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Procedural pain reducing methods and pain assessment in newborns
Linköping University, Department of Molecular and Clinical Medicine, Pediatrics. Linköping University, Faculty of Health Sciences.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Our knowledge of pain in neonates has increased significantly during the last fifteen years.We now have an improved understanding of the pain system and of the negative effects of untreated pain. Advances in neonatal care have increased the nwnber of preterm and severely ill infants who are treated in neonatal intensive care units (NICU). These infants are subjected to a variety of painful procedures as part of their management. Sufficient pain relief is needed and for this, valid pain assessment is one prerequisite.

The aim of this research was to improve the management of procedural pain and to examine the assessment of neonatal pain in clinical practice.

In an earlier study, oral glucose was found to reduce pain during blood sampling. To further evaluate the pain-reducing effect of oral glucose and to compare this effect with different blood sampling techniques, a trial was performed. The pain score was lower and crying time shorter in the venipuncture group than in the heel stick group when no glucose was given. When glucose was administered, the pain score was lower in both glucose groups than in the groups not receiving glucose (paper I).

In a randomized, controlled study, the effect of oral glucose was compared with that of a topical local anaesthetic, EMLA, during venipuncture. The pain scores were found to be lower in the glucose group and fewer infants were scored as having pain. Crying time was also shorter in the glucose group (paper II).

To compare the pain-reducing effect of oral glucose with that of breast-feeding shortly before venipuncture, a new trial was performed. The pain score was significantly lower in the infants receiving glucose than in those not given glucose. There was no significant difference in pain score between the infants who were fed and the fasting infants (paper III).

In a previous study we found an increase in heart rate in newboms when they received glucose as pain relief. We therefore investigated whether oral glucose in itself could cause an increase in heart rate in healthy infants. In a trial, infants were randomized to receive oral glucose or placebo without undergoing any painful procedure. The heart rate was significantly higher in the glucose than in the placebo group (paper IV).

Activation of endogenous opioids is suggested as one possible mechanism underlying the pain-reducing effect of oral glucose. We therefore investigated whether administration of an opioid antagonist would reduce the effect of oral glucose at heel stick in full-term newboms. There were no significant differences in pain score or crying between the group receiving an opioid antagonist before oral glucose and the group receiving placebo before oral glucose during heel stick (paper V).

To document whether pain is assessed in Swedish neonatal units and by what methods, a questionnaire was distributed to all neonatal wards in Sweden in 1993, and again in 1998. Only a small proportion of neonatal units in Sweden attempted to assess pain. There was a minor increase in the nwnber of wards that used a structured method for pain scoring. Docwnentation of pain is still inadequate and needs to be improved (paper VI). We compared parental assessment during blood sampling with measurement of the pain score with a multidimensional tool and crying. There was low agreement between these variables during the procedure (paper III).

In conclusion, we found that oral glucose reduces signs of pain from both heel stick and venipuncture blood sampling. Oral glucose reduces pain better than does EMLA cream and better than if the infant is breast-fed shortly before the procedure. Oral glucose increases the heart rate in infants and the pain-reducing effect of oral glucose in newboms was not diminished by injection of an opioid antagonist. Parental assessment of an infant's pain cannot replace measurement by pain scores. The pain assessment at neonatal units in Sweden needs to be improved.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2004. , 64 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 868
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-22319Local ID: 1516ISBN: 91-7373-840-9 (print)OAI: oai:DiVA.org:liu-22319DiVA: diva2:242632
Public defence
2004-11-19, Wilandersalen, Universitetssjukhuset, Örebro, 13:00 (Swedish)
Opponent
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-10-25Bibliographically approved
List of papers
1. Oral glucose and venepuncture reduce blood sampling pain in newborns
Open this publication in new window or tab >>Oral glucose and venepuncture reduce blood sampling pain in newborns
1999 (English)In: Early Human Development, ISSN 0378-3782, E-ISSN 1872-6232, Vol. 55, no 3, 211-218 p.Article in journal (Refereed) Published
Abstract [en]

The objectives of this study were to measure pain symptoms in healthy fullterm newborns undergoing routine blood sampling with different methods. The 120 study subjects were randomly allocated to one of four groups with 30 babies in each, namely venepuncture or heel stick, with or without oral glucose administration. Pain was assessed from the duration of crying within the first 3 min, the Premature Infant Pain Profile (PIPP) and changes in heart rate. When the babies received 1 ml 30% glucose prior to skin puncture there was no significant difference between the heel stick and venepuncture group either in mean crying time (12.9 and 11.6 s, respectively) or in PIPP score (3.9 and 3.3). When no glucose was given crying time was 57.3 s in the heel stick group and 26.8 s in the venepuncture group (P=0.0041) and the mean PIPP scores were 8.4 and 6.0, respectively (P=0.0458). This study suggests that if oral glucose is given prior to skin puncture the choice of blood sampling method has no impact on the pain symptoms.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25891 (URN)10.1016/S0378-3782(99)00018-3 (DOI)10332 (Local ID)10332 (Archive number)10332 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
2. Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream
Open this publication in new window or tab >>Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream
Show others...
2002 (English)In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 110, no 6, 1053-1057 p.Article in journal (Refereed) Published
Abstract [en]

Objective. A number of studies have shown that orally administered sweet-tasting solutions reduce signs of pain during painful procedures. The local anesthetic cream EMLA has recently been shown to be safe for use in neonates. This study compared the pain-reducing effect of orally administered glucose with that of EMLA cream during venipuncture in newborns.

Methods. Randomized, controlled, double-blind study including 201 newborns undergoing venipuncture for clinical purposes. Ninety-nine of the newborns received EMLA on the skin and orally administered placebo (sterile water), and 102 received glucose 30% orally and placebo (Unguentum Merck) on the skin. Symptoms associated with pain at venipuncture were measured with the Premature Infant Pain Profile (PIPP) scale (also validated for full-term infants). Heart rate and crying time were recorded.

Results. There were no differences in background variables between the 2 groups.

The results shows that the PIPP scores were significantly lower in the glucose group (mean: 4.6) compared with the EMLA group (mean: 5.7). The duration of crying in the first 3 minutes was significantly lower in the glucose group (median: 1 second) than in the EMLA group (median: 18 seconds). There were significantly fewer patients in the glucose group who were scored having pain (defined as PIPP score above 6); 19.3% compared with 41.7% in the EMLA group. The changes in heart rate were similar in both groups.

Conclusions. We found that glucose is effective in reducing symptoms associated with pain from venipuncture in newborns and seems to be better than the local anesthetic cream EMLA.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26432 (URN)10.1542/peds.110.6.1053 (DOI)10974 (Local ID)10974 (Archive number)10974 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. Feeding and oral glucose: additive effects on pain reduction in newborns
Open this publication in new window or tab >>Feeding and oral glucose: additive effects on pain reduction in newborns
2004 (English)In: Early Human Development, ISSN 0378-3782, E-ISSN 1872-6232, Vol. 77, no 1-2, 57-65 p.Article in journal (Refereed) Published
Abstract [en]

Aims: The aims of this study were to compare the pain reducing effect of oral glucose with that of being breast-fed shortly before venipuncture in newborns, and also the pain score and crying time with parents' assessment.

Design: Randomised, controlled trial.

Subjects: 120 full term newborns undergoing venipuncture randomly assigned to on of four groups: I, Breast-fed and 1-ml placebo; II, Breast-fed and 1-ml 30% glucose; III, Fasting and 1-ml placebo; and IV, Fasting and 1-ml 30% glucose.

Outcome measures: Pain during venipuncture was measured with the Premature Infant Pain Profile (PIPP). Crying time was recorded. The parents assessed their babies' pain on a Visual Analogue Scale (VAS).

Results: The PIPP score was significantly lower in the infants receiving glucose, than in those not given glucose (p=0.004). There was no significant difference in PIPP score between the infants who were fed and the fasting infants. The PIPP score was lower in group II (median 7) than in group I (md 10). There was a similar difference between group IV (md 9) and group III (md 11). The median crying times during the first 3 min in groups I, II, III, and IV were 63, 18, 142 and 93 s, respectively. There was low agreement between the parents' assessment of pain and the PIPP score and crying time.

Conclusion: Breast-feeding shortly before venipuncture has no major impact on the pain score but on crying time. The combination of oral glucose and breast-feeding shows the lowest pain score and significantly shorter duration of crying.

Keyword
Breast-feeding, Glucose, Neonate, Pain
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-45785 (URN)10.1016/j.earlhumdev.2004.01.003 (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved
4. Effect of oral glucose on the heart rate of healthy newborns
Open this publication in new window or tab >>Effect of oral glucose on the heart rate of healthy newborns
2005 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 94, no 3, 324-328 p.Article in journal (Refereed) Published
Abstract [en]

Aim: Increases in heart rate have been widely utilized as pain responses in different studies. In a previous study, we found an increase in heart rate in newborns when they received glucose as pain relief. Other research groups have shown a smaller increase in heart rate on administration of sweet solutions. We therefore investigated the question as to whether or not oral glucose itself can cause an increased heart rate in healthy infants.

Method: This was a randomized, controlled, double-blind study comprising 70 healthy newborns. They were randomly allocated to receive 1 ml 30% glucose or 1 ml placebo solution (sterile water) orally without undergoing any painful procedure. The heart rate was recorded during and at different times after this administration.

Results: The heart rate was significantly higher in the glucose than in the placebo group (p=0.020). The highest heart rate was noted during treatment, and the heart rate subsequently decreased in both groups (p = 0.002).

Conclusion: Oral glucose causes an increase in heart rate in healthy newborns not undergoing any painful intervention.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84854 (URN)10.1111/j.1651-2227.2005.tb03075.x (DOI)
Available from: 2012-10-25 Created: 2012-10-25 Last updated: 2017-12-07Bibliographically approved
5. The role of endogenous opioids in mediating pain reduction by orally administered glucose among newborns
Open this publication in new window or tab >>The role of endogenous opioids in mediating pain reduction by orally administered glucose among newborns
2005 (English)In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 115, no 4, 1004-1007 p.Article in journal (Refereed) Published
Abstract [en]

Objective. It has been demonstrated clearly that sweet-tasting solutions given before a painful intervention can reduce pain among newborns. There is no fully accepted explanation for this effect, but activation of endogenous opioids has been suggested as a possible mechanism. The aim of this study was to obtain deeper knowledge of the underlying mechanism by investigating whether administration of an opioid antagonist would reduce the effect of orally administered glucose at heel stick among term newborns.

Design. A randomized, placebo-controlled, double-blind trial with a validated, neonatal, pain-rating scale.

Participants. The trial included 30 term newborns undergoing heel stick, who were assigned randomly to 1 of 2 groups, ie, group I, with naloxone hydrochloride (opioid antagonist) 0.01 mg/kg administered intravenously before oral administration of 1 mL of 30% glucose, or group II, with a corresponding amount of placebo (saline solution) administered intravenously before oral administration of glucose.

Outcome Measures. Pain-related behavior during blood sampling was measured with the Premature Infants Pain Profile. Crying time and heart rate were also recorded.

Results. The 2 groups did not differ significantly in Premature Infant Pain Profile scores during heel stick. The median crying time during the first 3 minutes was 14 seconds (range: 0–174 seconds) for the naloxone group and 105 seconds (range: 0–175 seconds) for the placebo group. There was no significant difference in heart rate between the 2 groups.

Conclusion. Administration of an opioid antagonist did not decrease the analgesic effect of orally administered glucose given before blood sampling.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84855 (URN)10.1542/peds.2004-1189 (DOI)
Available from: 2012-10-25 Created: 2012-10-25 Last updated: 2017-12-07Bibliographically approved
6. Need for a reliable pain evaluation scale in the newborn in Sweden
Open this publication in new window or tab >>Need for a reliable pain evaluation scale in the newborn in Sweden
2000 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 44, no 5, 552-554 p.Article in journal (Refereed) Published
Abstract [en]

Background: A major problem in pain treatment in the newborn is the ability to assess the degree of experienced pain. Several different methods for estimating pain in the newborn have been introduced in recent years. The objectives of this study were to see whether pain scoring was used in Swedish neonatal units, and by which method, and furthermore to observe whether any changes had occurred between 1993 and 1998.

Method: A questionnaire was distributed to all Swedish neonatal units in 1993 and 1998.

Results: In both 1993 and 1998, 86% of all clinics answered the questionnaire. Two-thirds of these clinics used some method for estimating pain in the newborn at both times. Eight clinics used a structured method in the latter period compared to one in the earlier period. A higher proportion of units having full intensive care measured pain compared to other units.

Conclusion: The study shows that an unchanging low proportion of neonatal units in Sweden attempt to assess pain. There is a minor increase in the number of departments that use a structured method for pain scoring. Documentation of pain intensity is still inadequate and should be improved.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84856 (URN)10.1034/j.1399-6576.2000.00511.x (DOI)
Available from: 2012-10-25 Created: 2012-10-25 Last updated: 2017-12-07Bibliographically approved

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