- •
Medical procedures involving needle puncture are ubiquitous in contemporary health care; they are used to diagnose, treat and monitor medical conditions.
- •
Cumulatively, infants can be exposed to hundreds of needle procedures over the entire duration of a hospitalization.
- •
There is sufficient evidence to support the use of nonpharmacologic interventions, particularly breastfeeding, sweet tasting solutions, and skin-to skin care, as primary strategies for pain management during common needle puncture
Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update
Section snippets
Key points
Swaddling and containment
Swaddling and containment are interventions that aim to limit the infant’s boundaries, promote self-regulation, and attenuate physiologic and behavioral stress caused by acute pain.16, 17 These interventions are normally differentiated in that swaddling involves wrapping of the infant in a sheet or blanket; limbs flexed; head, shoulders, and hips neutral, without rotation; and hands accessible for exploration18; whereas containment refers to restricting the infant’s motions by holding or using
Evidence Summary
In the absence of breastmilk or supplemental infant formula, non-nutritive sucking, generally referred to as the placement of a pacifier or a gloved finger in the infant’s mouth to stimulate a sucking response, has been well-studied and reviewed in a recent meta-analysis.17 The systematic review consisted of the combined effect of 6 studies conducted in preterm infants, 7 in full-term infants, and 1 in infants older than 1 month of age. The authors concluded that there is sufficient evidence
Evidence Summary
Rocking is considered a gentle back and forth motion that stimulates a vestibular response. This movement can be accomplished via simulated means, but in the case of pain relief effectiveness is greater if provided by another person. Holding is defined as the holding of a clothed infant by either a parent or care provider. The research evidence for rocking and holding demonstrates some support for the effectiveness of this intervention as a pain-relieving strategy. In a recent meta-analysis,17
Evidence Summary
There is clear evidence that breastfeeding, when compared with placebo or a no intervention control, effectively decreased pain associated with common needle puncture procedures in infants.38, 39, 40, 41 Results from a recent systematic review conducted by Benoit and colleagues41 that included 21 studies; 15 evaluated breastfeeding or breastmilk in term infants, and 6 studies in preterm infants showed that direct breastfeeding was more effective than holding, skin-to-skin, and sweet tasting
Evidence Summary
Ventral skin-to-skin contact between a baby and its mother is commonly referred to as Kangaroo Mother Care owing to its similarity to marsupial mother–infant behavior. Because there may be times in which caregivers other than the mother are holding the infant, it is simply known as kangaroo care or skin-to-skin care. In this paradigm, the infant wearing only a diaper and cap is placed on the mother’s bare chest between her breasts and the two are wrapped together with a small blanket, sheet, or
Evidence Summary
Oral sweet tasting solutions (eg, sucrose in water) are the most widely studied nonpharmacologic intervention for pain management in infants and have been consistently demonstrated to have analgesic effects in infants. Multiple systematic reviews demonstrate a decrease in behavioral pain behaviors in infants given sweet solutions during common needle procedures when compared with placebo water or no intervention,39, 64, 65, 66 and sweet tasting solutions are recommended in consensus statements
Evidence Summary
There is some evidence that music therapy may be beneficial in relieving procedural pain in both full-term and preterm infant. Results from a recent review that included 9 randomized trials examining the efficacy of music for pain associated with circumcision and heel lance indicated that newborns exposed to music therapy seem to have greater physiologic stability and diminished pain response.82
Research and Implementation Considerations
Owing to the poor quality of some of the studies, a large variation in reported outcomes, and
Evidence Summary
Sensorial saturation is defined as a multisensorial stimulation consisting of delicate tactile, gustative, auditory, and visual stimuli84, 85 whereby, during the procedure, the infant's attention is attracted by massaging the face, speaking to the infant gently, and instilling a sweet solution on the infant's tongue. Results from systematic review of 8 studies examining the effect of sensorial saturation for pain relief during heel lance, intramuscular injection, and endotracheal suctioning
Evidence Summary
Researchers began evaluating the impact of parental presence and involvement in their children’s care during painful medical procedures and resuscitation using mostly observational studies.88, 89, 90, 91 Researchers developed a body of evidence for the pediatric emergency department and recent systemic reviews demonstrated that almost 90% of parents want the option of participating in their child’s procedures and involving parents has no negative effect on emergency staff performing the
Comparisons and combinations of nonpharmacologic pain management interventions
There has been increasing research comparing individual nonpharmacologic pain management interventions as well as their combined effects. When compared with a sweet tasting solution (oral sucrose), facilitated tucking alone is not as effective in relieving pain reactivity after a heel lance in very preterm infants.23, 118 However, its use as an adjuvant therapy, in combination with oral sucrose and non-nutritive sucking, seems to be beneficial.23, 119 Similarly, non-nutritive sucking alone when
Summary
There is sufficient evidence to support the use of nonpharmacologic interventions, particularly breastfeeding, sweet tasting solutions, and skin-to skin care as primary strategies for pain management during common needle puncture procedures. They are recommended for managing acute pain and distress in infants during common needle procedures (Table 2). Music therapy, sensorial saturation, rocking and holding, swaddling and containment pacifier, and non-nutritive sucking would be considered
References (124)
- et al.
Perceptions on pain management among Korean nurses in neonatal intensive care units
Asian Nurs Res (Korean Soc Nurs Sci)
(2014) - et al.
Long-term impact of neonatal intensive care and surgery on somatosensory perception in children born extremely preterm
Pain
(2009) - et al.
The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU
Early Hum Dev
(2017) - et al.
Facilitated tucking by parents' in pain management of preterm infants-a randomized crossover trial
Early Hum Dev
(2006) - et al.
Sucking-and sucrose-induced analgesia in human newborns
Pain
(1999) - et al.
Heart rate variability responses to nipple feeding for preterm infants with bronchopulmonary dysplasia: three case studies
J Pediatr Nurs
(2010) - et al.
Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial
Lancet Child Adolesc Health
(2018) Family integrated care for very preterm infants: evidence for a practice that seems self-evident
Lancet Child Adolesc Health
(2018)- et al.
Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials
Clin Ther
(2009) - et al.
Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood immunizations: systematic review and meta-analyses
Clin Ther
(2009)
The effects of a pacifying stimulus on behavioural and adrenocortical responses to circumcision in the newborn
J Am Acad Child Psychiatry
Non-nutritive sucking, oral breast milk, and facilitated tucking relieve preterm infant pain during heel-stick procedures: a prospective, randomized controlled trial
Int J Nurs Stud
Myth of the marsupial mother: home care of very low birth weight babies in Bogota, Colombia
Lancet
Physiological measures of kangaroo versus incubator in a tertiary nursery
J Obstet Gynecol Neonatal Nurs
Oral Sucrose for procedural pain in infants
Lancet
Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomized controlled trial
Lancet
Pain, nociception, and spinal opioid receptors
Prog Neuropsychopharmacol Biol Psychiatry
Facilitated tucking by parents in pain management of preterm infants- A randomized crossover trial
Early Hum Dev
Pain in Canadian NICUs: have we improved over the past 12 years?
Clin J Pain
Epidemiology and treatment of painful procedures in neonates in intensive care units
JAMA
Epidemiology of painful procedures performed in neonates: a systematic review of observational studies
Eur J Pain
Exposure to invasive procedures in neonatal intensive care unit admissions
Arch Dis Child Fetal Neonatal Ed
A cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units
Clin J Pain
Do we still hurt newborn babies?
Arch Pediatr Adolesc Med
Procedural pain in neonatal units in Kenya
Arch Dis Child Fetal Neonatal Ed
Eight years later, are we still hurting newborn infants?
Neonatology
Assessment and management of pain in newborns hospitalized in a neonatal intensive care unit: a cross-sectional study
Rev Lat Am Enfermagem
Procedural pain and brain development in premature newborns
Ann Neurol
Assessment and management of procedural pain during the entire neonatal intensive care unit hospitalization
Pain Manag Nurs
Sedation and analgesia practices at Italian neonatal intensive care units: results from the EUROPAIN study
Ital J Pediatr
Comparison of pain responses of premature infants to the heelstick between containment and swaddling
J Nurs Res
Nonpharmacological management of procedural pain in infants and young children: an abridged Cochrane review
Pain Res Manag
Neurodevelopmental care in the NICU
Ment Retard Dev Disabil Res Rev
Swaddling: a systematic review
Pediatrics
Management of pain from heel stick in neonates: an analysis of research conducted in Thailand
J Perinat Neonatal Nurs
Non-pharmacological management of infant and young child procedural pain
Cochrane Database Syst Rev
Facilitated tucking as a non-pharmacological intervention for neonatal pain relief: is it clinically feasible?
ACTA Paediatr
Swaddling after heel lance: age-specific effects on behavioral recovery in preterm infants
J Dev Behav Pediatr
Behavioral and physiological consequences of suckling in rat and human newborns
Acta Paediatr Suppl
Randomized trial of analgesic effects of sucrose, glucose and pacifiers in term neonates
Br Med J
A new look at some old mechanisms in human newborns: taste and tactile determinants of state, affect, and action
Monogr Soc Res Child Dev
Barriers, facilitators and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review
J Hum Lact
Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations
J Hum Lact
Analgesic effect of breast feeding in term neonates: randomised controlled trial
BMJ
Contact and nutrient caregiving effects on newborn infant pain responses
Dev Med Child Neurol
Soothing pain-elicited distress in infants with swaddling and pacifiers
Child Development
Breastfeeding or breast milk for procedural pain in neonates
Cochrane Database Syst Rev
Breastfeeding for procedural pain in infants beyond the neonatal period
Cochrane Database Syst Rev
Breast-feeding analgesia in infants: an update on the current state of evidence
J Perinat Neonatal Nurs
Hidden regulators in attachment, separation, and loss
Monogr Soc Res Child Dev
Cited by (46)
Maintaining parent-infant skin-to-skin contact during peripheral intravenous catheter insertion in a Dutch neonatal unit
2024, Journal of Neonatal NursingEffectiveness of maternal-targeted training on nonpharmacologic pain management on heel stick sampling: A randomized controlled trial
2023, Journal of Pediatric NursingThe effect of using maternal voice, white noise, and holding combination interventions on the heel stick sampling
2023, Journal of Pediatric NursingFacial expression as an indicator of neonatal pain in randomized clinical trials: An integrative review
2023, Journal of Neonatal NursingCitation Excerpt :In the present review, most studies reported the use of non-pharmacological methods before, during and after the painful procedure for filming facial expression. However, evidence indicates that, in clinical practice, many newborns have still undergone painful procedures with no analgesic intervention (McNair et al., 2019). Despite the available evidence, it is still common for painful procedures to be performed without adequate treatment, despite studies showing that newborns have a fully developed nociceptive system (Maciel et al., 2019).
Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks−American Pain Society−American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain
2023, Journal of PainCitation Excerpt :It is important to recognize that children learn from their pain experiences and the context in which pain is experienced.190,191 Those who receive parental or caregiver support during painful procedures exhibit less pain than those who did not have this support.192 The classification of needle pain presented in the current work highlights the current state of knowledge in needle pain science and clearly elucidates the components of the needle pain experience.
This article is an update of an article that originally appeared in Clinics in Perinatology, Volume 40, Issue 3, March 2013.