Procedural Pain Management for Neonates Using Nonpharmacological Strategies

Abstract

This is the second of a 2-part series to provide an overview of our current level of knowledge related to nonpharmacological strategies to diminish the pain associated with commonly performed procedures in the NICU. In our first article we discussed the prevalence of repeated pain exposure in the NICU and the importance of nonpharmacological strategies specifically containment or facilitated tucking, swaddling, positioning, nonnutritive sucking, and sweet solutions. These strategies are generally nurse-driven and we believe their importance has been underutilized. In this article we will emphasize the importance of maternal presence as a mediator for pain relief. The efficacy of breastfeeding, maternal skin-to-skin care (often referred to as kangaroo care), and multisensorial stimulation such as auditory and olfactory recognition will be the primary focus of our discussion. In addition, although primarily mother-driven, these strategies are ultimately nurse-enabled, thus the importance of this connection cannot be under appreciated with respect to successful implementation in the NICU.

Cobedding and Recovery Time After Heel Lance in Preterm Twins: Results of a Randomized Trial

“…10,35 This difference may relate to the lack of full ventral skin contact associated with previously studied skin-to-skin contact, as this is not possible among cobedding twins or may simply support the premise that mothers provide something unique when compared with other providers. 36,37 The prolonged period of separation of the twins before initiating cobedding (mean 18.7, range 2-87 days) may have diminished recognition of the familiar twin scent and could potentially explain the lack of reduction in pain scores after cobedding. In addition, most cobedding twins (58%) underwent a single heel lance within 3 days of being cobed together.…”

The relationship of prenatal maternal depression or anxiety to maternal caregiving behavior and infant behavior self-regulation during infant heel lance: an ethological time-based study of behavior

“…There is, however, substantial evidence that non-pharmacological pain treatments can effectively alleviate procedural pain in newborns based on a reduction in mean measures of pain behavior (primarily changes in facial movement), heart rate, and/or salivary cortisol levels [6, 7]. Examples include the use of oral sucrose as well as mother driven caregiving interventions (eg., kangaroo mother care, breastfeeding, facilitated tucking) [6, 7]. …”

Does daily kangaroo care provide sustained pain and stress relief in preterm infants?

“…It is not known whether direct skin contact is the factor that provides calming, or whether the multisensorial stimulation of being held and rocked combined with the mother's fragrance, heart-beat, voice and breathing provide stress relief for the infant [7]. Morelius [18] studied the effects of skin-to-skin care on stress levels in 17 pairs of mothers and preterm infants and found that salivary cortisol levels increased in some infants (38%) and decreased in others (38%).…”

“…Kangaroo care (KC) or skin-to-skin holding on the parenty's chest in an upright position, has been identified as one method that can reduce pain responses during painful procedures in newborn infants [7-12]. KC also facilitates bonding and may have benefits for infant neurodevelopment [13] and reduced morbidity and mortality [14].…”