Developmentally

Appropriate/Supportive

Interventions in the NICU

Many thanks to the

multi-disciplinary Sunnybrook

Team

Objectives

• To understand the various interventions that can

be implemented in the macro and micro-

environment within the NICU

• To appreciate the importance of these various

interventions

Interventions

• Environmental changes- macro and micro

• Cluster of care

• Non-nutritive sucking

• Positioning

• Skin to Skin Care

• Pain Management

• Family Centered Care

• Promote stability and reduce stress in the

infant

• Respond to the infant‟s cues

• Protect the family

Macro environment

• The NICU – design of the unit needs to be developmentally friendly

• The staff – needs to function as a team and be supportive of developmentally appropriate care

the staff needs also are taken into consideration

• Lights

• Sounds

Lighting

• Photometers to measure lighting

• <32wks GA

minimize ambient light exposure

use covers over isolettes

• Provide task lighting for staff and family

• Provide Night time staff exposure to adequate lighting

• Protect infants eyes from direct light exposure at:

Admission

Eye exams

Under phototherapy lights

Other procedures

In our unit

fully covered

isolettes until

approximately

32 weeks or while

critically ill

Cycled Lighting

• > 32 wks GA – cycled lighting:

210-270 lux from 7 AM to 7 PM

blankets are not permitted on top of the isolettes

infants are allowed 2 naps in dimness in

this 12-hour period

lighting is lower than 25 lux from7 PM to 7 AM.

• After 37 weeks GA – provide more complex

visual stimulation

Circadian rhythm

• In utero circadian rhythm of the fetus is set by mother by her activity level, eating, temperature, heart rate, blood pressure,melotonin and her cortisol levels

• Preterm infants in the NICU lack the maternal entrainment and are exposed to unpredictable lighting in the unit

• Cycled lighting may assist the preterm infant achieve some circadian rhythm in an appropriate timeline

Sound Levels

• average NICU is 70 - 80 dB

• recommended level is 50 dB

• well maintained and sealed empty isolette

should be 50 dB

• perceived loudness of sound doubles with

every 6 - 10 dB

• opening isolette doors gives perception of

sound 8 times louder

Sound

• Sound measurements to be done of the unit and

in the isolette and at the open bed space

• Sound reducing materials on surfaces in the unit

ie walls and floor

• Respond to monitors, equipment, pagers

• Attention to other noise producing equipment

• Traffic patterns in the unit – where high traffic,

keep babies away ( or at least the sickest)

• Reduce bedside conversations, other noises around bedside/isolette

• Want infant to hear mother‟s voice above background sounds

• Reduce lights – people talk quieter

• Reduce stress and crying of infants

• Naptime or quiet time

• Staff conversations

Noise Reduction

What doesn‟t work

• isolette covers

• infant foam ear covers

• curtains between baby areas

• “noise police” might work

Micro Environment

• Surrounding the infant:

Cluster of Care

Positioning

Touch- procedural / non-procedural

Pain management

• Use of expressed colostrum ( oral immune

therapy) and breastmilk

• Oral feeding = breastfeeding , bottle feeding

Cluster of Non-Emergent Care

• Should be according to infant‟s cues

• Should not be interrupting sleep

• Bedside nurse – the guardian: others to make an appointment as to when to handle ( other than a “hand-hug” by parent)

• Clustering of care is believed to support infant development by decreasing infant energy expenditure and promoting sleep.

•clustering of care with recovery time

•scheduled assessment times

•gentle, slow repositioning

•hand containment or nesting

Non-Nutritive Sucking (NNS)

• A reflex that is elicited when an infant sucks on a

pacifier, hand or any object that does not deliver

liquid

• NNS is important for infant‟s state regulation –

assists in calming the infant

• it is seen in utero as early as 11 - 13 weeks GA

• Use when there is maternal –infant separation

separation of mom & baby creates an

abnormal scenario

size appropriate, use during tube feeds

Cochrane Review (Pinelli and

Symington,2010

• NNS was found to decrease significantly the length of hospital stay in preterm infants.

• The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state).

• The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance.

• These infants showed less defensive

behaviors during tube feedings, spent less

time in fussy and active states during and

after tube feedings, and settled more

quickly into sleep.

Positioning the Preterm Infant

• Positioning is defined as “ a bodily posture

assumed by the patient or in which the

patient is placed to achieve comfort”

• “The particular disposition of the body and

extremities to facilitate the performance of

certain diagnostic or therapeutic postures”

Historical Perspective

• In the past, supine was the position of choice for infants,

• It allowed easy observation and easy access by caregivers

• The practice of supine positioning was challenged based on studies of respiratory function in adults.

• Attinger et al. (1956) studied preterm infants to determine the optimal position for care.

• Prone position was found to offer more benefits than supine or side lying positions. The findings of their hallmark study altered care in NICUs, wherein all infants were positioned prone.

• A 2001 review of 180 papers examined neuromotor

development and the physiological effects of

positioning and interventions in order to minimize or

prevent short and long tem negative outcomes

Emerging results indicated that:

• the development of posture and mobility in newborn

infants requires an optimal balance between active

and passive muscle tone

• prone position is physiologically more beneficial for

the preterm infant than supine and lateral positions

• prone position can lead to short and long term

postural and associated developmental problems

Why is Developmentally Appropriate

Positioning Important?

• Overall hypotonia (low muscle tone)

• Imbalance of active and passive muscle power

• Affects of gravity

• Lack of uterine containment

• Caudocephalic direction of neuromotor

development

Muscle Tone

what is it ?

Muscle tone

• The state of slight contraction usually present in muscles that contributes to posture and coordination

• Resistance of muscles to passive elongation or stretch

• Power and adaptability of the muscles during spontaneous movements

• Affected by state

• Factors affecting Muscle Tone in the Preterm population

Postural control

• Provides a basis for stability during movement

• Passive muscle power- slight, sustained contraction in anti-gravity muscles

• Supine posture – provides an overall impression of passive muscle tone

• Active muscle power- degree of vigour in spontaneous movements, fluent alterations in flex/ext – symmetrical, goal directed movements

Passive muscle tone

• Best observed when infant at rest – quiet

alert state

• State of slight muscle contraction that

contributes to postural control and co-

ordination of the extremity movements

• Begins approx 28 weeks gestation age

• Develops in a caudocephalic direction

28 week Gestational Age

Dubowitz et al, 1999

32 week Gestational Age

Dubowitz et al 1999

Posture: 36 - 37 weeks Gestational Age

Dubowitz et al 1999

36 weeks gestational age

Posture: Full Term

Dubowitz et al 1999

40 weeks

Active Muscle Power

• Is observed when an infant makes a movement in reaction to a situation

• As preterm infants have low muscle tone, they appear to develop exagerrated active muscle power

• Therefore increased extension with movements

Passive Muscle tone and active muscle

tone need to work in harmony to

provide stable postures and fluent

movements

The preterm infants have low muscle tone

and exagerrated active muscle power,

therefore very difficult to maintain a

posture or position without assistance

• Need to determine a position that is

medically effective and developmentally

supportive

“moving target”

• No long lasting perfect position

Positioning Goals

Goals of Positioning

Head Goals

• prevent head & neck hyperextension

• put neck in elongated position

• chin in neutral position or slightly flexed

downward

Nose Goals

• maintain normal nare shape

• prevent nasal notching and keep the

septum intact

• good alignment of tubing in the nostrils

Plastic surgery can‟t fix notches

please, spare the nares !

Eroded Caudal Septum

Columellar Transection

Columellar Notching

Upper Extremity Goals

• forward flexion of shoulders to prevent shoulder

retraction

• hands to midline

• hands to mouth

• grasp opportunities

Trunk & Lower Extremity Goals

• maintain a straight, aligned trunk

• hip and knee flexion to approx. 90 degrees

• prevent excessive abduction and external

rotation

• maintain knees in a midline (neutral) position

• feet - allow bracing, maintain a symmetrical

position

Principles of Positioning

• Flexion

• Midline

• Symmetry

• Alignment

• Weight bearing

• Containment

• Comfort and sleep

• Learning opportunities for the intimate caregiver

• Flexion: the act of bending or is the condition of

being bent

In utero, the fetus is maintained in a flexed position

by the uterine wall

In the NICU, the preterm infant should be positioned

in a flexed posture in order to imitate the intrauterine

posture and to enhance the development of flexor

muscle tone

• Midline :the line through the middle of the body ie

from the nose to the umbilicus.

• With positioning it is imperative to bring both the

upper and lower extremities towards the midline so

that the hands have easy access to the mouth,and

the hips and knees are towards the midline so

promote good alignment of the hips.

• As infant moves towards the midline, they are moving

into a position of flexion and as they move away from

the midline, they are moving into an extended

position which will increase stress and

disorganization.

• Symmetry is defined as “the

correspondence in size, form and

arrangement of parts on opposite sides of

a plane, line or point “ In positioning of the

preterm infant in the NICU this would

involve the placement of the extremities in

a similar position and direction

P

R

O

N

E

S

U

P

I

N

E

• Weight Bearing:It is important to be

cognizant of the body surfaces on which the

infant is lying hereby bearing their body

weight. These weight bearing surfaces are

also the pressure points from which the infant

is in contact with the surface of the external

support. Too much pressure or prolonged

weight bearing on one point can be a source

of pain and/ or discomfort.

• Movement occurs in the body parts that are

not bearing weight.

most of my weight

is on my head !

& that‟s not good

arm

knees

weight bearing

new weight bearing surfaces

side of face shoulder hip

• Alignment is the state of being in arranged in a line.

• Good postural alignment would mean that the ear is in line with the shoulder, in line with the hip, in line with the ankle.

• Good alignment in the infant will promote better quality movements ie the ability to move towards the midline into flexion, will enhance the development of age appropriate muscle tone and will decrease the likelihood to move away from the midline towards extension and therefore increasing the stress of the infant.

• Containment is defined as positioning the infant with the use of equipment to maintain the flexed midline position of the infant, giving the infant a sense of stability and security.

• The gentle pressure of the equipment will inhibit the big amplitude movements yet allow small movements which are normal in a fetus therefore a preterm infant.

• Promote comfort and sleep

• A multitude of learning opportunities for

the intimate caregiver

Good positioning is a positive oral experience

- hands to mouth, to midline

- gentle forward flexion

- Non- nutritive sucking

- reducing stress, allowing the infant to achieve

state regulation

- feeding readiness – cannot feed until achieve

systems stability in bed with handling and

then with holding

Passive and active positioning

• Containment is defined as assisting the infant

to achieve and maintain a flexed, midline

position by using blankets or equipment to

provide boundaries

• Blankets or positioning equipment provide

support and gentle inhibition of the large

amplitude movements of the extremities.

Containment does not restrain the infant.

Facilitated tuck:

• the tucked position is described as the infant being placed in

side lying, with the trunk being curled forward gently, with the

hips and knees flexed past 90 degrees and brought towards the

midline along with the shoulders and elbows flexed past 90

degrees thereby allowing the hands near the mouth or the face

(Ward-Larson et al, 2004)

• the gentle positioning of an infant‟s arms and legs in a flexed

midline position close to the infant‟s body while the infant is in

either a side-lying, supine or prone position (Hill et al, 2005)

• involves a caregiver providing the postural support with their

hands preferably on the head and feet while a second person

performs a procedure or routine care.

• These two studies demonstrated that the technique of facilitated

tucking during routine care and/or a painful procedure may be

an effective measure to reduce stress and/or pain for the infant.

Benefits: Positioning in Prone

• Gas exchange

• Chest wall synchrony with respirations

• Fewer episodes of apnea

• Sleep state improved

• Decreased energy expenditure

• Increased gastric emptying

• Decreased reflux episodes

Benefits: Positioning in Supine

• Visualize chest movement

• Chest movement with Oscillation or Jet

ventilation

• Umbilical lines, chest drain placement

• Less nare pressure when on Hudson Prong

CPAP

• Allows extremity movement

• “Back to Sleep”

Benefits: Positioning on Right and Left

Side!

• Head is in midline

• Hands to midline, mouth

• Sucking and grasping opportunities

• Left side decreases reflux episodes

• Pneumothorax treatment

• Post – op reasons

Equipment

• blanket rolls

• “headhuggers”

• “frogs”

• isolette covers

• “butterflies”

• prone pillow

• creative equipment

Long and short term

implications of positioning• Skull shaping

• Preference to face one way

• Increased trunk extension and shoulder

retraction

• Hips and other lower extremity postures

frequent right facing can lead to………

preferred right facing which can lead to……

weeks or months of therapy to return to midline

Skull Shapes

• Skull deformations occur after

embrogenesis

• Result from nondisruptive mechanical

forces ie postnatal positioning in the

NICU

• Skull weight bearing on the hard surface

Definitions• Dolichocephaly – having a cephalic index

<75%

common in premature infants usually caused by prone/ side lying positioning in the NICU

• Scaphocephaly – abnormal length and narrowness of skull, as a result of premature closure of the sagittal suture, usually accompanied by mental retardation

They will appear the same initially

• Central Occipital flattening –

Brachycephaly

( a Cranial Index >81% , indicates a

shortened anterior-posterior dimension

and widening of the bilateral eminences)

CI = 54%

• Plagiocephaly – asymmetric head

• known as Positional Plagiocephaly (

without synostosis) – deformation of the

skull(occiput) produced by extrinsic

forces acting on an intrinsically normal

skull

• from supine lying

• Right* ( most common)and Left occipital

flattening

Features of disorganized,organized

and self regulating behaviours

• Disorganized – tend to be jerky, frantic, flailing,

involve extension, repetitive movements that

tend to increase disorganization

• Self-regulating – start to calm, involve active

flexion, coming to the midline, jerkiness starts to

become more smooth,sucking

• Organized – smooth, flexion, hands and feet

together

Infant

Activities

Deep Sleep REM sleep Indeterminate

sleep

Quiet awake Active awake Crying Exhaustion

Heart rate Stable /

steady

Slight irregularity Irregular Irregular Irregular Irregular Bradycardia

Respiratory Regular

/smooth

Disruption of

regular breathing

pattern

Chaotic breathing

pattern

Regular /

smooth

pattern

Irregular Irregular Apnea

Colour Pink Pink Pink Pink Pink / red Red, dusky, circum-

oral cyanoses

Pale, mottled

dusky

Visceral none none none none Spit up Spit up Emesis, BM

Eyes Closed

& no

movement

lids closed or just

slightly parted, eye

moves under lids in

phasic patterns

‘heavy lids’ ‘fluttery

lids’

‘Dull’ eyes

‘Bright’

focused

Lids open, more

eye movement,

less focus

Eyes tightly closed

with grimace

Dull, unfocused

Face No

movement

Small twitch,

sucking motion

Twitches, brow

raise, smile,

Minimal

movement

Frequent

movements,

sucking, rooting,

grimace, hyper-

alert

Grimace, Gape face

Head &

Trunk

No

movement

Minimal to slow

rotation or lifting,

maintains tucked

flexed position

Larger smooth trunk

movement, diffuse

stretch

Minimal

movement

Mild arching,

extension,

Arching,

hyperextension,

Arching,

extension and

flaccid

• Red is stop, don‟t disturb, state is good:

• Green is „good to go‟ (i.e. capable of

feeding, interacting)

• Yellow is a state that needs assistance to

move into the red or green state

scent free in the NICU and in the isolette

Odours

• Cloth dolls “huggies”

• Perfume free zone

• Reduce exposure to noxious odours ( alcohol

hand wash)

• Protect from exposure to odour of cigarette

smoke

• Use of colostrum and breast milk

Maternal Scent Skin to Skin

Skin to Skin Care

(Kangaroo Care)

Skin To Skin Care

• Stable Infant placed upright with only a

diaper on mother or father‟s bare chest

• Willing caregivers – staff and

mother/father

• Transfer often the most difficult

• Length of time – a sleep cycle

Flexion

Midline

Symmetry

Alignment

Weight bearing

Containment

Comfort and sleep

Learning opportunities

& experiences

Infant Benefits of Skin to Skin

• Improves state organization, Increases the length of quiet sleep state (NREM) shorter periods of REM sleep

• Assists thermal regulation,

• Stabilizes respiratory patterns, oxygen saturation, reduces apnea, reduces bradycardia

• Increases rate of weight gain

• Functions as an analgesic during painful procedures

• Shortens hospital stay

• Positive impact on physiological and behavioral organization and later for mental health outcomes

• Positive impact on perceptual, cognitive and motor development

Maternal Benefits to Skin to Skin

• Increase mother‟s milk production

• Positive impact on breastfeeding outcomes

• Improves maternal adaptation to infant cues

• Positive impact on mother infant attachment

• Positive impact on maternal sense of

competence, during hospitalization and after

discharge

• Positive impact on paternal feelings

Infant Massage

• Numerous studies :

claim many short and long term benefits for infant and mother

• Can be a simple as a hand hug to infant massage

• Need to watch the infant‟s cues and reactions

• Probably best to teach the mother and closer to term age for the infant

Massage

• Massage has been found to soften scar

tissue by freeing restrictive fibrous bands

and increasing circulation

• Release the underlying adhesions

• Reasons: cosmetic

promote full lengthening of the

affected structures with

growth

Scars

• Surgical - PDA Ligation

- Abdominal

• Procedural - Central lines

- Chest tubes

- IV infitration

- tape removal

Pain Assessment &

Management:

Pharmacological and

Non-Pharmacological

Interventions in the

NICU

Sharyn Gibbins, RN, PhD

May 15, 2006

Pain

“Pain is an unpleasant sensory andemotional experience associated withactual or potential tissue damage ordescribed in terms of such damage”IASP

• Pain has been defined further as a subjective experience that is best understood through self-reports

• Verbal communication and self-report are considered the “gold standard” for pain assessment

Challenges to the Pain

Definition

In the absence of verbal communication, other indicators such as physiological, hormonal, biochemical and behavioral responses to painful stimuli should be considered forms of self-report that are surrogate markers to infer the existence of pain in high-risk populations (Warnock & Lander 2004)

Efforts should be directed towards increasing recognition of pain and developing broader sources of information to infer the subjective experience of pain in nonverbal neonates

PHYSIOLOGICAL

INDICATORS

BEHAVIOURAL

INDICATORS

BIOCHEMICAL/HORMONAL

INDICATORS

Increased Heart Rate Increased Facial Actions Increased Cortisol

Changes in Respiratory rate Cry Increased Epinephrine

Increased Intracranial Pressure Increased Body Movements Increased norepinepherine

Fluctuations in Blood Pressure Changes in State Increased Growth Hormones

Decreased Oxygen Saturation Fussiness/Sleeplessness Decreased Prolactin

Changes in Heart Rate Variability Flexor withdrawal reflex Decreased Insulin

Dilated Pupils Consolability/sleep patterns Protein Catabolism

Palmar Sweating Decreased Immune Responses

Summary of Pain Responses

Difficulties with Interpretation

of Individual Pain Responses

• Behavioral but not physiological indicators are predominant during painful procedures in preterm infants

• Repeated pain affects pain response

– preterm infants who were born at 28 weeks gestation and hospitalized in a NICU for 4 weeks (early preterm group) had significantly higher heart rates and lower oxygen saturation levels during heel lances than preterm infants born at 32 weeks (late preterm group)

– the more recently a preterm infant had experienced a painful procedure, the less likely he/she would demonstrate behavioral pain

responses to subsequent painful procedures

• Responses are influenced by gestational age, behavioral state and severity of illness

• Biological Factors

– gender differences

Myths of Pain

in Infants

“Infants Lack Myelination”

• The neural pathways for pain perception are present in newborn neonates (Anand, 1993; Fitzgerald, 2000;Humphrey, 1964 )

• The density of nociceptive nerve endings in the skin ofneonates is similar to or greater than that in adult skin(Anand 1993)

• Nociceptive pathways to the brainstem and thalamus are myelinated by 30 weeks gestation (Anand & Carr, 1989;

Anand et al.,1989; Fitzgerald, 1993; Rakic & Goldman-Rakic, 1982)

Myths of Pain

in Infants

“Capacity for fetal pain is limited”

• Fetal awareness of pain requires functional thalamocortical connections (Lee et al, 2005 )

• EEG patterns denoting wakefulness is present around 30 weeks

– Lack of surrogate markers

– Neuroanatomical evidence reports developmental ranges (21-30 weeks)

– Purpose was termination NOT preterm infant management

Pain in Infants

• Approximately 8.2% of the contacts in the NICU are comforting

• Stevens et al (1999) found that infants born between 27 to 31 weeks gestation received a mean of 134 painful procedures within the first two weeks of life and approximately 10% of the youngest and/or sickest infants received over 300 painful procedures

• Porter (1999) found that preterm infants experienced, on average, over 700 painful procedures during their hospitalization

• Gibbins et al. (2002;2005) found the mean number of painful procedures per day was greater than 5 (range 0 to 10) and 12/day if non-tissue damaging procedures were included

• Stevens et al. (2005) found the mean number of painful procedures per day was greater than 10

Measurement & Assessment

of Infant Pain

Assessment

• Assessment involves subjective judgment about the quality and significance of pain for a particular infant

• Assessment may include measurement but also involves clinical judgment based on observation

Measurement

• Measurement is used to

(a) quantify pain

(b) evaluate the effectiveness of pain relieving interventions and/or

(c) compare pain responses across situations with the same infant and between infants

Limitations in

Infant Pain Measures

• Plethora of infant pain measures– Limited psychometric analyses of existing pain measures

• Certain high-risk populations excluded– ELBW (<1000g) (Grunau et al., 2000; Morison et al., 2003)

– Cognitively impaired (i.e. Drug influence) (Stevens et al)

• Certain situations excluded– Chronic vs. Procedural vs. Disease related

ELBW

• Flexing and extending extremities, finger splaying,

fisting and mouthing (Grunau et al 2000, Holsti et al. 2004)

• Startles, twitches, jitters and tremors were not

associated with pain

• Decreased salivary cortisol in ELBW infants

• Pain responses in ELBW infants (Gibbins et al)

Neurologically impairedStevens et al. 2005

• Infants at highest risk for NI demonstrated less physiological and behavioral responses to painsignificant within-subject effect of phase was found with:

- facial activity (F(3,239) = 45.58, p <.0001)

- maximum HR (F(3,302) = 5.80 , p =.0007)

- minimum HR (F(3,302) = 6.81, p =.0002)

- minimum 02 (F(3,297) = 5.72 , p =.0008)

• Compared to cohorts B and C, significant between-subject effect with cohort A exhibiting:

- less facial activity (F(2,233) = 12.17, p=<.0001)

- lower maximum HR (F(2,302) = 14.4, p <.0001)

- lower minimum HR (F(2,302) = 5.52, p<.004)

- lower mean cry fundamental frequency (F(2,33)= 3.57, p<.039)

Procedural Pain

• Procedural pain in neonates still not treated

consistently

• Measures to manage neonatal pain can be both

pharmacological or non-pharmacological OR a

combination of both

Painful Procedures or

Conditions

• Heelsticks – (more painful than venipuncture (Shah,2002)

• Venipuncture/arterial puncture

• Skin lesions, abrasions, IV burns

• Rib,clavicle and extremity fractures

• Chest drain insertion

• Picc lines

• IM injections

• Surgical procedures

• Removal of adhesive tape/bandaids – may be the most frequent “painful” procedure (Franck,2006)

• Intubation

• Eye exams

• Pharmacological

– alleviate pain with drugs that are safe and effective

• Non-Pharmacological

– therapies, such as environmental or behavioral

interventions, that do not include pharmacological agents

One does not preclude the other

For the NICU infant, there should always be environmental

and behavioural strategies in place

Approaches to Pain

Management

Stevens, Gibbins, & Frank, 2000

Developmentally Sensitive

Strategies

• Environmental strategies can help by:

– Indirectly by reducing total amount of noxious stimuli

• Behavioural strategies may:

– Block nociceptive input along ascending fibers

– Activate descending endogenous opioid and non-opioid pathways-decrease nociceptive transmission

• Interventions-activate attention and arousal systems that help modulate pain

• Standard of Care for all painful procedures

NICU Environment

• Reduce noxious stimuli

– Multiple painful procedures, frequent handling

plus environmental factors increase the

infant‟s stress responses

• Promote calm environment ( macro & micro)

– Promote physiologic stability

– Individualize care – according to infant‟s cues

– Handle slowly –promote self regulatory

behaviours

– Provide adequate preparation and support esp

prior, during and following a painful procedure

Developmental Interventions

Comfort Measures

• Research examining

multiple

developmentally

sensitive measures to

reduce pain is limited

– positioning

– facilitated tucking ( using

hands)

– containment ( using

equipment)

– non-nutritive sucking

Non-nutritive sucking

• Mechanism unknown-

theory is that the release of serotonin (only when

sucking) may modulate, directly or indirectly the

transmission and processing of nociceptive stimuli (Blass,

1995)

• Studies-preterm and term

– Meta-analysis 3 studies significant reduction in heart

rate after heel prick (1997)

– Heelstick –decreased crying time (Field & Goldston, 1984)

Sucrose

• The most studied non-pharmacological pain relief treatment in newborns

• Sucrose-disaccharide consisting of fructose and glucose

• Hypothesis/Mechanism of action-sweet taste promotes analgesia through activation of the endogenous opioid release that attenuates nociceptive information

• Reduces heart rate and behavioural indicators of pain

• Initial data supported that sucrose was effective in reducing pain that led to studies evaluating the efficacy and safety of sucrose, as well as the most effective dose in reducing pain

Sucrose for management of neonatal

procedural pain

• Evidence has been available for several years that sucrose is effective in managing pain in newborns

• 30 RCTs, meta-analysis (Stevens et al, 1997) and systematic reviews (Stevens et al., 2002)

• CPS and AAP have recommended its use for treatment of procedural pain in neonates (AAP, Pediatrics, 2000)

• Consensus statement (Anand et al. 2001) that advocate for sucrose as frontline or adjunct therapy for most painful procedures

Dosage and Administration

• Dose dependent on Gestational Age

• Dose of 0.5mls used for preterm and up to 2 mls for term infants

• Must be administered on the anterior aspect of the tongue

• Most effective if administered 2 minutes prior to painful procedure; Lasts up to 5 minutes

• Dose can be divided to allow for re-administration for longer procedures

• Most effective in conjunction with pacifier-synergistic/additive effect

• No data on maximum dose

Conclusions

• Infants have a capacity for pain by mid gestation

• Pain has immediate and long term consequences

• Physiological, behavioral and biochemical indicators

are proxies for pain in infants

• Pain measures must be population/ and context specific

and have established psychometric properties

• Certain high-risk populations excluded– ELBW (<1000g) (Grunau et al., 2000; Morison et al., 2003)

– Cognitively impaired (i.e. Drug influence) (Stevens et al)

• Certain situations excluded– Chronic vs. Procedural vs. Disease related

Conclusions

• We need to use developmental strategies and non –pharmacological methods as much as possible

• We need to be judicious in our management of post operative pain and procedural pain.– When we chose pharmacological measures

• Chose the right drug

• Start low

• Use objective measures to evaluate and titrate to each baby‟s needs

• We need to develop guidelines for pain assessment and management

Infant Massage

• Numerous studies :

claim many short and long term benefits for infant and mother

• Can be a simple as a hand hug to infant massage

• Need to watch the infant‟s cues and reactions

• Probably best to teach the mother and closer to term age for the infant

Massage

• Massage has been found to soften scar

tissue by freeing restrictive fibrous bands

and increasing circulation

• Release the underlying adhesions

• Reasons: cosmetic

promote full lengthening of the affected

structures with growth

Scars

• Surgical - PDA Ligation

- Abdominal

• Procedural - Central lines

- Chest tubes

- IV infitration

- tape removal

Nothing about my babies, without

me

• Parents are not visitors

• Part of the team

• Involved in making decisions

• Participate in Rounds

• Participate in care

• Controlling infection in the unit is of utmost

importance but it does not mean excluding

parents from caring for their infants( Venkatesh et al, 2011)

• Many units now have a parent support position

as part of the team ( former NICU parent)