Efficacy of swaddling and heel warming on pain response to heel stick in neonates: a randomised control trial

Procedural pain in the neonatal intensive care unit triggers a cascade of physiological, behavioral and hormonal disruptions which may contribute to altered neurodevelopment in infants born very preterm, who undergo prolonged hospitalization at a time of physiological immaturity and rapid brain development. The aim of this study was to examine relationships between cumulative procedural pain (number of skin-breaking procedures from birth to term, adjusted for early illness severity and overall intravenous morphine exposure), and later cognitive, motor abilities and behavior in very preterm infants at 8 and 18 months corrected chronological age (CCA), and further, to evaluate the extent to which parenting factors modulate these relationships over time. Participants were N=211 infants (n=137 born preterm 32 weeks gestational age [GA] and n=74 full-term controls) followed prospectively since birth. Infants with significant neonatal brain injury (periventricular leucomalacia, grade 3 or 4 intraventricular hemorrhage) and/or major sensori-neural impairments, were excluded. Poorer cognition and motor function were associated with higher number of skin-breaking procedures, independent of early illness severity, overall intravenous morphine, and exposure to postnatal steroids. The number of skin-breaking procedures as a marker of neonatal pain was closely related to days on mechanical ventilation. In general, greater overall exposure to intravenous morphine was associated with poorer motor development at 8 months, but not at 18 months CCA, however, specific protocols for morphine administration were not evaluated. Lower parenting stress modulated effects of neonatal pain, only on cognitive outcome at 18 months. Show more

Infant pain is a clinical reality. Effective pain management in infants requires a specialist approach--analgesic protocols that have been designed for older children cannot simply be scaled down for CNS pain pathways and analgesic targets that are in a state of developmental transition. Here, we discuss the particular challenges that are presented by an immature CNS for the detection and treatment of pain. We show how the application of neurophysiological and neuropharmacological approaches can help to overcome the problems inherent in measuring and treating pain in infants, and how research data in these areas can be used to devise age-appropriate methods of assessing pain as well as strategies for pain relief. The evidence that untreated pain in infancy results in long-term adverse consequences is presented, thereby emphasizing the need for a longer term view of infant pain management. Show more

There is a plethora of infant pain measures; however, none of them have been validated for extremely low for gestational age (ELGA) infants ( 36 weeks. Physiological data during four phases of a routine heel lance were collected by placing disposable ECG electrodes and pulse oximetry probes on the infant's chest. Behavioral data were collected by videotaping facial activities, and cry data were collected by audio recording. Four facial activities (brow bulge, eye squeeze, nasolabial furrow, vertical mouth stretch) in response to acute pain were present in ELGA infants. Facial activities increased following painful procedures and the magnitude of responses was proportional to GA with the youngest infants (<27 6/7 weeks GA) showing the least amount of change. Decreased oxygen saturation and increased heart rate were associated with the most invasive phase of the heel lance; however, the differences were neither clinically or statistically significant across age groups. Cry was not a sensitive pain indicator in ELGA infants, due to the presence of endotracheal tubes in this high-risk population. ELGA infants have similar pain responses to older infants, but the responses are dampened. Other factors such as severity of illness, frequency of painful procedures or medication use should be examined, as they may influence the pain responses in ELGA infants. (c) 2007 S. Karger AG, Basel. Show more