Are there developmentally distinct motor indicators of pain in preterm infants?

Morison, Sara J.; Holsti, Liisa; Grunau, Ruth E.; Whitfield, Michael F.; Oberlander, Tim F.; Chan, Hock Chuan; Williams, Linda

doi:10.1016/s0378-3782(03)00044-6

Cited by 64 publications

(97 citation statements)

References 27 publications

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“…Table 3 for definitions of each of the indicators). All of these indicators have been validated individually for assessing acute pain in preterm infants (Grunau et al, 2000;Stevens et al, 2000;Morison et al, 2003;Holsti et al, 2004). Moreover, the 5 facial actions we selected have been validated for assessing postoperative pain in infants born preterm and up to 18 months of age (Peters et al, 2003).…”

Section: Methodsmentioning

confidence: 99%

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Holsti

Grunau²

2007

Pain

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Accurate pain assessment in preterm infants in the neonatal intensive care unit (NICU) is complex. Infants who are born at early gestational ages (GA), and who have had greater early pain exposure, have dampened facial responses which may lead to under-treatment. Since behavioral and physiological responses to pain in infants are often dissociated, using multidimensional scales which combine these indicators into a single score may limit our ability to determine the effects of interventions on each system. Our aim was to design a unidimensional scale which would combine the relatively most specific, individual, behavioral indicators for assessing acute pain in this population.The Behavioral Indicators of Infant Pain (BIIP) combines sleep/wake states, 5 facial actions and 2 hand actions. Ninety two infants born between 23-32 weeks GA were assessed during 3, one minute Phases of blood collection. Outcome measures included changes in BIIP and in Neonatal Infant Pain Scale (NIPS) scores coded in real time from continuous bedside video recordings; changes in heart rate (HR) were obtained using custom physiological processing software.Scores on the BIIP changed significantly across Phases of blood collection (p < 0.01). Internal consistency (0.82) and inter-rater reliability (0.80-0.92) were high. Correlations between the BIIP and NIPS were modest (r = 0.64, p < 0.01) as were correlations between the BIIP and mean heart rate (r = 0.45, p < 0.01). In this initial study, the BIIP has been shown to be a reliable, valid scale for assessing acute pain in preterm infants in the NICU. Keywordspremature; infant; pain; assessment IntroductionPreterm infants undergo repeatedly painful diagnostic and therapeutic procedures to ensure their survival. In order to provide appropriate pain management in this population, accurate assessment of pain is necessary (Anand et al., 2005), yet complex because we are limited to indirect measures of pain responses. And although infant pain responses have both behavioralCorresponding author: Dr. Liisa Holsti, Centre for Community Child Health Research, F611, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4. Canada, Phone: 604-875-2000, local 5200, Fax: 604-875-2384, E-mail address: lholsti@cw.bc.ca. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. and physiological components, dissociations between behavioral and physiological pain responses are common (Barr, 1998;Morison et al., 2001). Furthermore, facial actions are the relatively most specific behavioral pain indicators in preterm infants, yet these responses may be dampened. Grunau et al...

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Section: Methodsmentioning

confidence: 99%

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Holsti

Grunau²

2007

Pain

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152

117

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“…29 The purpose of the present study was to determine whether a subset of NIDCAP movements could be used as valid acute pain cues in preterm infants.…”

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confidence: 99%

“…28 Although the second study measured pain responses over longer periods of time and compared the NIDCAP with other reliable infant biobehavioral pain measures, it included only 10 infants, and the time of each handling phase was not controlled. 29 The purpose of the present study was to determine whether a subset of NIDCAP movements could be used as valid acute pain cues in preterm infants.…”

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confidence: 99%

Specific Newborn Individualized Developmental Care and Assessment Program Movements Are Associated With Acute Pain in Preterm Infants in the Neonatal Intensive Care Unit

Holsti

Grunau²,

Oberlander

et al. 2004

Pediatrics

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Objective. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is widely used in neonatal intensive care units and comprises 85 discrete infant behaviors, some of which may communicate infant distress. The objective of this study was to identify developmentally relevant movements indicative of pain in preterm infants.Methods. Forty-four preterm infants were assessed at 32 weeks' gestational age (GA) during 3 phases (baseline, lance/squeeze, and recovery) of routine blood collection in the neonatal intensive care unit. The NIDCAP and Neonatal Facial Coding System (NFCS) were coded from separate continuous bedside video recordings; mean heart rate (mHR) was derived from digitally sampled continuous electrographic recordings. Analysis of variance (phase × gender) with Bonferroni corrections was used to compare differences in NIDCAP, NFCS, and mHR. Pearson correlations were used to examine relationships between the NIDCAP and infant background characteristics.Results. NFCS and mHR increased significantly to lance/squeeze. Eight NIDCAP behaviors also increased significantly to lance/squeeze. Another 5 NIDCAP behaviors decreased significantly to lance/squeeze. Infants who had lower GA at birth, had been sicker, had experienced more painful procedures, or had greater morphine exposure showed increased hand movements indicative of increased distress.Conclusions. Of the 85 NIDCAP behaviors, a subset of 8 NIDCAP movements were associated with pain. Particularly for infants who are born at early GAs, addition of these movements to commonly used measures may improve the accuracy of pain assessment.Major advances in neonatal care now enable a high proportion of preterm infants to survive. During a time when medical concerns focused primarily on stabilizing the physiologic needs of preterm infants, Als, a developmental psychologist, developed a theory and systematic method of assessing the developmental needs of preterm newborns, the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).1 Als hypothesized is a high priority for caregivers in the NICU because early pain exposure may alter nociceptive pathways 9 , 10 and may also contribute to changes in other areas of development. , 12Although improved pain assessment and management is a clinical priority, accurate identification of pain responses is complex for a number of reasons. First, preterm infants respond with facial, motor, and physiologic changes to acute pain, but they differ from termborn infants in that their responses are of smaller magnitude, particularly at younger gestational ages (GAs). 13 , 14 Second, preterm infants at earlier GAs may display different pain behaviors than infants at later GAs as a result of neurologic immaturity. Such behaviors may not be captured in the current pain scales because the behaviors chosen have been based on behaviors seen in term infants. Third, no physiologic or behavioral threshold specifically marks the presence of pain. Finally, although using a single pain index is eas...

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“…The volume and color of gastric residuals are often used to reflect feeding intolerance, but the NEC-predictive value of this marker is uncertain [6]. Decreased physical activity is an early sign of adverse body conditions in both children and adults [6,7] and is also a common observation in neonatology.…”

Section: Introductionmentioning

confidence: 99%

Physical Activity and Gastric Residuals as Biomarkers for Region-Specific NEC Lesions in Preterm Neonates

Cao

Andersen²,

Li³

et al. 2016

Neonatology

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Background: Necrotizing enterocolitis (NEC) is a serious feeding-related inflammatory gut disease with high mortality. Early clinical markers of NEC are of great importance for optimizing preventive interventions. Objective: Using preterm pigs as models, we hypothesized that an early postnatal onset of NEC can be predicted by decreased physical activity during the first few days after birth. Methods: Cesarean-delivered preterm pigs were fed parenteral nutrition and increasing amounts of formula for 5 days after birth (n = 120). Their physical activity was quantified by a continuous camera surveillance system and they were evaluated twice daily for clinical signs of apathy, discoloration, respiratory distress, abdominal distension and diarrhea. The volume of gastric residuals and the presence of macroscopic NEC-like lesions in the stomach, intestine and colon were recorded at euthanasia on day 5. Results: Half of the pigs (48%) showed clear NEC-like lesions on day 5, and these individuals had more adverse clinical symptoms from day 3 but decreased physical activity already from day 2 relative to the unaffected pigs (both p < 0.05). Only animals with NEC lesions in the small intestine had lower physical activity on days 2 and 3, and the increased volume of gastric residuals was specifically related to colon lesions (both p < 0.05). Conclusions: Decreased physical activity precedes the clinical symptoms of NEC in the small intestine of preterm pigs, and increased gastric residuals predict NEC lesions in the colon. Physical activity and gastric residuals may function as clinical biomarkers for region-specific NEC lesions in preterm neonates.

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Are there developmentally distinct motor indicators of pain in preterm infants?

Cited by 64 publications

References 27 publications

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Specific Newborn Individualized Developmental Care and Assessment Program Movements Are Associated With Acute Pain in Preterm Infants in the Neonatal Intensive Care Unit

Physical Activity and Gastric Residuals as Biomarkers for Region-Specific NEC Lesions in Preterm Neonates

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