Behavioral Responses to Pain Are Heightened After Clustered Care in Preterm Infants Born Between 30 and 32 Weeks Gestational Age

Abstract

Objective-To compare biobehavioral pain responses of preterm infants born at differing gestational ages (GAs) when pain was preceded by a rest period or by a series of routine nursing interventions.Methods-In a randomized, within subjects, cross-over design, facial (Neonatal Facial Coding System), sleep/wake state and heart rate (HR) responses of 43 preterm infants [mean birth weight: 1303 g (range 590 g to 2345 g); mean GA at birth: 30 weeks (range 25 to 32)] were examined across 3 phases of blood collection (Baseline, Lance, and Recovery) under 2 conditions: pain after a 30-minute rest period versus pain after a series of routine nursing interventions (clustered care). Infant behavioral responses were coded from continuous bedside videotapes. HR was analyzed using custom physiologic signal processing software.Results-Infants born at earlier GA (<30 wk) had equally intense facial responses during the Lance phase regardless of condition. However, later born infants (≥ 30 wk GA) showed heightened facial responses indicative of sensitized responses during blood collection when it was preceded by clustered care (P = 0.05). Moreover, later born infants had significantly lower facial (P = 0.05) and HR (P = 0.04) reactivity during Recovery when blood collection followed clustered care.Discussion-Earlier born preterm infants showed heightened states of arousal and poor ability to modulate HR during Recovery when an invasive procedure was preceded by routine tactile nursing procedures. Alternatively, later born infants exhibited sensitized responses when clustered care preceded blood collection. Our findings support the importance of cue based individualized approaches to care.

Skin conductance as a marker of pain in infants of different gestational age

“…However, term infants are not used to dealing with painful stimuli. Their behaviour is just more organized 18,19 . Much work has been done relating to pain assessment in preterm infants.…”

Procedural pain and brain development in premature newborns

“…While it is recognized that procedures differ in pain intensity, we count every skin break as a "marker" of acute pain-related stress exposure in the NICU, since due to sensitization, the impact of a procedure is not a direct function of the degree of tissue damage. 31 All nursing staff in our NICU have been trained to carry out precise recordings of every skin-breaking procedure, including each attempt; therefore we have highly consistent chart information on every infant. Since ongoing chart review would require 24 hour presence of a research nurse, we conducted chart review when the infant was discharged.…”

Invasive Procedures in Preterm Children: Brain and Cognitive Development at School Age

“…Future research with larger samples is needed to address whether recurrent lifethreatening complications such as necrotizing enterocolitis may also have predisposed infants to ischemia and related myelination disturbances. Preterm infant responses to invasive proceduresvary depending on GA, sleepwake state, illness severity, and previous exposures to pain, [55][56][57][58][59][60][61][62] therefore it is difficult to determine the extent of pain perceived for a specific procedure. Furthermore, although we adjusted for cumulative morphine exposure in our models, we could not account for pain management that may have been provided during a given procedure.…”