
-]
?1-i
je ne faisquepensera d'autresexpériencssdouloureuses.
si-i
avecinquiétude,je souhaitequela douleurdisparaisse.
»1-'
je nepeuxm'empêcherd'y penser.
n
ui-l
je ne fais que penser a quel point ya fait mal.
u i-l
je nefaisquepensera quelpointjeveuxqueladouleurdisparaisse.
"L_l il n'ya rienqueje puissefairepourréduirel'intensitédeladoulêur.
ui-l
je me demande si quelque chose de grave vaseproduire.
... Total
36
VF
Copyrighte l W?
Midrad JL Sullii-m
PCS
Age:.
CliëntNo.:
Sex: M(_J F(_J
Date:.
Everyone experiences painfui situations at some point Intheir tives. Such experiences may include
headaches, tooth pain. pint ar muscte pain. People are often exposed to situations that may cause
pain such as illness, injury, dental procedures or surgery.
We are interested in the types of thoughts and feelings that you have when you are in pain. Listed
betoware thirteen statements describingdifferentthougnts andTeelingsthat may be associatedwith
pain. Usingthe follow!ng scale, please indicatethe degree to whichyou havethese thoughts and
feelingswhenyou are experiencingpainO - not at all
1-toastightdegree 2 - toa moderatedegree
When Fm in
3 - to a greatdegree
paul...
f
l,_;
I vfssiry all the time about whether the pain will end.
;'_
I feel I can'tgo on.
i;-l
It's terrible and I think it's never going to get any better.
l\
,
'._i
It's awAil and I feel that it overwhelms me.
f:_l
I feel I can't stand it anymore.
"i_l
I become afraid that the pain will get vvorse.
[
7!_'
I keep thinking of other painfül events.
,Q
I anxiously want the pain to go away-
n
9l
.G
I can't seemto keqï it out ofmy mind.
I keep thinking abouthowmuch it hurts.
I keep thinking about how badly I want the pain to stop.
ïï
u;-'
There's nodiing I can do to reduce the intensity of the pain.
u ..- i
I wonder whelher something serieus may happen.
... Total
35
4-allthetime
4/03/2015
Psychologyof PAIN:"Justthinkingabout
it makes you want to scream
sometimes..."
Prof. dr. Erik Franck
Pijn = datgenewat iemanddie pijn ervaart, zegtdat het is, en
dat pijn bestaat, wanneer de persoon zegt dat hij/zij pijn
heeft
International «ssoclalton for the Study al Pain: "êËn Onplezierige SEnSOtie
en emotionele ervaring die is geassocieerd met
daadwerkelijke of mogelijke weefselschade of is
beschreven in termen van zulke schade en die wordt
gecommuniceerd met gedrag"
^
f^ -'». -» .
., ><»-..
-tlf-V--
crRwKHnai?
Hereditaire
Sensibele
en
Autonome
Pijn = onplezierige zintuiglijke of emotionele ervaring, die
gepaard gaat met feitelijke of mogelijke weefselbeschadiging of die beschreven wordt in termen van die
beschadiging
Vroeger...
Neuropathie
(HSAN)
Hoe meer pijnprikkels, hoe meer signalen naar de hersenen,
hoe meer pijn wordt ervaren...
Maar waarom ervaart dan niet iedereen dezelfde pijn bii
dezelfde weefselbeschadiglng
4/03/2015
Temporele aspecten
Acute, subacute, recurrente en parsisterende pijn
Deduurtijd datwe pijn ervaren zalonzeperceptie
bepaler
T *^ . .f-',
^c ». w
î " ..^.
>.
bs-a - -
'. ^. -fr , pw
fitQC^SîÏWV ! Sflf^t»tHSIt
^
'^ "^j;r>»
r^
K.
.
.
'.... -»
OOssi-,ft ï^. t. 't.
C Ï^. ÎW^TVIS
Ïïesctmïtmg
p9Ïhwaï- -..
^' /DA ^
. -'l-
t:"''^
.. »,.. ",.»
tt.
:T.
4/03/2015
Psychische impact van pijn
Pjjnonderzoekgeeft als belangrijkste psychosocialeeffed-en van pijn:
. Algemeen interesseverliÊS
* Concentratiestoomissen
. Gevoel van verlies aan autonomie
. Geyoelvan controleverlies
Irritatie/ agressie, woede
Allerlei angsten
. verandering van iichaamsbeeld, kwaadheid up het eigen lichaam
vemnindering van het gevoel van eigenwaardeen verandering van het zelfbeeld
daling van de libido, de affectieve en seksuele driften
zich sociaalterugtrekken, vereenzaming
het gevoel dat het teven geen zin, geen betekenis heeft (filosafische crisis)
een gevoel van hopeloosheid, uitzichtloosheid
een algemeen gevoe) van lijden
depressie
doodsangst
l
atles watje aandacht
geeft groeit
Aandacht voor pijn
Na een trauma is acute pijn vaakgeblokkeerd en de
persooniszichniet bewust van zijnverwondingen
Andersom blijkt dat aandacht ook kan leiden tot pijn zonder
weefselschade
Hoewelaandachtsprocessenbijnaaltijd automatisch
verlopen, is het een belangrijke stap in pijn perceptie
Vigilantie
voor pijn
Ontdekken van de
pijnbedreiging
Vigilantie ^.
Maar kan deels ook beïnvloed worden door psychologische
processen
Pijn vraagt aandacht,distractie kan pijn perceptie
verminderen
piekeren
4/03/2015
Pijn catastroferen
Te.ice^s cm te focussen op de pijn en ?ijn eigen
zelf-effectiviteh: êgat'efie evs'Le'-en
Catasircferer is tevens gerelcteerc aar:.
Depressie en nervositeit
Negatievealgemenegezondheidsstatus
Grotere beperking van sociale activiteiten
Lagerenergieniveau
Meer psychologische 'distress' en oijn-ge relateerde
beperkingen
Vicieuzecirkel (passieve pijncoping)
Catastroferen
Gedachten:
^ ^
iseencoping-respons
.
.
"ik kan niet tegen pijn'
*"ik kan mijn pijn niet beinvlaeden'
.
"ik moet een diagnose hebben'
.
*;k kan met pijn niet meerleven'
kar veranderen door
.. 'nijn pijn moe* "ledissh apgeicstwordfin'
csychoscdaie .rterventies
Emoties:
.
Angst
.
Boosheid
.
Irrrtatie
y^^"
f^, t
f»l^t,
r-f*y
l
Speelt ook een rol in
pijnintensiteit en
Gedrag:
.
.
.
Ve-mijden van activiteiten en beweging
Focuasenop pijn
Sleeds minder sociale contacten
pijnbeievirg tijdensde
^"^^-e^NS^ *-ïtr<
geboorte er i" het
FOStpc rtL.m
Emoties en pijn
Pijr beïnvloedt onzeemoties en onzeemoties beïnvloeden
onze pijnervaring
Negatieve emoties kunnen ep S manieren ge-eiateerd
zijn aan pijnperceptie:
. verhogen ssrratische sersifvteit
. kLrnen pijr verocrzaker (neurologisch)
. zijr hetRevolg van pijr
. Pijn ep negatieve emoties komen samen voer en
interaRsren
4/03/2015
Angst
Factoren die een rol spelen bij de afname
van pijnperceptie
Zelf-effectlviteit
Pijn-copingstrategieën
Bereidheid om te veranderen
Acceptatie
SPIERSPANNING
Rjngedrag
Pijr'tietfrtny
\
i /'
'\ c
Pijngedrag
^
..^'
Watwe doen wanneerwe pijn
s»' ^ '> .-^ nw se -w
ervaren noemt men pijngedrag
f.
Het wordt beïnvloed doorzijn
gevolgen
pijnGedrag
Pijn wordt Zichtbaar door gedrag
Factoren die pijngedrag beïnvloeden
Zelf-effectiviteit
Het niveau waarop en hoe iemand zal reageren is
multifactorieel bepaald
Zelf-effectiviteit verklaart voor een deel coplng aan
pijncondities
Qntwikkeiingsniveau
De psychologischetoestand
Angst
Persoonlijkheid
Wanneer HV zelf-effectiviteitoi/encrtotten
Wanneer HV zelf-effectiviteitoncferschotten
Geslacht
Distractie
Verwachtingen
Ge7insomstandigheden
Culturele factoren
---':(?r a.. ', .o'trs'r
L. ~-r
^'j
>^
4/03/2015
Aanvaarding
Pijn-coping strategieën
Cccire Bericht op reductie van oiin:
CopingSkiBs
Betere aanpassing aan blijvenae pijn
Relaxatie
Legere nveausva'- pijrgerelateerde angst en vermiid;ne,
Afieicirg
deprEssie, fysieke en psychoiogische beperkinger
herdet:niëren
Actief sroces
Expressie van emoties
Zoeker van emotionele steun
Zoeker naar spiritueel comfort
Pijnbestrijding
Begint bij de diagnose van pijn
Meten = weten
Vervormingen op2niveELS'
. Tss Ce puur sc-netische en Ce belevingervan deer de
patiënt
. Tss de pijnbeleving en de registreerbare mecedeling
Pijnbestrijding
Richtlijnen voor vroedvrouwen
Vertrouwen w;n"er e-be"cuder
L'c^smel.jke, psychische e'- scciale factoren
CatEstrofere":"herkederen"
! verstrekker
Aanmoedigen om pijn te uiten
Is er sprake van angst? Zo ja, niet negeren maar
benoemen er bespreekbaar maken
4/03/2015
Afleiding werkt
Post-op chirurgischE patn: zij
die hun pijn vaker moesten
beoordelen
ervoeren
erik. franck@uantweroen. be
erik. franck@kde. be
meer
pijn
Bedankt -Thanks - Merci
Afleiding werkt het beste voor
een lage of gemiddelde
pijnintensiteit en wanneer de
afleiding emotioneel geladen
Dovep-ess
'v-
Research and Reports in Neonatology
REVIEW
Analgosedation in neonates: what we know
and how we act
Karel Allegaert '2
CarloVBellieni3
'Department of Development and
Regenerat'on, 2KL Leuven and
Neonara' Intensive Care Unit,
Un;vers:ty hospitals Leuven. Belgium;
SDeparur, ent of Ped'atrics, Obstetrics
and Reproduction Med;cine,
Univers'ty of Siena. Siena, Ita'y
Abstract: Inadequate pain management in neonatal Hfe impairs the neurodevelopmental
outcome.Italterspainthresholds,painandsiress-ralatedbehavior,andpliysiotogicresponsesin
la:er!its. At the sametime, there are emergingauimal experimental anahumanepidemiologie
data on the impact of anaÏgosedatives on neuroapopto&is and impaired neurodeveiopmental
outcome. As a consequence. the map. agement ofaeonatal pain is in search of a new equilibrium since diese cor.f.icting (undertreatniem versus overtreatment) obsen-auons are (he main
drivers ofits current management. Such tailoring includes new treatment modalities, and also
rr.ore effective implementation strategies. The search for tailored nonpharmacoloeic (ie, less
invasive techniques, preventive strategies. complementary techniques) and pharmacologic
(eg, dexmedetomidine, intravenous aceiaminophen, reir.ifemanil) treatir.ent modalities are
discussed anj reflect the increased knonledge on neonaal pain ma.nag.iment. Despite this
increasingknowledge("toolbox")regardingneonatalpain,there is sti1l a major gapbetween
kuowledge("whatweknow")andpractice("howweact").Consequentiemorere'.earchactivity
on methods for effective implementation of the available knowledge is needed. Illustrations of
effective approaches, eg, the Evidence-Based Practice for Improvine Quality (EPIQ) initiazive,
to bridge lllis gap are provided. This is followed bv an intersubjective proposal on priorities for
contemporary dinical management and a research agenda.
Keywords:pain, newborn, prevention. gi.iidelines
Introduction
Why pain management in neonates is of retevance
Already more than ihree decades ago, the myth that immaturity precludes neonates
from pain perception and its negative eflFects was rejected bv Anand et al when they
documemedthat inadequateperioperativeanalgesiaresultedin highermorbidityand
mortality. ' Moreover, it became apparent tliat these negative effects were not limited
to neonatallife, butvverealsoobservedinlaterpediatriclife andbeyond. -"iInessence,
adequateanalgesiainneonatesshouldnotonlybeendrivenbvempathyorethics,but
is valid, appropriate, and needed medical and nursing care.5
More recently, experimemal daiain animals have provided evidence that perinatal
Correspondence: Karel Allegaert
Neonatal Intens've Csre Unit.
University Hospita!, Herestraat 49,
3000 Leuven, Belgium
Tel-32 '634 3850
Fax+32 :634 3209
exposureto analgosedativesalsoresultsin reducedbraingro\vth, decreasedneuronal
packing density, and less dendritic growth and branching.6'7This is because of the
impact of analgosedatives on axonal growth and apoptosis of neuronal tissue. There
seemsto beanage-relatedwindowofvulnerabilityforapoptosisordendriticchanges
relatedto humanneonatallife and infancy.respectively. Theseanatomie findingsare
Email kareLallegaert@uzleuven. be
associated with learning and motor disabilities.
submit your maiiuscript |
Research and Reports in Neonatology2013:3 51-61
/ A-. dnvt- -P--
http' -i-.. '. .. nt-g;!C. :i47";k:<. S376ïï
51
©MI] UijaEilaidIdliini.Ihi!m* is publi*lds. ;t.i "K'c;'nis in-'Klni ;;i-!iimii- &nli«ConimiAtibulion- Ki' Csr-wcil :;rF;'»;, .'.Sj
Dovep.. ^<
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may he fwnd
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tom/p«rmiB.
:r:.i;:,:
Allegaert and Bellieni
Dovepress
Extrapolation of animal experimental observations
Now we know that babies are full patients in terms of
to the human newborn are obviously limited and mainly
theirrights,andthatneonatesdofeelpainandareevenmore
vulnerableto pain.Thesemorevulnerableneonatesareprecisely those that aremost exposedto painful interventions.
Finally,thesubjectivityinherentinneonatalpainassessment
based on associations. 6 9 There are data on an association
betweenmajorneonatalsurgery(numberofinterventions,
disease severity) and neurodevelopmental impairment.
However, exposure to analgosedatives is only one of the
factors associated with a negative outcome. Obviously,
neonates who repeatedlyundergo anesthesia during infancy
are more likely to have other risk factors for impaired
neurodevelopment. At the same time, we know from animal
experiments and the clinical studies by Anand et al that
probably further contributes to the wide variety ofpractices.
All these reasons explain why pain management in neonates
warrants a focu.sed, population-tailored, individualized
approach related to assessment, treatment, and preventive
strategies since all these aspects (assessment, treatment,
prevention) have population-specific issues (Figure l). 10
surgerywithoutanalgesiahasa majorimpactonmorbidity
and mortality. 1-"'7
Measurement/assessment
Why pain management
in neonates is different
The absence of verbalization is very likely one of the most
important obstacles to proper diagnosis, quantification, and
treatment ofneonatal pain. Pain in the newbornis often not
From the above-mentioned arguments, it is obvious that
effective pain management is an important indicator of the
easily recognized and remains commonly undertreated or
untreated. 10"13In general, if a procedure is painfulin adults,
qualityofcareprovidedto neonates,not only from an ethical standpoint,butalso in terms ofprotectingthe long-term
outcome. ''9 Neonates cannot assert their rights, and their
it should be considered painful in neonates. Because the pain
thresholdis lowerin the newbom, it is reasonablethat pain
reactions to pain are not so evident as in adults. Moreover,
will be greater in neonates compared with adults for a similar procedure. Newboms depend completely on caregivers
medicaltreatmentinitiallyhasa strongfocuson savingtheir
lives, acceptingthatwell-beingis only secondary.
This includes aspects related to comfort and stress reduction,
(parents, healthcareprofessionals)to recognizetheirneeds.
Treatment
Maturational aspecls affect drug dose (pharmacokinetics)
Changes 'n praclices affect primary oulcome variables (pharmacodynamics)
''
' .\
Assessment
Prevention
Pain scaies
Growing evidence on effectiveness
of non-pharmacological modalities
\
Intersubjecfivit-y
Hetero-assessment
/
Individualized approach
Combinaüon of unit specsfic guideilnss
and Ehe individuai needs of the newborn
Figure l Why pain management in neonates warrants a focused approach.
^^
submityourmanuscript
Dovepre-sii
Research and Reports in Neonatology2013:3
Neonata! pain management
Dovenress
and should cover evaluation/assessment, prevention, and
managementofpain. .
Treatment
When we apply the concept of developmental pharmacology to analgosedatives in neonates, this should be based on
systematic assessment (pharmacodynamics,concentrationeffect), titrated administration ofthemost appropriate analgesia(pharmacokinetics,concentration-time),andreassessment
was receiving concurrent analgesic or anesthetic infusions
forotherreasons.Consequently,the investigatorsconcluded
that large numbers ofprocedures were performed and most
were not accompanied bv analgesia. 19 The?ie findings are
unfortunately very similar to the data published by Simons
etal andcollected5 vearsearlier.23In theirdatasetcomprising
151 preterm neonates, each neonate was subjected to 14±4
procedures per day. Pre-emptive analgesiawas provided
to less than 35% of these neonates. and about 40% did not
(pharmacodynamics)to adaptandtitrateexposuretoeffects
receive anyanalgesic therapy during their stayin the neonatal
(pharmacodynamics).5
Clinical management and subsequent primar\' pharma-
intensive care unit. 20
Similar results were reponed when practices were com-
codvnamicoutcomevariablesshifted.To illustratethis,respira-
pared between two time intervals in the same region. 21-22
torysupportaftersurfactantadministration(InSuRe[Intubation,
Surfactant andRapidExtubationj) ismuchmore common than
Survey data on analgesiapolicy andpractices for common
invasive procedures at Italian neonatal intensive care units
prolongedventilation, andhôthemiiahasbeenintroduced
were compared forthe years 2004 and 2010 to ascertain the
as aneffecrivetooi to treatperipartumasphyxia.' This results
in the need for new pharmacokinetic/pharmacodynamic data
extent to which neonatal analgesia for invasive procedures has
in new (sub)populations.
changed since publicarion ofthe Italian guidelines. According to paired data from 75 neonatal intensive care units,
the practice ofpainmonitorinehasbecome more common.
Preventive strategies
However, only21% and 17% ofneonatal intensive care units
Environmental (noise, light). behavioral (positioning) and
nonpharmacologic (sucrase, breastfecding, pac'fier) iutervemions can prevent, reduce, or eliminate pain and may
routinely assessedpain during mechanical ventilation and
after surgery, respectively. Similarly, routine use ofmedication for major invasive procedures was still limited (35% of
lumbar punctures, 401:/o oftracheal intubations, 46% during
improve comfort. Suchinterventinns need to be validated
first, and subsequent;y compared and integrated in routine
care. 14"17Following validation, emphasis should be placed
on integration. Promotion of clinical research, diffusion of
knowledge, and validation of the effectiveness of imple-
mechanical ventilation) and postoperati\'e
mentation strategies to improve analgosedation remain
largely midertreated andunderscored in this age group. 21'22
crucial.
Similar conclusions can be drawn when we focus on pain
Despite this, we do not stick
management during a specific procedure (heel lancing,
Europe), 23 or 011 pain assessment (Sweden). " At the least,
to the guidelines
there is still room tor improvement.
Despite ethical issues, increasing awareness, and the availability ofguidelines on procedural pain, neonates still often
experience avoidable pain. " The discrepancy betvveen the
available knowledgeand clinical practice has been reillustratedbvCarbajaletal. I9Epidemiologiedataontheincidence
This review illustrates the progress made in the search
for better tailored nonpharmacologic and pharmacologic
interventions, without being a systematic review of all
studies reported on such interventions in neonates. Tailored
ofpa'.nfulproceduresandtheirmanagemer.t duringthefirst
niques, preventive strategies, andcomplementarv- techniques.
Tailored pharmacologic interventions focus on new compounds (dexmedetomedine, intravenous acetaminophen,
remifsntanil).Inadditionto providingadditionalknowledge
on neonatal pain management, we also focus on the need to
do more research regarding meihods tor effective implementation ofsuchknowledge.This is becausethereis still a
gap between knowledge (what we know) and practice (how
we act). Illustrations of efFective approaches to bridgethis
14 days of admission were prospectively collected over a
6-week period (2005-2006) in 430 neonates admitted to
tertiary care neonatalintensive careunits in theParisregion
of Francs. Of 42,413 painful procedures identiced, 2. 1°/o
were performed with pharmacologic therapy only, 18.2%
with nonpharmacologic therapy only, 20. 8% with pharmacologic and nonpharmacologic therapy, and ''9. 2% without
speeific analgesia; 34. 2% were performed while the neonate
Research and Reports in Neonatology2013:3
pain treatment was
also inadequate. Consequently, the authors concluded that
despitethe improvements in neonatalanalgesiapracticesin
Italysincethenationalguidelineswerepublished,painisstill
nonpharmacologicinterventionsfocusonlessinvasivetech-
suhmit ycur manuscnpt
53
Dovepress
gap,eg,the Evidence-BasedPracticeforImprovingQuality
(EPIQ) initiative and care bundles, will be provided. This
ingly, the lancing with sucrose group still had higher scores
compared with the venepuncture without sucrose group (470
is followed by an intersubjective proposal on priorities for
versus 230).
contemporary clinical management and a research agenda.
Endotracheal suctioning is also a stressfül procedure,
commonly associated with pronounced fluctuarions in vital
signs. Cordero et al compared two endotracheal suctioning
frequencies in preterm neonates and concluded that there was
Tailored nonpharmacologic
treatment: intensive "care"
nobenefit ofsystematicroutine suctioningwhencompared
in addition to intensive "cure"
Not only what but also how we perform
procedures matters
Environmental (noise, light), behavioral (positioning), and
nonpharmacologic(sucrose,breastfeeding,pacifier)interventionscanprevent,reduce,oreliminatepain,andmayimprove
comfort. Adaptationsofprocedural techniques or practices
may be a very powerful method of preventing pain and
reducing stress. 9'16'17 Such strategies include light and noise
reduction,nestingorswaddling,minimizingpatiënthandling
(eg, preserving free periods for sleep, avoidingconsecutive
blood sampling, clustered care), use of central venous catheters insteadofmultiple peripheralperfusions, individualized
monitoring techniques (registration ofvital signs, blood pressure measurement intervals), tailoring nursing techniques (eg,
frequencyofendotrachealsuctioning,skinandwoundcare,
tape andwound dressing), andpromoting skin-to-skin contact
between newborns and parents. In essence, methods matter,
and adaptations ofexisting techniques can be very effective
in reducing pain. The available evidence is illustrated based
on published data related to venous blood sampling and
endotracheal suctioning in Tieonates.
Venous blood sampling is commonly performed in
neonates. In addition to complementary interventions like
non-nutritivesucking,sucrose,orcontainment,thetechnique
usedforblood samplingis alsoofrelevance, asshownin two
studies including 120 and 100 healthy term neonates. In the
with suctioning as needed. 27 Based on these findings, an
evidence-based protocol whereby ventilated newborns were
suctioned only asneeded according to clinical indicators was
developed. This protocol was subsequently introduced as
part of a collaborative quality improvement initiative2 8 and
rcsultcd in a significantdecreasein thenumberofprocedures
performed. 29
In addition to frequency ofsuctioning, procedural adaptations (disconnection, deep versus shallow) may also reduce
distress. There is evidence to suggest that endotracheal suctioning without disconnection improves the short-term outcome
when focusing onvital signs, likely reflecting a reduced stress
response.30 In contrast, diere is no evidence of the benefits
or risks of deep versus shallow suctioning of endotracheal
tubes in ventilated neonates. 31Disconnection and deep versus
shallow endotracheal suctioning have been evaluated in two
recent Cochrane meta-analyses. 30'32Using a crossover design in
252 infants to compare endotracheal suctioning with orwithout
disconnection, suctioning without disconnection resulted in a
reductionin bothfrequencyand severityofhypoxicevents. 30
Similarly, endotracheal suctioning without disconnection
resulted in a more limited changein heart rate. The number
ofinfantshavingbradycardiceventswasalsoreducedduring
closed suctioning. Interestingly, four-handed care to facilitate
containment during endotracheal suctioning also resulted in a
significant decrease in stress and defense behavior. 33
studybyLarssonetal,venepuncturebyneedlewascompared
witheithera small orlargelancet(heel lancing).25Sampling
Add-on value of nonpharmacologic
with only one skin puncture was successfül in 86% (needle
puncture), 19% (small), and 40% (large lancet) of cases, and
median time for collection was 191, 419, and 279 seconds,
respectively. Lowerpain (Neonatal Facial Coding) scores were
recorded in the needle group than using either of the heel
Awareness of the persistently high number of painful
procedures perförmed, combined with concerns regarding
the potential adverse effects of drugs and perhaps also the
aim to involve parents, has resulted in evaluation of alternative, nonpharmacologic interventions in neonates. ' 10
Nonpharmacologic interventions have wide applicability
for neonatal pain management alone or in combination
with phannacologic treatments. These interventions are not
necessarily substitutes for or alternatives to pharmacologic
interventions, but are complementary. Nonpharmacologic
interventions can reduce neonatal pain indirectlyby reducing
lancingtechniques. Similarobservations were reported in a
study by Ogawa
et al2 6 in which 100
healthy term
neonates
were randomly allocated one offour groups (venepuncture
versus heel lancing, oral sucrose versus water). Using this
design, the Neonatal Facial Coding score was significantly
lowerin the venepuncture group (230 versus 580). Interest-
54
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interventlons
Research and Reports in Neonatology 2013:3
Neonata' pa'n management
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the total amount ofnoxious stimuli anddirectly bv blocking
nociceptive transduction or transmission, acüvation of
descending inhibitory pathways, or by activating attention
andarousalsystemsthatmodulatepain.Non-nutritivesucking. providing sucrose, glucose, or human milk, swaddling
andcontainment procedures,sensory stimulation, andkan-
self-regulatory ability when swaddled. When compared
with massage alone, excessively cr\-ing infants cried less
when swaddled. In neonatal intensive care units, the data
are somewhat more contradictory. In meta-analysis, it seems
that swaddling has a pain-reducing effect, maintained for
longerintermneonatesthaninpretermneonates.38Because
garoo care are complementary interventions.33"37 Some of
the primary outcomes of studies related to swaddling and
the available evidencs on the benefii tor analgosedation m
containment are less commonlv summarized, an illustrative
overview of studies on facilitated tucking in of (pre)term
neonates is summarized here.
neonates (either or not combined or compared with other
Non-nutritive sucking
complementaryinterventions) is providedin Table 1.37.3M8
There is limited evidence on the use of non-nutritive suck-
Most of these studies were not blinded, had a crossover
ing asa single intervention to promote behavioral outcomes
andgastrointestinalfunctionorfeedingtoleranceinpreterm
and high-risk full-term infants, but it has been linked
design, andordereffects are rarely reported. However, the
to a reduced length of hospita! stay and improved pain
management.
3U :':-
Non-nutritive sucking does
not
appear
to
have any short-term negative effects, but data on long-term
outcome are not available. Forprocedural pain management,
aacifiers reduce pain scores in neonates. .
Sucrose, glucose, and human milk
available evidence suggests a modest reduction in pain
with a laster i-eturaofphysiologic fluctuations to baseline.
Facilitatedtucking alone was less effectivewhencompared
withuseofsucrose. However,facilhatedtuckingin combination with sucro.se had an added value (ie, synergism) in the
recovery phase, with lower pain scores compared with both
single interventions. 45The same synergism concept hasbeen
documentedwhencombiningbreastfeedingwithskin-to-skm
contact for analgesiaduringheel prick.37
The most extensively evaluated nonpharmacologic interven-
tion. for procedural pain relief in neonates is oral sucrose
(12°/o-'249o),glucose(30%),ormother'smilk,withorwithout
non-nutritivesucking(pacifier). It isbelievedthatthe effects
ofsucrose and non-nutritive sucking are mediated byboththe
endogenous opioidandBonopioid systems. 3-'"-'7Thers ismetaanalyricalevidencein supportoftheuseoforalsucrose24°o,
glucose30%,ormother'smilkincombiuationwithapaciner
shortlybeforea painfulprocedure(eg,bloodsampling,nasogastric tube placement, immunization. 'vaccination). -"53 Compared with topical anesthesia, acetaminophen, or tnorphine,
glucose;sucrose resulted in the most prominent decrease in
pain during heel prick procedures. '5"37 Consequently, this
becamethe mostcommonlyusedintervention for procedural
Multisensorial stimulation and sensorial saturation
Sensorial saturation refers to multisensorial stimulation
consisting of simultaneous delicate tactile. gustaiive, auditory, andvisual stimuli. 43This procedure consists of simultaneously attracting the infant's attention by massaging the
iüfant's face; speaking to The infaat gently but firmly, and
instilling a sweet solution onthe infant's longue. Nonpainful
stiir.ulationby engaginga numberofchannels(ie, auditory,
tactile, visual, vestibular, gustatory) is thought to compete
with the painful sensor^' input. In a recent systematic review
on this topic, ten studies were retrieved that had evaluated
at least partial sensorial saturation. Based on the evidence
collected, theuse ofanoral solutionaloneseemedto beless
analgesiti in iieuiiates. To niake it i-nore cffective, this should
be combined with use of a pacifier and the sweet solurion
should be administered on the tongue shortly (2 minutes)
before the start of the intervention. 3"" This time interval is
effecrivc than sensorial saturation, whiïe sensorial stimulation
without a sweet oral solution was ineffective. "5Consequently,
h was concluded that sensorial saturation could be used for
thought to refleci endogenous opioid release. Interestingiy,
breastfeedingin additionto holdingandskin-to-skincontact
provided superioranalgesiaduringheel prickwhen compared
effective than oral sugar alone and promotes interaction
between the caregiver and infant.
with sucrose with or without skin-to-skin contact. 37
Swaddlingand containment
Preterminfantsshowimprovedneuromusculardevelopment,
lessphysiologic distress, bettermotor organization, andmore
Research and Reports in Neonstology 2013:3
newbornsundergoingminor painful procedures. It is more
Tailored pharmacologic
treatment modaiities
Whentheconceptsofneonatalpharmacologyareappliedto
neonatalanalgosedation,theyshouldbebasedonsystematic
assessment, followed bv correct (eg, titrated administration,
55
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Table l Studies on fadlitated tucking combined or compared with other complementary inter/entions
Reference
Corffetal3'
Study design
Randomizedcrossoverstudy in 30 preterm neonates (25-35 weeks)to comparetheeffectsoffacilitatedtuckingwiththoseof
routine care on vital signs and sleep disruption after heel lancing. Facilitated tucking resulted in a lower heart rate, a shorter crying
time, and less sleep disruption.
Fearon et al'"
Responses of 15 preterm neonates to swaddling after a heel lance were quancified. Procracted behavioral disturbances were
reduced b/ swaddling.
Ward-Larson
et i\v
Hill
et
al1 2
Randomized crossover study in 40 preterm neonates (23-32 weeks) to assess the impact offacilitated tucking (second nurse) on
pain related co endotracheal suctioning. Painexpression durjng facilitated tuckingwas significandylower.
Randomizedcrossover study in 12 preterm
neonates
(25-34 weeks) to compare the impact of facilitated tucking with routine
care
on the stress response during routine nursingassessments. Nine of 11infants received a lower PIPPscore with facilitated tucking.
Axelinet al"'
Prospective, randomizedcontrolled trial in 20 preterm neonates(24-33 weeks)to assessthe impactoffaciliatedtuckingby
parents on pain expression (NIPS)and vital signs duringendotracheal/pharyngealsuctioning. Facilitatedtucking resulted in a lower
NIPS (median 3-5) score.
Liaw et al"
Randomized, controlled crossover trial in 34 preterm neonates (29-37 weeks) to compare non-nutritive sucking with facilitated
tuckingand routine care on pain responseafter heel lancing. Both facilitated tuckingand non-nutritive suckingresulted in a reduced
pain response, but non-nutritive sucking was more efFective.
Cignacco
et
Randomized controlled trial in 71 neonates (24-32 weeks) to assess the effect of sucrose, facilitated tucking, or both, on the pain
al15
following heel lancing.
resulted in synergism.
response
Liawet al'"
Facilitated
tucking
was
less effective
compared with sucrose. Combination of
both interventions
Sundaram
Randomized controlled trial to assess the impact of non-nutritive sucking, sucrose, and facilitated tucking either alone or combined
on sleep-wakestates after heel lancingin 110 infants (gestational age 26.4-37 weeks). Combined non-nutritive sucking, sucrose,
and facilitated tucking resulted in the best preservation of the infant'ssleep-wake states.
Randomized, controlled, crossover pilot study in 20 preterm neonates (28-36 weeks) to compare the impact of facilitated tucking
et al'"
with no intervention after heellancing.Faciliiaiedtuckingresulted in significandylowerpainscores.
Gerull et al'16
Compare the influence of faciltated tucking, sucrose, or both on cortical activation, heart rate, and periphenl oxygen saturation
(SaO., ) after 125 heel lancing procedures. Sucrose was more effective in reducing the reaction to pain than facilitated tucking.
Application of both interventions had no additive effect
Marin Gabriel
et
al37
Breastfeeding with skin-io-skin contact, compared with sucrose with or without skin-to-skin contact during heel lancing.
Breastfeeding
with skin-to-skin
contact
provided superior analgesia
when
compared with
both individual intervenrions.
Abbreviations: NIPS, Neonatal Infant Pain Scale; PIPP, Premature Infant Pain Profile.
loading dose) administration of the most appropriate analgosedative (eg, effects/side effects) with subsequent reassessment ofthe newborn and, ifindicated, further adaptation
(eg, increase, decrease, synergism). 5'9We aim to illustrate the
progress made based on aspects ofthe pharmacokinetics and
pharmacodynamics of specific newly emerging compouuds
(dexmedetomidine, intravenous paracetamol, remifentanil)
in neonates. Although these compounds have "dripped" into
our units, we need to be aware that the evidence in support
of these newer compounds is still limited.
Optimal analgosedation is rapid in onset, predictable, unre-
central postsynaptic <x2-adrenoreceptors, leadingto inhibition
of norepinephrine release, resulting in sedative, analgesic,
opioid-sparing, and anxiolytic properties, as well as side
effects such as hypotension or bradycardia. 50-"
Dexmedetomidinehas many claimed theoretical advantages over standard sedatives with regard to adverse drug
reactions and does not affect respiratory drive. 52"54At present,
clinical experiencewith dexmetomidinein neonates is only
anecdotal. 51 However, it holds promise as a useful tooi for
analgosedationin neonates.
Dataare not yet availableto
fonnulate any recommendation, except for the fact that this
drug should only be used in clinical studies to obtain valid
data on the risk/benefitprofile in neonates.
lated to active metabolites, and shows rapid dissipation of
effects on discontinuation.Preferably,the drugis nonaddic-
Acetaminophen
tive (physical dependence orwithdrawal on discontinuation),
andwithouttoleranceoradverseeffects.9'50Dexmedetomidine
Acetaminophen is thé most commonly prescribed drug for
mild to moderate pain, including in neonates. In addition to
may become a potentially useful compound to attain this
in neonates. Dexmedetomidine is a strongly lipophilic
oü-adrenoreceptor agonist with a oc2/0tl activity ratio of
1, 620/1. Its mechanismofaction is via G-protein activation
enteral formulations, intravenous formulations are available.
Dexmedetomidine
,
56
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Such formulations enable administration when the enteral
route cannot (yet) be used and should improve predictability by reducing variability in absorption. 55 The effect
Neonatal pa. n management
Dovepress
compartment concentration for acetaminophenof l O mg/L
is achieved following administration of a loading dose. 56'5'
Compared with opioids, tolerance does not develop during
repeated administration, but there is an analgesic ceiling
effect. s6'57 Based on these facts, the concept ofmultimodal
analgesia has been introduced in neonatal intensive care.
more recently remifentanil havebeenevaluated, mainly for
shortproceduressuchasendotrachealintubation,retinallaser
surgery, or percutaneousintravenouscentral catheterplacement, and there is some anecdotal experience during major
surgery or maintaining analgosedation during mechanica!
ventilation. 62 Remifentanil hydrochloride is a short-acting
Veryrecently, Ceelie et al documented a clinically relevant
^l-receptor opioid agonist. It achieves its peak analgesic
and significant (-66%) morphine-sparing effect in neonates
cotreated with intravenous acetaminophen following major
Tioncardiac surgery, thereby documenting the validity of
multimodal analgesia in neonates. 55
Incontrast, acetaminophen hasa limited analgesic effect for
procedure-related pain. Shahet al documented that admmistration of acetaminophen (20 mg/kg orally') was ineffective for
pain relief related to heel prick. 5IIThe efFects ofacetaminophen
(20 mg.. 'kg rectally) in neonates following vacuüm extraction
has been documemed bv Van Lingen et al. s:'Acetaminophen
improved their clinical condition (eg, drinking behavior), but
withoutdifferencesin painscores.Very recently, usinga preemptive approach (ie, in all cases, in-espective ofpain score) in
123 term neonates following assisted vaginal delivery, infants
effect within a minute ofadministration, ie, 3-4 times faster
bom bv assistedvaginal deliverv'had lovv pain scores in the
infusion during percutaneous central catheter placement
in preterm infants, 54 preterm neonates were assigned to
remifentanil infusion (0. 03 .iLg'kg per minute) or placebo
when compared with fentanyl and much faster in comparison
withmorphine.62
Table 2 summarizes the studies on endotracheal intu-
bation with remifentanil in neonates. and illustrates the
variability in strategies and outcome criteria.""" There is
variability ir. the clinical chaTacteristics (preterm or term,
use of InSuRE, or continuation of ventilation), outcome
criteria (intubation score, duration ofprocedure, physiologic
variables), comedication, and doses (1-4 ,u,g/kg intrave-
nously, slowbolus) evaluated.Thetotal numberofneonates
expo&edto remifentanilinthesestudiessuggeststhatfurther
studies on dose-seeking and safety are needed. To assess the
analgesicandprocedur&l elïcacy oflow-doseremifentanil
hnmediate period after birth, irrespective of acetaminophen
exposure. 61 However, acetaminophen (20-25 mg/kg rectally)
given to term newborns shonly after birth was associated with
an aggravated subsequeni stress response during heel lancing
on day 2-3 ofpostnatal life. 61
in addition to 0. 3 mL of 12% oral sucrose combined with
non-nutritive sucking. " Pain scores were sigcificantly lower
in neonates exposed to remifentanil, suggesting bettei pain
and distress cor. trol without a difl'erence in duration of the
Remifentanil
procedure. In essence, remifentanil is a very short-acting
Besides morphine and fentanyl, there are also observaticms on
compound with limited reported experience in neonates at
this time. Its pharmacologic profile seems suited for short
shorter-actingopioidsin neonates.Alfentanil,sufentanil,and
Table 2 Studies of remifentanil for endotracheal intubation
Reference
Study design and results
Pereirae Silva
et ai"
Welzing et ïlt'
Double-biind,random'zedcontrolled trial in 20 preterm neonates (28-34 weeks) to evaluate irtubation conditionsfollowing
morphine 150 ug/kg or rem. fentanl ' jlg/kg, both with midazoiarr 0.2 mg;kg. Overall condition was better in the rem;fent2nil group.
Prospective study in 21 preterm neonates (29-3' weeks) irezted with rem'fentanil 2 j..g.;kg and atropine l O ^g/kg lor the InSuRE
procedure. Outcome variables were intubat. on conditions. time until extubation, and comp ications. Intubation conditions were
rated as excellent orgood. Averageextubationtime after surfactint was '6.9 (range 1-45) minuies.
Double-blind, randomized controlled trial in 30 (pre)term neonates. Remifentani! 3 ug/kg was compared with fentanyl 2 |^g/kg
and succinylcho'ine2 mg/kg. No differences were found in t;me until successful ;rtubat:on ('56/247 seconds). Premedication
with remifentani' attenuaied physiologic respoiiies;ilur'iig iiitubaiuii comparablew'lh those of fentany; and succiny;cholinein
neonates. Intubat.on conditions were rated more favonbly with fentanyl and succiny;choline. Muscu;ar rigid'tywas observed in the
Choong et al"
remifentani' group (n=2/15).
Hume-Smith
et
al6i
Norman
etal"
Remifentani; effective dose-seeking(ED;,) study in 20 neonates and young infants ^mean weight5.9 kg). When coadministered with
glycopyrroiate
lO
ug/kg and propofo;
5
mg/'kg.
the ED
of
remifentanil was 3. l -3. 5 pg/kg.
Randomized controifed trial ;n 34 preterm neonates (<37 weeks). Atropine/morph'ne compared with giycopyrroiate. thiopental,
suximethonium, and remifentan'! (l j^g/kg). ;ntubation score was superior in the remifentanil group [5 (iQR 5-6) to 12(IQR 10-13. 5)].
Fluctuatior.s in phys;o;ogicvariab.es weremore pronounced and prolonged itcer rrorphine.
Abbreviations: InSuRE, Intubacion. Surfactanc anc ^.apid Extubat-on; !QR, interquartile range.
57
iscr'pt i ./
DoTCpre' ^
procedure-relatedanalgosedation.9-62Itsgoodpredictability,
rapidonsetofaction,andrapiddisappearancearesuggested
to be advantageous. Clinicians also need to be aware of the
potentially rapid development oftolerance, the phenomenon
ofhyperalgesia,andthe potential risk ofchestrigidity.69
Collaborative initiatives for
quality improvement and efféctive
implementation in daily practice
A promising approach to facilitate implementation ofbetter
practices to improve pain management in neonates has been
described by Dunbar et al. 28Twelve neonatal intensive care
units in the Neonatal Intensive Care Quality Improvement
Collaboration focused on improving neonatal pain and
sedation practices. In essence, these units developed and
subsequently implemented evidence-based practices for
pain management andsedationin neonatesusing the EPIQ
approach.28'70This strategyemerges as an effectivetooi for
quality improvement within and between neonatal intensive care units, and not limited only to pain management.
In essence, this strategy is based on a stepwise approach.
First, the group of units introduced changes through plando-study-act cycles and tracked performance measures
throughout. Strategies for implementing potentially better
practices varied between neonatal intensive care units on
the basis of local characteristics. Individual units identi-
fied their barriers to implementation, developed tools for
improvement, and subsequently shared their experience
with the collaborative. Using this approach ofcollaborative
quality improvement techniques enhanced local quality
improvement efforts, and resulted in effective implementation ofpotentiallybetterpractices at participating neonatal
intensive care units. 28
Similarly structureel initiatives have been reported
recentlybyZhuet al in CanadaandDiendl etal inAustria.71-72
Zhu et al reported that knowledge translation initiatives
focusing on education, reminders, audit, and feedback had
Dovepress
On contemporary pain
management and a clinical
research agenda
Nonpharmacologic and pharmacologic pain management
becamean indicatorofqualityofcareprovidedto neonates
following the pivotal publications by Anand et al. ' In the
meantime, neonatal care itself has also evolved towards
less invasive care, as reflected by the introduction ofininimal enteral feeding to shorten the duration of parenteral
nutrition while the duration of endotracheal ventilation is
shortened through early nasal continuous positive airway
pressure or the InSuRe approach. The emerging data on pain
management and shifts in clinical care resulted in the need
for a new equipoise. I-l° This new equipoise has an impact
on contemporary pain management and affects the clinical
research agenda. Although to a large extent our subjective
opimon, contemporary management relates to the three issues
mentioned below, ie, pain management is not a stand-alone
activity, needs a structured approach, and new techniques
and drugs do potentially result in new (side) efiècts.
Effective neonatal pain management
is not a stand-alone activity
Effective neonatal pain management should be an integrated
part ofdevelopmental care. Further evidence ofthis comes
from the finding that improved behavioral outcome in former preterm infants was associated with both the level of
developmental care and pain managementprovided during
theirneonatalstay.A higherlevel ofdevelopmentalcarewas
associated with higher scores for attention and regulation,
lessexcitability,andlowerstressscores,whilea higherlevel
of neonatal pain management was associated with higher
attention and arousal and less lethargy. The association
betweendevelopmentalcareandpainmanagementsuggests
that the combination ofboth support better neurobehavioral
stability. 75
a positiveeffect on documentationofpain assessment,pain
management, pain prevalence, and pain intensity. 7'A similar
approach, focusing on care providers and protocol-driven
pain management, has been reported by two Austrian neo-
natal units. 73A potentially powerfültooi formaking progress
may be to integrale parents into the health care team, as has
been described earlier for facilitated tucking. Taddio et al
recently reported on the development of a parent-directed
educational pamphlet and video about the management of
vaccination-related pain in infancy"and thereby illustrated a
valid approach to developing parent-tailored tools. 7'1
58
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Structured approach for pain
management is needed
There is no doubt that all neonatal intensive care units need to
adapta validatedpainassessmenttooi andanalgorithmoutliningtheresponsesofhealthcareprovidersifabnormalpain
scores are detected. This has recently been reillustrated. 71"73
Reachingconsensuswithin the neonatal intensive careunit
care team on interpretation of an abnormal pain score and
developing an algorithm of care for each pain scenario is
crucially important. The same algorithm should also provide
Research and Repons in Neonatology 2013:3
Neonatal pain management
Dovenress
pathways for infants who do not respond to treatment or
experienceadverseevents.This structuredapproachshould
startwithroutineuseofa validatedpainassessmentscorefor
the givenagegroup andshouldbefollowedby a conditionspecificpain managemer.T p-oïocol witli a limited number
of compounds ("tooi box") for which caregivers are aware
of(side) effects. Moreover, these pain management protocols should also focus on titration of analgesics, including
a decision tree on when and how to increase and decrease
exposureto analgesics.5'"73
Until more advanced tools to assess pain become avail-
able, we should apply a validated pain assessment tooi in
clinicalpracticeandtrainneonatalintensivecareunithealth
care providers in using these tools in a standardizedway
to guarantee an acceptable variation in assessing neonatal
pain. '.Althoughsomemore sophisticatedmethodslike skin
the design of these Studies, necessitating consideration
of the "placebo" component of any trial. 7E'71' However,
we also need to take potential overdosing into account.
Consequently, we encourage clinicians, as well as the
ethica) committees and other stakeholders involved, to
designdose-findingstudies,whichareneededto improve
adequate (effective, neither overexposure nor underexposure) administration of analgosedatives in neonates.
The experimental observations in animals concerning
neuroapoptosis force us to reconsider the modalities
used, including both drugs andthe doses administered.
Although any study design can be criticized, the report
by Ceelie et al on the effect of acetaminophenon postoperative morphine needs in neonates illustrates such a
balanced approach in study design.58'8°
canductance have been suggested, these techniques need
further evaluation in different settings before implementation in the clinical setting can be considered. To illustrate
this, skin conductauce changes not only reT1. ect the stress
Acknowledgment
response, buthavealso beenobservedfollowingchangesin
vital parameters unrelatedto pain.76'77
Disclosure
Theauthorsreport no conflicts ofinterest in this work..
New techniques result in new side effects
References
Potential new sideeffects include opioid tolerance, neona-
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toxicities. Caregivers should familiarize themselves with
the contemporary management of these side effects, and
anyprotocol shouldaimto limit the numberofpharmacologictreatment modalities usedwithinanygivenneonatal
intensive care unit. It is better to build experience on
the effect and side effect profile of a Ik-mted number of
compounds, instead of going for a "drug of the month"
approach.59-73
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l. Development andvalidation ofmore sophisticatedpain
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2. Collection of long-term outcome data after neonatal
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drugs commonly administered to neonates.
3. An appropriate study design is required for neonatal
pain studies. It is obvious that pain should be avoided in
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Résultats de Fétude EPIPPAIN 2 :
étude épidémiologique des gestes
douloureux chez les nouveau-nés
Sm. Èïi. e Courtois, Ricardo Carbajal
Höpital Armand Trousseau, Pai-is
France
Douleur et inconfort en periode périnatale i
25 mars 2015 - Bruxelles
Introduction
La douleur du nouveau-né, enjeu en santé publique
Physiologie
Perception de la douleur a partir du 2èmetrimestre de gestation (i'hutiaet
Ancnd.2001}
Systèmes inhibiteurs de la douleur immatures a la naissance (Fazgerald, S99 i)
Conséquences néfastes a long terme de la douleur (Tadd'. o et c.1 1997; 2002)
Amélioration de la prise en charge de la douleur du nouveau-né
necessite
Connaissance précise du problème : indispensable a i'amélioration des
pratiques
-caucucn
L'épidémiologie permet de répondre a des questions qui
ne peuvent pas être abordées par des études
randomisées
Nombreuses recommandations ont été publiées
Fossé, variable selon Ses centres, entre les connaissances
existantes et ies pratiques
Étude EPIPPAIN 2
Frmcipaux objectifs de l'étude EPIPPAIN 2
EPSdemiology of Procedural PAin ;n Neonates: EPIPPAIN 2 study
Incidence des gestes doulpureux ou stressants chez Ie nouveau-né
en Réanimatioïi 6 ans après Epippain l
Evaiuation de la douieur en temps réel
Coupleravec Epipage 2 :assodations entre Ie nombre des gestes
subis et les traitements analgésiques reûs avec Ie développement
neurologique ultérieur
Incidence des gestes douloureux ou stressants et leur prise en
charge tors des transgorts de nouveau-nés par les SNUR
pédiatriques d'lle-de-France
AUTRES : pratiques de sédation analgésie pour la ventilation
mecanique', pratlques pour l'jntubatidh trachéale (Réaet SMUR),
début de validatión d'üne échelle de conditions d intubation
Matériels et methodes
Unités de réanimation néonatale et de réanimation pédiatriqued'lle-de-France
en 2011
Critères d'inclusion
Réa:Tousles nouveau-nésadmis,< 45 SAd'agecorrigé
SMUR :Tous les nouveau-nés transportés, <45 SA d'age corrigé
Durée de l étude
Réa : 6 semaines
SMUR:2mois
Suivi des nouveau-nés
Réa : dés leur admission et jusqu'au 14ème jour d'hosDitalisation. Puis suivi de ia
cohorte EPIPAGE
SNUR: la duréetotale du transport
Cahier de suivi pour chaque enfant :tous les gestes douloureux réalisés et les
traitements administrés
" Gestes doulcureux et inconfcrts. bês en "éanimatioR
2- Gestes douioureux et inconrortebles en SiÛn
3- Ponction ai.' talon: pnse en charge de Sadouleur
/- Foncticn veineuse: prise sn c'iarge de la dculeur
Centre
ü
l
éSIgibies
f l nat
48
46
Ë
46
21
35
19
'ï
42
H
ü
<ü
as
a
o
.
Nb
ü'inciusicns
57
A
o
Nb
d'enfants
r-<
M
co
N
'u
c
lTOTAL
.1
Taus
50
46
46
43
21
34
18
41
d'irdusion
Nb
l TAUX
EP[PAG?iEP<PAGE|
87, 7%
22;
44, 0%
95, 8%
100, 0%
93, 5%
100, 0%i
97, 1%
94, 7%
97, 6%1
251
54, 3%
26!
31'
56, 5%
72, 1%
121
201
15;
57, 1%
58,8%
83,3%
32 i
22 i
241
78, 0%
29, 2%
50, 0%
68, 6%
12!
52, 2%
26
24
44
44
92, 3%
100,0%
35
23
39
67
61
16|
35
23
38
100, 0%
100, 0%
97, 4%
625]
51
76, 1%|
61
14j
100, 0%;
5891
94, 2%|
87,5%!
36, 8%
14
32| 62, 7%
23 i 37, 7%
14 ioo, o%!
331
56, Z%| '
Caractéristiques de 589 nouveau-nés
Agê gestattonnei
32,9 (29, 9-36, 6)
24-29 SA
148 (25, 1)
30-32
151 (25,7)
33-36 SA
152 (25,8)
37-42
24,3^2,0
(23,4)
Poids de naissance(g)
1750(1203-2705J
Garôn
338 (57, 4)
Infaorn
377 (64, 0)
Age è t'acfmissiön(heuresj
597-5050
1, 5 (0, 6-5, 0)
Score CRIB
l (0-2)
0-15
6(4-12)
1-14
29 (4, 9)
Chirurgie pendant l'étude
Durée de participation (jour)
Décès
44 (7, 5)
Hospitaliséaprès 14 jours
129 (21, 9)
Verrtilation mécsnique
3S8 (65, 9)
Les 10 gestes dculoureux les plus fréquents
Aspiration nasale
11636(28.4)
Ponction au talon
8995(22.0)
Aspiration trachéaie
8734 {21.3}
Adhésifs(retrait ou réfection)
4080 (10.0)
Ponction veineuse
1152 (2. 8}
Sonde gastrique (pose)
1107 (2. 7)
Ponction artéri&He
(1. 9)
Cathéter veineux periphérique (pose)
735 (1.8)
Ponction a l'orteil
524 (1. 3)
Cathéterveineux périphérique (retrait)
521 (1,3}
TOTAL
40927 (100,0)
Epippain l : 42 413 gestes douloureux ont été notifiés
10
Les 10 gestes stressan+" 1e^ plus fréquents
Soinsde nursing
22087 (35, 4)
Aspiration buccale
11347 (18, 2)
Mesure de la pression artérielle
11166(17, 9)
Mesure des paramètresphysiologiques
7754 (12, 5)
Pesée
3540(5, 7)
Protection des yeux (photothérapie)
1386 (2, 2)
Radiologie
1104 (1, 8)
Toilette
1093 (1, 8)
insertion d'une canule nasale
974 (1, 6)
Manipulation tubes et cathéters
555 (0, 9)
TOTAL
62312 (100, 0)
Epippain 1:18 556 gestes stressants ont éténotifiés
11
EPIPPAIN l: nb de gestes douloureux selon Ie terme
fCarb^cü eï at JAl^'IA 2008;300: C~7C)
.
f.
i-ss.
Is.:
'w-j
l ^
s ?
r"'
!.;
l--'o^
. !;unj.
[ ti N ^
l
l
l
T^!iMl^!i. i"i^
liE?Hlui Jjyl!-[?. i!
rfcf-:
'ÏÏ^^rM.
'ï. -s ^Ï: ^j. .'41
Semeines de gasÈatson
^
>.'
.
fr;!
EPIPPAIN2: nb de gestes douloureux selon Ie terme
it
2* .'.'
-O
-
ï
;.-
as
Ht
r
;i
i;
»
t::H-
^
3. . -
?.
36
33
27
GdtationalAg«, wit
No.
(;.°:teG ;i.;'.e.;5
21
13
29
32
".3
50
52
49
48
35
15
39
27
29
Nombre de tentatives pour réussir Ie geste
Aspiration nasale
Ponction autaton
Aspiration trachéale
Ponction veineuse
11636
§2.5
97.6
8995
8734
1152
1107
783
96.9
69.6
735
275
45.0
46.2
137
48
69.3
Ponction lombaire
Sonde gastrique
Ponction artérielle
Insertion cathéterveineux
74.4
72.3
13.7
2.0
19.5
16.8
7
8
0.1
4
5.1
20.3
24.3
4.4
4.2
0.0
9
20,3
14,4
9.5
12.4
12.5
Insertion cathéter arténel
périphérique
42
46. 3
17. 1
29
40927
82.8
85.0
6.9
14
1.1
3.8
69
Ponction du dotgt
Insertion tathéter vésicat
5.0
18.4
41
Tous les gestes douloureux
12
7.1
0.4
58.3
97.6
Intubation trachéale
1.2
0.1
2.6
20,0
13.9
25.0
2.4
Insertion cathéter central
2.6
0.3
10 8
0,0
122 24.4
10.3
2.8
0.0
1.4
5
16
22
5
5
2
10
3
22
Analsésie de certains gestes
66,7
69,6
86^ ! 81,6
65, 5 70,1
26,4
25,9
31,9
42, 3 42,6
41,6
68, 6 j 59,4
83,0 88, 4;
28,1 20,8
29,5
90, 2 l 92,8
38,8
61, 8 i 50,9
6'4-6^-i
Asptration trachéale
4, 6
1,6
Poncüonautalon
55, 9
1,7
S8. 2 44, 0'
Ponction veineuse
65, 7
Ê,3
", l 71,9
Ponction arté'ielle
57, 6
5.0
Intubationtrachéale
0, 0
40,9
Injection SC
72, 3
5.4
1, 8
25,7
TOTAL
75-2 l 62, 2 j
82,1 i 82,4 ;
.\
Epippain l
15
Analgésie pour gestes avec effraction cutanée par centre
(Ponction veineuse, ponction artérielle, ponction au talon)
-1
TOTAL
p
o
N
M
L
K
J
non
-OUI
H
G
F
D
c
B
A
0%
16
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
55,5
Gestes douloureux : Facteurs associés a
Futilisation d'analgésie spécifique au geste (l)
Nombre de
gestes
OR (IC 95%)
Pvalue
Sexe
Fille
17992
Garfon
22935
l [référence]
1, 15 (1, 09-1, 22)
7187
7285
8236
18219
1. 35 (1, 22-1, 50)
1,39 (1, 25-1,54)
1, 37 (1, 25-1. 51)
< ftOl
< ,001
< ,001
5017
24311
11599
l [référence]
0,24(0, 22-0, 26)
0, fi4 (0, 59-0, 70)
<,001
< ,001
gestationnel(SA)
37-42
33-36
30-32
24-29
Mode respiratoire
Ventilationspontanée
Ventiiation mécanique
Ventrlation non invasive
Ajusté sur
les
centres,
;a
cstégorie
< ,001
l [référence]
du geste
et
chii -urgie Ou;/iôn
17
Gestes douloureux : Facteurs associés a
Futilisation cTanalgésie spécifïque au geste (2)
Nombrede gestes
OR (IC 95%)
Présenteparentale
Non
Öuf
36896
4031
l [reférence]
1,07 (0, 97-1,17)
4988
0, 169
Jour du gsste
Jl de t'ho&pitatisation
J2-J14de l'hospttalisation
35933
l [référence]
1, 51 (1, 38-1,65)
Heure du geste
Jour {7h-18h}
Nuit(19h-6h)
20897
20030
0, 95 (0, 90-1, 00)
24279
16648
0,62 (0.57-0,67)
,
40927
0,96 (0,95-0.97)
,
<,001
l [référence]
0,065
Analgésiecontinue
Non
Ow
Score CRIB
l [référence]
001
001
Ajuste sur les centres, ia categorie dy geste et chiru'-gieO.j'/Non
18
Scores moyens de douleur de lajournée
(minimum, médiane et maximum)
Score DAN moyen par jour d'hospitalisation
1,5
0,5
o
j2
J3
j4
J5
J6
J7
J8
J9
J10
Jll . 12
J13
J14
Jour d'hospitalisatlon
-l ""Moyenne des media nes par enfant
20
Moyenne des minimums pa' enfant-
--Moyenne des maximums par enfar't
Principales caractéristiques des gestes
pratiqués en SMUR
446 nouveau-nés inclus dans 5 SMUR
Age gestationnel moyen (DS) : 35, 2 (4, 5) SA
Age médian (IQ) du nouveau-né a ia prise en charge : 3, 8 (1, 6- 43,4) h
420 nouveau-nés on eu un geste douloureux ou
inconfortable sur 446 nouveau-nés inclus
1485 gestes dont 579 douloureux (selon classification
Epippain i)
21
Principaux gestes douloureux (n=579)
Adhésifretrait ou réfection
113
19,5
Ponction au ta Ion
109
18,8
KTveineirx périphériquepose
99
Sonde oro-gastnque pose
92
Aspiratron trachéale
57
Intubation trachéale
40
17,1
15,9
9,8
6,9
Aspiration nasale
33
5,7
Sonde naso-gastrique pose
15
2,6
Autres
22
3,6
/~~\
v-/
aractéristiques des gestes douloureux
Gestejour ou nuit (n=562)
Jour
(52, 1)
(47,91
VJC
vs
293 (&2. 1)
162 (28, 8)
(19. 0}
VN!
129 (23, 5)
Aucwe analgésiepourle geste
375 (66,7)
Non phormacc'. 3gique
;61 (28. 6)
25 (4, 4)
Phgrmacologique
l (0. 2)
Phormaco'oyK fue et non phannacologique
Analgésie/sédation totale (n=56Z)
Aiicwe amlgéüe/séclotion
Spécifiqueau geste Liwquemefit
270 (48, 0)
163 (29, 0)
lOb (18. 7)
24 {4.3 >
Carttinup uniquement
Continue et soécifiqueau
Atropine:19(55, 9%)
Morphine:5(14,7%)
Celocurine : 2 (5. 9%)
Diprivan : i (2, 9%)
IVl:dazolam
2 (5, 9%)
Sufentanit
2 (5, 9%)
Morphine
3 (8, 8%)
Diprivan
l (2, 9%)
Sufentanil
* 2 nouveau-nésont eu 2 doses dé Midazolam
*s l nouveau-né a eu 2 oases de Sufentanil
*** l nouveau-né a eu 2 doses de Midazolam
4 (11, 8%;
Atropine
Atropine
Midazolam"
l\i:. dazolam
Atropine + Morphine
Atropine+Sufentani)
Atropine + Sufentanil** + Midazolam*''
24
Sufentanil"' + Midazolam + Atropine +
Celocunne
7 (20, 6%)
l (2, 9%)
2 (5, 9%)
1(2, 9%}
9 (26, 5%)
2 (5, 9%)
Jour (7b-I8h59)
4215 (46, 9)
Mode de ventilation
Ventilation trachéale
Ventilatioi non invasive
Ventilation spontanée
3687 (41, 0)
3463 (38, 5)
1845 (20. 5)
Nombre de tentatives
l tentative
2 tentaïives
3 tentatives et plus
Opérateur paramédical
Présencedes parents
Analgésie/Siédationcontinue
Analgésie/sédationspécifiqueaugeste
Analgésie/sédationtotale (spécifiqueet/ou continu)
>
Score de douleur aiguë (Score DAN)
^ Médiane(IQ) l (0-3)
^ Extrêmes : 0-10
26
8783 (97, 6)
179 (2, 0)
33 (0,4)
8506 (98, 8}
873(9, 7}
2487 (27, 6)
5236 (58,2)
6764 (75, 2)
§
3
'0
t/i ^
<N »o
00
oo m
in
us
n; ^
li
IQ ,0-
co
'uT s
ti-II
in
00
ra
F:
3
%
m
1/1
§
FM
q-
s
01
v
I1
>s
S: u;
\\
<u
c
i.
~s
.a
ns
c
c
.
c^
<z
ii
y
-<u
c
§
.y
t
c
o
y
^
c
^
m
+
c
o
&
-. . ^.. " -^, -.. -^. -j. ^--l-
iü
a.
j
E
s
.1
_1>
o
<<y
i
i i
i
l
<u
g 9
3
x
l
ï
ut
ö
§
3
<y
01
l
<L
-Q
.
c.
c
,
<L)
s
sê
ï
^ -^-"^^.
-»
ïiplttliuiys. HKiiMnN
r-
03
FM
Facteurs lies a Fabsence d'utilisation d'analgésie
spécifïque au geste (analyse multivariée*) - l
Sexe
Fille
2616
l [Référence]
Garyon
3684
0.79 (0.63-0.99)
1094
1257
1694
2255
0. 57 (0. 38-0. 87)
0. 53 (0. 37-0. 77)
0. 50 (0. 35-0. 73)
Age gestationnelen classe, SA
37-42 SA
33-36 SA
30-32 SA
24-29 SA
l [Référence]
Mode de ventilation
Ventilation spontanée
1373
Ventllation trachëale
2473
Ventilation non mvasive
2454
l [Référence]
5.23 (3.60-7.62)
1.54 (1.22-1.94)
* Modèle marginal GEE-Ajusté sur les centres
29
Facteurs lies a Pabsence d'utilisation d'analgésie
spécifique au geste (analyse multivariée*) - 2
Présence parentale
Won
5722
Oui
578
l [Reference]
0.74 (0.57-0.95)
6037
263
l [Reference]
O 76 (0.44-1. 30)
Intervention chirurgicate durant Ie séjour
Non
Oui
Moment
Jour
2916
l [Reference]
Nuit
3384
0. 97(083-1. 15)
l [Reference]
1.74 (1. 18-2.56)
1.09 (1. 01-1.17}
Analgésiecontinue
Non
4435
Ou;
1865
CR18
6300
* Modèle marginal GEE -Ajusté sur les centres
30
31
p
Jour(7h.l8h59l
1239(65,7}
Mode de ventilation
Venïitoïiofl trochéale
Ventilation non invasive
709 (37,6)
631 (33,4)
Ventilationspontanéë
547(29,0}
Nambre de tentatives
l teniative
2ïenïatives
3 tenïatês et plus
>4tentatives
Présenceparentale
AnalgésiÊ/sédationcontinue
Analgésie/sédation spéctfique augeste
AnalgésiÊ/sédationtotale (spécifique et/ou continue)
Nombre de ponctions veineuses par nouveau-ne:
«/ Moyenne (DS): 3, 8 (2, 8)
^ Médiane(IQ):3(2-5) ...
32
^ Extrêmes : l - 19
1164 (61, 7}
343(18, 2}
188 (10,0}
192 (10, 2)
120{6,4}
437 (23,2)
1434 (76, 0)
1639 (86, 9)
Analgésie spécifique utilisée durant les
1434 ponctions veineuses
Succlon non nutntive seule
175(12. 2)
Solution sucrèe seule
216 (15. 1)
Succion + Sotution sucrée
882 (61. 5)
Paracétamol seul
80(5. 6)
Paracétamol + Succion
46 (3. 2}
Opioïde seul (morphine, fentanyl, sufentanil, nalbuphine)
9 (0.6)
Allaitement maternd seul
6 (0. 4)
Peau a peau
2(01)
Autres
18 (l 3)
33
Score de douleur lors de la ponction veineuse
en fonction du nombre de tentatives
o o
o
i l
U'T^
j ;i ^ Ï 'r
C I T f li II
Nb.
ï
Facteurs lies a une augmentation du score de
rlrm1i°-?-Ei- -
fana1^<2^ rnn1+ivariPFl*i - 1
Fille
Gar;on
749
1040
Ref
-0. 23 {0. 13)
37-42
306
Ref
33-36
479
-0. 10 (0. 20)
-0.03 (0.22)
0. 10 (0.21)
30-32
24-29
556
0. 638
0. 893
0. 625
Mode de ventilation
Spontanée
532
Ref
Non invasive
610
-Q. 32 iC. l6)
-O 47 (0. 20)
Trachéale
647
0. 044
0. 018
Chirurgie
Non
Oui
* M odele marginal G E E
Ref
1687
O 47 (0,30)
0121
sur les centres
Présenceparentale
Non
Oui
t. on
Oui
1676
Ref
113 -0. 75(0. 16)
1789 0.38(0.05)
<0.001
1373
Ref
416 0. 26(0. 21}
0.222
373
Ref
1416 031 (0. 16)
0. 050
Analgésie Spécifique
Non
Cd
*
Conclusion - l
'. Tres grande motivation des équipes pour la douleur du nouveau-né
' Participation de la totalité des services de réanimation néonatale
d'lle de France
Taux d'inclusion tres élevé pour l'étude EPIPPAIN 2 :94, 2%
d'indusions
Gestes douloureux toujours tres fréquents
Analgésie pour les gestes douloureux a augmenté par rapport a
2005'-2006 : de 20, 8% a 28, l %
Mais recommandations partiellement respectées (AFSSAPS-ju-n 2009)
37
r^.
onclusion - 2
La ponction au talon :
Geste frequent:
corroboré aux autres études (Carhjjd et a:.,2C38;Hamson, 2009;
Analgésie non systématique
Aucune analgésiepour 24,8% des ponctions au talon
Mais analgésie totale plus frequente que dans EPIPPAiN l (75, 2% vs.
62, 2%) (Carbajaieta:.,2008)
En pratique :
Privilégier la ponction veineuse
Moins douloureuse que la ponction au talon: en fonction du capital
veineux de l'enfant
Utilisation systématique d'une analgésie spéciftque au geste
Solution sucrée,allaitement, peau a peau,ou médicamenteux
Réfléchir a Ia pertinence de la surveillance glycémique systématique
38
L/onciusion - 3
La ponction veineuse :
Geste frequent:
'A des nouveau-nés ont eu plus de 5 ponctions veineuses
Tentatives nombreuses: seulement 61 ,7% réussies dés la l ere tentative
Anaigésiequasiment systématique
87% des ponctions veineuses réaliséesavec analgésie
En pratique :
Développer des stratégies pour réduire Ie nombre de tencatives
Promouvoir la présence des parents
Futures analyses :
Suiv! de ia cohorte EP!PPA!N-EPIPAGE permettra d'avoir des données
sur ie développement neurologique et les possibles assodafions avec
douleur et traitements
Breastfeeding as pain
management
: i'S-'*:-. -. . . !<;;
f: n: i
Pzin and ï!isccmfcrt :n the perinatal period - BFHt symposium - Frusseis, 25/03/15
Acute responses of pain in neonates
'tf^''fl^c"'", 'i\i'fs. "'t' ''. »"'';''/T', vc '^"..o . '"'*. r*'"'"r»;'~>-: E .~''"-. 'Qr ^J!'"Y"'>
r't/UL. fc. ÛVfc: Je. ""''1/'^Y5 c,:r'ï i U^:C^C:'ic. l c'. 't£r i. 'ir't. 'ï
Iva'ua'acn /quanrificsuo'"1 of ro:dcus s'un'u
. Behavicura! changss (assessrnsnt toois)
. PhysiologJCal changes (sssessmenttoois)
. Changes ;n stress hormones (ressarch)
. Cortical changes (research]
Measurement of pain in neonates
Examplesofneonatalpainassessmemtools
Tooi
Parameters
Score
Utillty
Procedursl
Premature infant
Gestational age, behaviora: siate.
Total fi-21
pai-. profile
hean rate, oxyge" samratior, brov»-
sôre^ C-3, <: m:nir". a^ pain,
eac.tï parameter
(PIPP)Qï)
bulge, eye squseze., iaso;abial :urrow >i2 moderate te severe pain
FLACC(S)
Face, legs,activity, cr^, consoj;abili^ lota':- C-10 eachparameter
and
po&toperative
pain
ProceJiiral
&corea 3-2^ >4 moderate
and
pain, >~ severe pain
postoperative
Alertness, calmness, respiratory
To^l 8^3 each parameter
Pain snd
distress. movement, muscie tone,
scoreri 1-5, ; "-26 adequate
sedation in
facid! tensttï"., ï;ood press'jre, hear"
sedation, ^2 made^Lüte
N1CU
pain
COMFORT scale
(behavicrai
and
physio Logica!
sedation/analgesia
paramete-s) <2ö)
COMFORT
Alertness, calmness,
Total' 8-30 each parameter
Postoperative
behavior scale
response (ventilated neonate) or
scored 1-5. >17 moderate
vam m NICU
UI)
crying (not ventiiated), movement,
pain reqi unng intervention
respi ratory
muscle tone, facial expression
Walke- S. Paediatr Anesthesia 2014; 24: 39-48.
Longterm consequences of pain
Variability in pain expression characteristics in former preterm infants.
Alleaaert K1, Devlieaer H. Bulckaert D. Naulaers G. CasaerP. Tibboel D.
l J Perinat Med 2005;33(5):442-8.
CoTeiation of postconception and gestationai agewith pre-procedural
and relative increase in heart rate
Correistion
between
length
of stay end
pain
expr ession: due to cumulative i
procedurai pain?
j
Allegaert K, J Ferina;Mea 2005; 33: 442-448.
Longterm consequences of pain
9 Poorer motor and cognifve scsles
. Impairmentofgrowth
. Reduced wnite matter and subccrticai grey
matter maturation
. Aitered corticospinai tract strucrure
protection frcm persistenï sensitizsucn cf
":?\^
cz. nï;. -avs c. nd rc'-sr. ^.'-:; c^'nc'?fn^
£, ;"&ccc ov ï;. 'c£3c ^:rJv^v c'* >' :c :
cievc!cpmant
WalkerS. PaediatricAnesthaesia 2014; 24:39-48
Painful procedures in neonates
8 Vsr. ipunc-j res
. -iee. -stx'' bicod üra"n/£
.
immumsc. ^crs
. Surgery
. ïucticnini
. Gavage-tube p'acement
. Tape remova
Treatment of pain 'n young children
Recucdon er "smtul even-:;s
Aitcred rrocecure (venipunct^'re '^ heel isnce)Y*
tasting lolution, outeome; i . 1 Behavtoural pain ïcons tor VP VS HL.
<t3 ï!L"-x: . ^Ï^^-. ASf:
l^ ". -. ^yv
w> mr-. ..
*
w;. m. <-^
t-^-
.
.
ShahV. Cochrare DatabaseSyst Rev2011:CDOOU52
Treatment of pain in young children
l. :A.' . ; ^ ; .
r
i ;.", u . r
ure
iv
"/li
r-;'^
n
co
(v -ni;xi ^ctur(
03
met
'^. s
"s
K
U
i^ri
t^
.
Shah V. Cochrane Database Syst Rev 2011; CD001452
.
< opicci sne3t;"z'ac psin prevention
"'harrnacoiogi ca
neasures
Too many crying babies...
Too many crying babies: a systematic revïewöf
pain management practices during immunizationsi
on YouTube
Denise Harrison"',
Margatet Sampson'. jessica Reszel1, Koowsar Abdulla', Nick Banowman'. Jordi Cumber',
Ann Fulier', Claudia Lr', Slu-rt Nicholls' and Calherine M Pouild'
i
îtt:
«
ifl
l
eo
-fci%ïfE;-;<ed %tt4 ^. u-rtï!?!, iE)
li.»
-'.se. eiAw*?)
ï
i
<ü
. 4-;v^^ïfSÏS . t8)
! .-.
« ^ i .'^*.si^^ï ï r.^sjtpf'? ï p%;t:
BuC'.:.-. A. t';i;-<l''fi!5'A''i.3.;<r'tui iï«tt.. lï
ttijêcsoh
t cctioa
^t-r ISSAE
i";êctt a11
Harrison D. BMC Pediatr 2014; 14;134-
Too many crying babies...
Table 1 Observable pain management strategies used
during immunization
Strategyin=142)
N (%l
Table 2 Observablepain management strategies used
post immunization
93 (655)
Distraction using singing cr talking*
Strategy, n='!20?
N 1%)
îsTracTic, " using singing ^' 'slking*
94 (79, 7)
Talking only
90 176. 3)
Talking only
92 (64. 8)
Singing ard talking
4 (3. 4)
Singing and talking
1 (0.7)
54 (38)
Holding (any positior)
Front-to-front
34 (28.3!
Front-to-back
7;S8;
Fionwo-side,
ï\
Front-to-back
4(2.8)
21 (14.8)
Fronl-to-side
28(19. 7)
Combination ofpositiors
Non-nutrrtive sucking
1 (0.7)
n (7. 7)
Dlstraction using any toy
S (6.3)
Noisy toy
Noisy toy
2(1. 4)
3:lent toy
Silent toy
7 (4.9)
Front-to-front
65 (54.2]
Holding (any position)
'U.S
'2.5J
Combination of positions
Non-nutritive sucking
13 , 92;
Disnactionusinganytoy
10 "O!
;sing -
3.3'
ró^l
ild nat distinguish if singingor talking was i;seti.
8 (5. 6)
Rjcb'ig a1 irjection site
*2 miss-iï: - could not distirguish if singingor talking was used.
No video showed breastfeeding or the use of sucrose/sweet solutions
Onlyfour showed the infants being held in a fi'ont-to-froji^po. sition_^
Harrison D. BMCPediatr2014; 14:134-
Redi
rsö
;
^ n
p?;?L-rr:rit
3a;n:'UE svents
ügioi l
T'^. ^-. r
milk
K 7- i
t. -ski ,.
l. Breastfeeding or breast milk
Cochrane DatabaseSvst Rev. 2012 Dec 12;12:CD004950.doi: 10. 1002/14651858.CD004950.I
Breastfeeding or breast milk for procedural pain in neonates,
Shah PS1, Herbozo C. Aliwalas LL. ShahVS.
10 studies: breastfeeding
10 studies: supplemental breast milk
16 studies: heel lance
4 studies: venipuncture
Figure 4. Forest plot of comparison: l Breastfeeding vs control, outcome: l . 9 Neonatal Faciai Coding Scon
(NFCS).
Cwittoi
Stw^fK-SiAgroup
View
SP Totai fctean
1, 9. 1 BreastfBachflVSfornwiaTsciSitfl
WB'ssmn3;IOS
2£
2<
3'
Suhiotal (95-10)
31
êia-aflaie^' Kaiapo'ics&ia
Testftr m'sia' B-ÏC'. 2= O. S6 (P = 1, 3^
1 A2 Breestfesdinflvs 3 B*IKOSC
niS3T:ar. 2:3l
23 Ïl
SiAtotai (?5Fi Cl;
31
31
Me» Dlfference
SU Waï «Otyttt
ftf, FJK&d.96* a
23
2. 5
3C . GE 3%
30 lüO. GIi
35::-C. 63 \BT
li£{, [-0. 63, t. MJ
6. 8
C£
3- 100. 0%
31 100. 0%
hié'. È-t. si if. e:k hel aco'L'ao e
'est 'y overal er6 ri, 2= E..:7 (F
<
C.
00001)
*3:JSfeasaeetKn»vs noUing ty mother
LetlB20D8
0. 62 0. 29
31
^:sS"-ar-:C3
23
2. 4
31
0. 64 0. 11
^. 6 ÏA
SuMJMHSnO]
62
HelerogBnertif:Chf=KM.df=1 (P= O Oli;l*=a-<%
38
3S
BB. 2%
D. B%
58 lUIJll
-0. 32[. D. 43, -B. 21]
-1. 9(^3. 12, -O. BBJ
-n.33[.Q.<4. -U.Z3]
Tastfar overall BKoü.Z= 6.14 (P <; C 00001)
1. 9. 4 BHi3«f»c<Trg w non-nutraiye sucUrfl wltti pacffier
Wtiigsnsr2009
2. 9
1. 4
31
4. 9 23
3:
SuWNalfftS^Ctï
31
31
Heierucene'ifr. Notadpl'iabie
TBstftr overall effed 2=3 39 (P= O.OM7)
1. 9.5 Bf<a.<f(ffi<iuKj lift iîfrteiwetrto,'
!. VE;s"^n2(:^
:. ï
l;
51
SxMiïtaif'ïS-ia-r
31
Hetercgeneitf Nalapplicable
Testfcr werall affBri-Z= 8. 73 (P < 0. 00001)
7. '
1. 15
-iaoh3. i5, -a. e£i
. -Z. DEll-3. 15, -0, 951
29
2P
Testforsubqroup dilTerences; Chr= 131. 311t- 4 (P < O. ODOQIi. [. = 97 0%
Shah P. Cochrane Database Syst Rev 2012: COD04950
Figure 5. Fofest plot ofcomparison:2 Supplemental breast milk vs control, outcome: 2.8 Neonatal Facial
Coding Score (NFCS) at 2 minutes.
Supplenietriallifeastirtik
StUtfyarSui»gT
Con»ru!
Mâr Rrffereni;»i
Tutai Meas SP Tolei Weigiil d', Fixea. SSy. tl
ciip
2.0, 1 Sitpfllamenld breati ftiBf vs plKebo (wffte'ï
3:a:. ;a-2'r:1
5E<
;.. 4E
'S
SaBUUnB-iCT.
E. -IE 3. 25
W
27 -0. 3% -C. B. ^ 3. -053-
II "lUBi C.W1.1U,.1|.M)
Hele^GEi9^'N!:iai:pl:c3bre
Test<;- neral; eflftict Z= ? 56 w . ; .: 'ró'33';
Suppieittailat bi easrt milh </s
OBdaaan201D
5. S*
2£.?.
aibMÏSMCD
pi ^cüo
C. -tR
(2 ilosrfs itfiwale'i
13 6::- 3;?
U
36 100. 0% . 0. 59 h0, 83, -0, 35)
;« fUIUIS .ILSB[.IUB;.n.35I
HBterogeneit/: Nol applicaüle
TestfDF werall effect: Z= < 82 F < O 00001)
ÏJB^ Suwlenrentd brGast mfik vs 12. 5% sucfose 'sinê üsse)
0;dosan2010
siiMDri(8s*ai
5.64
0.46
-& 4.72 0.45
ia
2f 1000%
zs iimm,
Q92[a. 6<. 1.;[)|
amviM. f.yn
Heterogene^: Not applicabls
Test tor owrall effect';= Ë.53 (P < O. OOOD1)
2J6.4 SuppïemBrtd breast rrelk vs ï2A% sucroso (? ctosas)
OZttógan2010
StiWütai ï O'
£64
0.46
16 £.<£ D.<
^0
13 100.0% D.16ha.l1. ti 43]
23 100-0% ti.16t-0. 11. 0..I3!
Helerog&nsity; Notappiicable
Test for overall effect: 2= 1. 1 7 (P= 0. 24)
?ASSiwlBn»Bnta)bieiistmflkvs(wNl<Riesursupp'eniwlaito)i;i!.
Ozdogan2010
5. 64
0. 45
-a 6. 78 0. 24
sunul'alwïai
""
""
11 '"" ~"
-ini!lk
33 '31C%
- -. 4i. -'. J" -C. ;';
2') mü; . 1;t4ilJ7. Wli
HeleroaanBit/ Ntrtapplicable
Test tor overall effcrt: Z= 9. 55 (P ' O. OD001)
Testforsubqroup differences' ChP= 157 13. df= 4 fP * C D0001), . -. = 97. 5%
Shah P. Cochrane Database Syst ?ev 2012: CD004950
Figurc 6. Forestptotofcomparison: 2 Supplemental breast milk vs control, outcome: 2.9 DouleurAigue du
Nouveau-né(DAN) at 2 minutes.
BtiKlyofSubgroup
2A1 StwfcmCTtal breasl m»kw 20%sucruw
Maöiai20Q5
2. 2
0. 55
1D
subtoiai pm CD
ia
Helerogeneity. Nolapplicable
TBEtforcnrerall 9nect2=B.49 (P= O G2)
.
233. SupplBmeiffal lireast mShw. placBba <wa(w}
Math3J2D06
2. 2
0. 65
19 :
1B
SiÉXofalpS
HiCIÏ
HeterosBnett^Nolappllcable
Test ror overall er'Ect:Z= 3. 95 (P < 0. 0001)
2.9.3 Siîptamafrtal ta-aast mflk vs nonîuimwe suckiifl
Mathai20DB
2. 2
0. 65
1B .
Si*rtnta!(S5%CI) .
1B
Hetaroganefr;Not applicaüle
Test tor overall Bffect2= 3. 33 (P<O. D001)
?Sf. * SivfA'nNintal bieasl milhvs nus-Higt;
Mathal2D05
2.2
0. 55
Subtrtal (95% Cl)
Helarogeneitf Nol applicable
Testforovsralt effect-Z= 2 37 (P- D 02)
2.9S Supptemertal breast mBkvs rocking
Mathal200C
2. 2
065
SuMdal (P5% Cl)
Helerogeneity; Notapplicsble
Testïor overall effecEZ= 4. 61 (P < 0. 00001)
Control
an SP Total
IWBt^pt
Mean Mfference
frf, Fixed, 95% Cl
17 100. D%
17 lOIUKi
0, 10^. 30, 0. 50]
(UD[-fl, 3C, fL50]
15 10C. a% -1. 10[-165, -0, 55]
15 io(un. -1. 10 M. fis, -assi
20 100. 0%
0. 80[0. <0, 1, 20]
20 1QO-0*.
O.OÜ[0.4Ü.1.20]
1B ;
18
17 100, 0% -0.50E-D.91. -C. 09]
17 lonjOïi -o. 50i-a. fli, -tu)8]
IS 1
18
17 1DG. O%
17 IDIUiï
1. 10[O. G5. 1. 55|
1. 10 [B. 65, 155]
Chiï- 57. 10, df= 4 ff' .; ÜOODOD.P= 93. 0')»
Ejpplementaltireastmllk Favourscont-o
Shah P. Cochrane Database Syst Reu 2012: CD004950
AUTHORS' CONCLUSIONS: If available, breastfeeding or breast milk should be used to alleviate
procedural pain in neonates undergoing a single painful procedure rather than placebo,
positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as
breastfeeding for redudng pain. The effectiveness of breast milk for painful procedure should be
studied in the preterm population, as there are currently a limited number of studies in the
literature that have assessed it's effectiveness in this population.
The effectiveness of breastmilk for repeated painful procedures is not
established, and further research is needed.
The effectiveness of breast milk for painful procedures should be studied
in the preterm population.
Shah P. Cochrane Database Syst Rev 2012; CD004950
Pain relief effect of breast feeding and music therapy during heel lance for
healthy-term neonates in China: A randomized controlled trial.
ZhuJ1. Hona-Gu H2. Zhou X3. Wei H4. Gao Y5. Ye B6. LiuZ7. Chan SW8.
288 healthyterm neonates recruited - 250 completed trial
Heel lancing for metabolic screening
4 groups BF, MT, BF + MT and no intervention
ZhuJ. Midwifery2014:S0266-613E
Table l
Nconatai baseline demographic and diiiicdi chai'dctciistics (i!-25ü).
Coiitrol sroup ;n-61;
GesUtiondl age (day)
NeaiiaLal age .. 'cay^
B'~' wsig.:f i'kg'.
yb;e
Duration ofsampting (second)
273. 70 (8. 82;
3. 11 (0. 49)
3. U (035)
51 X
61. 11 (47. 96)
MTfiroup(n-62)
275.2e'll. «'
337 (0. 58)
3. 28 (0. 30)
52X
65. 34 (51. 13)
BFgroup(n=64)
BF-MTgroup (n=63)
277.12 IS.22)
3. 34 (0. 4dj
3.2S , C.4;'
5&r
47.SC IJ1.04J
276. 24 (6. 94)
3. 24 .:C. 5C'
i.lS '4. 33,
4®;
53. 73 (42. 69)
l .\';;<": BF^brcast fetding; BF ; MT-cnmbinatior. ofbreast 1'eedinE and musk therapy: MT^music thera;y. Xesu::s me expressec ia mean 'SDj,
n etiange afiimnatos' NIPSi.'. four groups over ümc' (ii^25U).
Müdp. diffcrencc from
contnri graup
Group effect
F(p-va1uei
TtmecTTed
F/p-value)
Interactiun ctt^ct
Tim<prf;r< p,
,
J'ip-ul.K;
i
ATüte: GFÎire.isi 'ceding; DF+MT-.combinatianarürei.it ft'eci;.ig a'.d ;T~ ;,;,;.--therafiy;MT^mu^ ihfMpy.
. fa;;j<..ï:-^l ii.e.sues ANCÜVA t.dJL^te.! [ry h.iseline NIPSSïüres, geitaiioiulage, iieunaca;ai{e, üirth weiijhL^ciidci.diid duidtionui sdinplJi'E
"Medti Lâsêc/erCLme-MtPSmcait score duRngprowriure-baMlineNlPSmeai: score.
ZhuJ. Midwifery2014;S0266-6138
Cdmparison of neonates' pain response betweeii faur groups for Üiewhole procedure (n-250).
MT(n-62)
BF(n=64j
4. 83(2. 45)
5.03(2. 41)
13. 65(234)
1-1.89 ;2.37)
5.59
<0. 001
101.61(9.43)
90.36(9.27)
27.32(9.01)
27.17(9.12)
13.17
< 0.001
Beforeprocedure
Duringprocedure
l niinulfafterprocedurf
0.00(0.01)
6.43(0.23)
2.34 (Q.29)
0.00(C.02)
5.06(0.22)
1.98(0.29)
0.03(0.02)
3.08(1.88)
0.35 (037)
0.02(0.02)
4. 38(220)
0.24(0.28)
0.62
20.56
6.26
0.761
< 0.001
< 11.001
5 minules after procedure
0.74 (0. 18)
O..II (0. 17)
0.09 ;0. )6)
0.01 '0.17;
1.89
0.065
Control(n=61)
Latency 10 first cry (second)
Durationoffirstcrying(second)
BF+MT(n^63)
NIPS score
NOK: BF=breastfc<:dins; BF+MT=mmbin. itlon of breast feeding and inusictherapy; MT^music thcrapy; NIPS-Neonata] Infaiit Pain Scale.
ANCOVA adjusted by sesfational age, nconatal age. birth weight. gmder, and duration af sampling.
*ÏUUKXKCioL.MUlTt&,Ul^Sn^..."..".
_.J
Zhu J. Midwlfery 2014; S0266-6138
Pain relief effect of breast feeding and music therapy during heel lance for
healthy-term neonates in China: A randomized controlled trial.
Zhuj1, üsmûJi2, Zhfiu^3, WËLÜ4,Saa^5, ïs^6, LiiiZ7, ChanSW8
CONCLUSIONS: BF could significantly reduce pain response in healthy-term neonates during
heel lance. MT did not enhance the effect of pain relief of BF.
IMPLICATIONSFORPRACTICE:healthy-term neonatesshould be breastfedto alleviate pain
during heel lance. There is no need for the additional input of classical music on breast feeding in
clinic to relieve procedural pain. Nurses should encourage breast feeding to relieve pain during
heel lance.
ZhuJ. Midwifery2014;S02G6-6138
Comparison ofAnalgesic Effect ofDirect Breastfeeding, Oral25%
DextroseSolutionandPlaceboduring lstDPTVaccinationin Healthy
Term Infants: A Randomized, PlaceboControlledTrial
GAURAV GOSWAMI,AMFT ÜPAUHYAY,NAVRATAN KUMAR GUPTA, RAJESHCHAUDHRY, " DEEPAKCHAWLAAND
#V SREENFVAS
120 infants coming for their first DPTvaccination
Breastfeed group, 25 % dextrosefed group and distilled ;
water group
i
Indlan Fediatrics 2013; 50: 549-653
::, '.. < r-. o-'J r )')^f< . fri^. -!:. "
TI . *> ';. T'.l;'l . , M:-\.
i r
;(:>t kl
(. -;";
(v,, ;, ;
!Weight(kg)
10. .';'., l)
il) l '
4. 6(0.4)
4. 6(0.5)
4.4(0.4)
39(4.3)
47(9.2)
'. ï"ll
''. ;'|(<r>
Timesincelastfeed(mm) 45(8.2)
'Ï1k-ir":iifj:i;''--1. 1'
1": 1111
. l. "^):\t
)
)
!K.
'
I.
IT. ..., <.....:
..
IIl.
lll1 !'
ic' i c. -':'"
l Crv
Direct
l duration .:'-t:üsi
.
2S%Dextrose Dislifled
sohiïion
waler
Pvaïue
2i-:Su
>. s'.
f/;.
Med.ar
!|0-.
iTWWtidrótB ^fterAwiïi jfftietSmitt
.
Et B^^. -ulll-tï . riï«W <"*»'£t*t-L*éiWJBtff
Indian Pediatrics 2013, 50:649-653
WHAT IS ALREADY KNOWN?
Breastmilk, breastfeeding,andsweetsolutionshavepainrelievingeffectsin minoroutpatientsproceduresand
injections.
WHATTHISSTUDYADDS?
Breastfeedingduring and beforeintramuscular DPTinjection is as goodas 25% dextroseas an analgesicin
infants younger than three months.
Indian Pediatrics 2013; 50:649-653
2. Oral sucrose / glucose
Sucrose for analgesia in newborn infants undergoing painful
procedures (Review)
StevensB, YamadaJ, LeeGV, Ohlsson A
StevensB. CochraneSyst Rev. 2013.CD001069
Figure l. Forest plot of comparison: 3 Heel lance: sucrose 20. 50X vs. control (sterile water), outtome: 3. l
Duration offirst cry (s).
TrBatmant
SludyolSubnimip
Maan
Harrisnn 2003
-3. 32
Control
54 66.73 .'36
61. 98
33 a
135 128
Msthai 2006
0:1..'. ;8C5
17
25
38
23
156 108
n/. Fued. gs-ci
17.3% -20.41 h52.0G, 1.24]
7B.S%
-5.0B[-17.40, 7. tO]
2.B», -21.001-BE.65.i. 4<.
4<. 65]
65]
96 10D.B»
TBtalOStCU
96
-tetBrnaanBiv Chl'« 1.98, dfs 2 (P s 0. 37); 1-= 0%
Wean Difference
W. Rxed, 95% Cl
Mean DCTerence
SP Total Mean SP Total UfaBt»
A99I-20.07.
l7, 2.10)
Z.
.
Test for overall effect: Z=1. 59 (P= 0. 11)
l!]D -50
Favourstrealme-t
S5CTDD
Favours conlrol
Figure2. Forestplot ofcomparison:3 Heel lance:sucrose20-50%vs. control (sterilewater), outcome:3.2
Total crying time (s).
Treaïmerrt
Sfudy or Subgroyp
lsik2000a
Mamal 2008
Total (85» Cl)
Control
Mean SQ Total Mean
105
60.53 9.2
78 16
9B
Mean Oifference
Mean Difference
IV,Fixed,95%Cl
SP Total Weight
78. 6% -44.47h50.1Q, -38.94]
2[). <» -19. 00 [-30. 1 i. -r.eai
16
n/, Fixoll, 95'.a
12.1
45
43 100. 0K -39. 21il-44. 29. -34. 241 .
HBteroneneNif: Chp= 16. 07, df=1 (P< 0. 0001); r= 34%
^ - ^-
Test for overall effect 2= 15. 32 (P < D. D0001)
cavour£lrealment
Favours control
Stevens B. Cochrane Syst Reu. 2013. CD001069
Rkardo Carbajal, MD; Richard Lenden, MD;Vincent Gajdos, MD; Myriam Jugie, MD; and
Alain Paupe, MD
Administration oforal sucrose +/- non-nutritive sucking
Outcome measures: physiological, behaviouralof both pain
indicators with or without pain scores
Carbajal R. Pediatrics2002, 110- 3B3-393
Crossover Trial of Analgesic Efficacy of Glucose and Pacifier in Very
Preterm Neonates During Subcutaneous Injections
RicardoCarbajal, MD; RichardLenden,MD; VincentGajdos,MD;Myriam Jugie,MD; and
Alain Paupe, MD
- 40 very preterm neonates- prospective study
- Two treatments in crossover manner during two consecutive
subcutaneous infections oferythropoietin
30 % oral glucosevs placebo (25 infants)- 30 % oral glucose
vs 30 % glucosefollwed by suckinga pacifier
Outcome: use of douleur aiguë nouveau-né pain scale
Carbajal R. Pediatrics2002;110:389-393
Crossover Trial of Analgesic Efficacy of Glucose and Pacifier in Veiy
Ricardo Carbajal, MD; Richard Lenden, MD; Vincent Gajdos, MD; Myriam Jugie, MD; and
Alain Paupe, MD
TABLE l.
DAN; A Beh.lllt. ral Acule
; NeonMes (16)
TABLE
2.
Perinatal
ChaTacteTistics ot 39 Preterm NewbornsWïc Completed
the
Studv of Ana]-
EtSic Effects of Glucose aid Fadfias
Cabn
Trial l 30% Glucoae
Vimua Pl.ceho (Sll.rik
Waler) (n - 24)
Sniveisand altematesgentJeeyecperüngand closing
Detennine the intensity of l or rncn-e af the ïollowing
i' eye squeeze brow bulge, nasolabia!fiuiüw.
MiJd, intermittent with rehjm to calm
Moderate
Gcstational age (wk)
Very pronounced, continuous
Birth wdgM (g)Boys/girl
Vaginal/C^sarenndelivery
AFGAR score (5 min)+
Fostnatal age (d)*
Weight at inclusian (g)'
Arnusal state score+t
Higher than 0.2 L/min 0; needs
Umb movements
Detemmw the intensity of ane or more of the
tollowing signs: pedals, toes spxead, legs ten&ed
and pulted up, agitation of nrms, withdrawal
reaction.
Mild, intennittent wïth return to üilm
Moderate
Very pronounoed, continuous
Vocnl expression
No complaints
Moans briefly. For the intubated child, Jooks anxiou?
28.1 (27. 3-29.0)T
28.3 (27-3U.O)t
1036('1*1-1128)
17/7
6/18
8(7-9)
26. 4 (22. 4-30 3)
1-234(1120-1348)
2(1-4)
Wli
Tria] 2 30% Glucose
VCTSUS 30% Glucose
Plus Fadfier (n = 15)
29. 1 (27. 8-30, 4)''
26.5 (27.4-31. 01t
995(848-1141)
9/6
3/32
9 (8-10)
26 (220-29.11]
1209(1059-1359)
20-3)
4/15
' Mean and 95% canfidence interval.
1 Median and interquartile.
i Median and interquartÜe were the same for both adï
Intermittent ciying Foi tlie intubated child/
expression af mtemutteiri ei
Long lastang crying, COTIÜTIUOUShciwl Far the
itubated child, expression of contini
crying
Toü>]
Carbajal R. Pedlatrics 2002; 110:389-393
Ricardo Carbajal, MD; Richard Lenden, MD; Vincent Gajdos, MD; Myriam Jugie, MD; and
Alain Paupe, MD
TAB LE 3
Pacrfier m :
Mean and Mediïrn rain Scares Obtained With Plncebo, Glucose, and Glucose Plus
1 Pretecm Neonales During SubcutAneous InjectioiiB
Pain Scores With DAN Scale (0-lü)'
Plaoebo Sterile
Water
30% Glucose P
Flus Padfier
Valuet
30% Gluc
;>' ~- 24)
Med;
y. es'
;;.iterc;u?.r&3)
IE',;. Cl!
7 (2.5-9. 75)
6 (4. 6-7.5)
-. 5 i'. -s}
4 -2.7 5. 3'
K\ 'r, = ï5',
Ve:.., /.
N't.-.n
;i-^-qL.a-Ï.
e)
4 (2-7)
4(1-6;
4. 6 (3-6. 2)
3.S (2-5 5)
Clfc'dicEK
lt Ü ;".-:1TC.l-' T'. I pt'in; 1'. ;, mn\iTn
t 'Aï(cir-\cr
ï'KÏTiz^-Tar. K iesl.
Caroajal R. Pediatrics 2002; 110; 389-393
RicardoCarbajal,MD;Richsrd Lenden.MD;\'incent Gaüos,MD;MyriamJugie,MD:and
Alain Paupe, MD
Oral glucose 0. 3 mi 30 % has an analgesic effect in very preterm infants,
during subcutaneous injections
- No additionaleffect of pacifier, in contrastto term infants. Lackof power?
8/24 preterm infantsdid not showany relief in pain
Carbaja: R. Pediatrics2002:110:3BE-393
' Res Theorv Nurs Pract. 2014;28(4):335-4B.
Nonpharmacologicaltechniques to reduce pain in preterm infants who
; receive heel-lance procedure: a randomized controlled trial.
'mi P', Chieppi M. Maini A. Muanos T. Sootti D. Tzialla C. Scudi
- 35 premature infants- Randomized controlled trial
- 3 heel-lance procedures
- 3 study arms: 35 standard procedure, 35 music (Sonata K 448
- Wolfgang Amadeus Mozart), 35 glucose)
- Outcome: use of PIPPpain scale
Bersoml P. Res Theory Nurs Pract 2014; 28:335-348
' Res Theon/ Nurs Pract. 2014;28(4):335-48.
Nonpharmacological techniques to reduce pain in preterm infants who
receive heel-lance procedure: a randomized controlled trial.
BeraomiP1,ChieppiM. MainiA. MuanosT. SpottiD.TziallaC. ScudellerL.
DISCUSSION:Both glucose and music were safe and effective in limiting pain increase when
compared to standard procedure in HLprocedures in preterm infants.
Bergomi P. ResTheory Nurs Pratt 2014;28: 335-348
3. Skin-to-skin care
Skin-to-skin care for procedural pain in neonates
GelesteJohnsron', MushaCampbell-êo2, AnandaFcmandes5, DarleneInglis2,DavidStreinei'1,RebekahZee2
' Ingr.m SchoolofNursicg,McGillUn;veisity,Q^t.ebec,Csuucii.;NeonataiIr.tcnsiveCircUnit,I'XTCHeaithCenm H.ili^x,C.ir.s.da.
:"Dep-ttmer.t otChiit!He.kh,CoimbraCollegeo.''Nursiig,Coirabra,Portusai. ' Kun'r-Lr.r.cnfc'dAppliedResearchUnit,Deputment
orClinicaI Epidcmiology ar.d Biostïtistics, Room 3G31, Ncith Yoric, Canada
19 studies (n= 1594 infants)
15 studies: heel lance as painful procedure (other 4: venepunction,
IM, vaccination)
11 studies: SSC vs control - 8 studies: SSC vs other treatment
-
Outcome: heart rate (11, but only datafrom 4), PIPP(5)
CochraneDatabaseo' Systematlc Reviews 2014;CDOOS435
3. Skin-to-skin care: PIPP score
Studyor subgl-oup
5kn .to-sfc'n
i/tf-> (. '. :'
Cong201
7
-r:;, i. . '. l
;32?f25;
31
6M
!0
l: i; ..
-i
; 7 r,.. '',
l
Total (95% Cl)
fc'
f,
)ll
l,. «^: ..
l';. ;:..
L...;;.' -r^l. '. J.. !.
'
20
5<(3,e7: . ;
129
139
;,
.;'1-!
M5[^11.77, |
.
...
%
I1.';!l :. .. . ^-;
1. 74'Lón'
.
n; [ . ., ^. 1 .
^1. 74 [-3. 51, 0. 06:
: ^4^. 63'
i ^. "(4.47)
..:.. -.. ] !
.
-
^
34
7. 3%
9A %
100.0 %
. 5. 23 : .~i .& 284;
-3.21 [ -3.94, -2.48 ]
:'
PIPPscore 30 sec after painful p'ocedure
Cochrane Databaseof Systematte Reuiews2014;CD008435
j
3. Skin-to-skin care: PIPP score
5-l. dy orSübgroup
Skin-to-skin
Control
Differer-ce
Mea^
Differerce
Weight
N
Mear(SD)
Gong20 i
7
16.57 C.3)
1476 (2. 59)
39.9 K
l .79 [ -0.08. 3.66 ]
Gong 20 i [
6
7.75 (3)
0.33 (5.6)
35 %
-2.58 [ -6.57, 3.1; 1
39.5%
-.05 [-2^3, 0.83 I
N
Maan(SD)
!YFixed,95ie Cl
Heel lance
johnston 2003
31
8. 97 (3. 83)
34
0.02 (4.0B)
johnstan 2008
3
9.65 (6. 93)
3
0.58(4-13)
Total (95% Cl)
78
6.7% .053 [-3 83, :.??:
79
100. 0%
0. 04 [-1. 14, 1. 23]
Heterogereity Chi2 -5. B!, df- 3 (P = 0^2): 2 =48%
Testfor overalt effert Z - 0.07 (P = 0.94)
Tesï tor subgroupdifferences' Natapplicable
PIPPscore 120sec after painful procedure
CochraneDatabaseof SystematicReuiews2014; CD008435
3. Skin-to-skin care: heart rate
D^fierpn-p
MfanfSDÏ
ir(SDl
.
VFi^cï5%Cl
IVFiwd55?;C
H<wi lanrs
Ca. tra 2CG8
Ccng2CC?
7
)755(4CI;e'
2Ë
5ESÉ(123É)
5
1732(3ËC9)
i5&73f5j5)
C.-n£2C ;
17 , ^2^(192é)
5 , iéÉ77(, É3)
Liidn2-^-Hc:f. 2CC5
12
12
Total (95% Cl)
:7(.-13(^17)
67
i7CöÉ(9.;^
54
IC;'¥
23C[-17é5 2225]
i£^%
2i;[. 1-114 IG4C1
3C.5K
-25; [-1658 ! 1 52 ]
54 i %
C57[. 3CË 9 2; j
100. 0 %
0. 35 I -6. 01, 6. 71 1
HcTpTCt-pT, ?^-Chr' -C;5 öf=5fP-G. 97/. " -CCSfe
Tp?t fcr cwn fffcr- 2 - C. l l (F = C. 5 )
Durlng painful procedure
Tft'-:fcr?i. b£mt. p=ifipn>n^ Ni-:-. ipF:i^blf>
jbî;F
Sfcn. tn-ckirN
MMniSD^
IVFiiied?SK Cl
' Hpe: Iww
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3:
:S95 f3; 15;
28
!É7;(?:83j
9-!^
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7
:ï32é(63;l
s
Méwiió. eÉi
C'?%
É37[-9 33 3 77;
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7
15269 (:386;
ï
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:(!-\%
-27.;[-i46é 9;C]
:;
-É.14F33;
2
:È635(65ó)
Lj=m^r-.hcp2CC£
Total (95% Cl)
67
ÏÏi .
54
7?C[. 2137. B57]
5.11 i-. 1:. 7é : 341
100. 0 St /<Ï. 73 [ -8.86, 1.39
Hp-Frrïg-ïn-ty O-J - 2C1 !:f- 3 ;F - C5É; l3 =CG%
Tf"-tfcrc^f>fj."-tZ=:.-lJ(F=-G 5;
TpF-Kr
tiibgnr. iip eiflprmrss
Following painful procedure
N[-;1 ;ippK-,ib:F
IC
G C
-Êochrane'Gatabaï
Itte-RAfiews2014; CD008435
3. Skin-to-skin care: care provider
3iflèrenCf>
C Terence
!Wia:d.95% Cl
IVFxec, 95% Cl
1 Palher
^r-sten 23\ l
Snbtotd (95% Cl)
31
795 %
-C.9-' [ ..2.5É.C.6E 1
34
79. 5 %
-0. 94 : -2. 56, 0. 68:
Sleteroger'etyrcTapplicai
Test for werï:\
effect Z ---
2 A'ter-st" Eew e
;ct in;tw2C
205% .li3r. 582. 056]
S 37 ,3.5,
2
Silbtotal (95% Cl;
10
20.5 % .2.63 : -5.62, 0.56;
8
Heterogereity: nctapphcabe
Testforcwral
effect 7- = i. é2 (r) - 0. 1 l;
Total l9Wo Cl;
38
100.0% ^-1.29 :-2.73, 0. 16]
42
Heterogene^ Ch:2 Ô. SÉ, d+'-- : ;P^:;£/l-i -00%
Tfïtfcrcve.
o. -'fetZ^
75(P ^03B;|
~e<tforsiifcgmiipd;fferences Ch .: --- C.=é.d'' - l (F " C.T, /. l' -C
After 120 sec: no difference i
Cochrane Daiabaseo'Systematic Reviews 2014;CDa08435
Geleste Johnston , Marsha Cïmpbell-Yeo-', Ananda Fernandes-'. Dailene Inglis2, David Sueiner4, Rebekah
' Ir.sr-m Schoo;oï.Nursir. g,McGilIUcivenity, Quebec, Car. sca.2Ncor. atal Ir.tensivc dx Cr. it,IWKHer. ithCenüe,Halifax, Canada.
3DepartmcntorChilcHe;!th, CoimbraCQll<:geofNi. K;r.g. CoimbK.?orti-gal. ''Kunm-Lunenfel>lApplicd
ü+rC!;n". ca.l Epidemlorógy ar. d Biostztistics, Room 3G31.. North Vork, Cï. r.ï. iis.
Research
Unit, Depanment
SSCs.ppears to beeffecrive, asmeisured bycomposite pain indica'-ors ar.ci includir. g both physiologica! ar.d behaïioursl indicators,
. «ndsare fo; E single pïir-fui procedure such as s heel 'acce. Pureiybehavioura! indicacois ter.ded to t'avour SSC bu; there remains
questionable bi.^ regardir. g behaviour. ;] indicEtors. Physiological ir.dicaroiswererypically notdirïerer. t betw'eer. conditions. Or. lywo
studies compared moiher pi ovideis
to
ethers, with cor.-significa--t iesu!ts. There
\vas
more
hererogeneity
ir.
the stiidies with behavioural
1 or composite outcoines. There is a need tor rep;icatior. studies, ïh. i.t use simiisr, cie.Lrlydehced outcome?. New studies exaaiir. ir.g
. optim»' duracion ofSSC,gestational sgegroups, repsated use, u-.d lor. g-term effectsofSSCareneeded.
CochraneDataoaseo' Systematic Reviews2014;CDOOSA35
Trial of repeated analgesia with Kangaroo Mother Care (TRAKC Trial).
CamEbe!l^<eQj^1,JohnstonC. BenoitB. LatimerM.VincerM.WalkerCD.StreinerD.InalisD.CaddellK.
- 258 premature, stable infants
Single blinded randomized parallel group designs
3 study arms: KMC, combined KMC/24 % sucrose, 24 % sucrose
- Outcome: use of PIPP pain scale, maturity of neurobehavioral
functioning (NAPI scale)
Campbell-Yeo.
BMC Pediatr 2013; 13: 182
Take home messages
If available, breastfeeding or breast milk
should be used to alleviate procedural pain in
term neonates undergoing a single painful
procedure
Take home messages
Administration ofglucose/sucrose has similar
effect! ve n ess
Take home messages
The effectiveness should be further studied in
preterm infants
Take home messages
The effectiveness should be further studied in
repeated painful procedures

Douleur et inconfort en periode périnatal Pijn en discomfort

Transcription

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