中国新生儿疼痛管理循证指南（2023年）

疼痛不仅扰乱新生儿的生命体征和内环境稳态,影响康复进程,反复疼痛刺激更是神经发育障碍和部分慢性疾病的重要危险因素之一。为规范和标准化我国新生儿病房的疼痛管理实践,进而有效预防和减轻疼痛对新生儿身心发育的不良影响,国家儿童健康与疾病临床医学研究中心(重庆医科大学附属儿童医院)遵循世界卫生组织指南制订的原则和方法,组织多学科专家制定了《中国新生儿疼痛管理循证指南(2023年)》。该指南针对新生儿疼痛的分类及定义、常见致痛源、疼痛评估原则、疼痛评估方法、镇痛原则、非药物镇痛方法、药物镇痛方法、家属参与疼痛管理方法,以及疼痛管理记录方法9个临床问题,基于最佳证据和专家共识形成了26条推荐意见,以期为医护人员实施新生儿疼痛评估与镇痛管理提供指导与决策依据。[中国当代儿科杂志,2023,25 (2):109-127]     

Evidenced‐based clinical practice guideline for management of newborn pain

Aim: To facilitate the uptake of evidence and to reduce the evidence practice gap for management of newborn pain through the development of a clinical practice guideline. Method: An audit of practice and an appraisal of clinical practice guidelines were undertaken to establish current practices and guideline availability for the management of newborn pain in 23 hospitals in Australia. Guidelines were appraised using the Appraisal of Guidelines for Research and Evaluation instrument. A literature search was undertaken to acquire the evidence for best practice for management of newborn pain. Results: Neonatal units in 17 hospitals had clinical practice guidelines. Each was peer reviewed and assessed according to the domains of the Appraisal of Guidelines for Research and Evaluation instrument. There was lack of consistency across the guidelines. As a result, a best practice guideline was developed based on current best evidence and the Royal Australian College of Physicians recommendations. To facilitate an ongoing compliance with the guideline, an audit tool was included together with algorithms for procedural pain and pain assessment. Conclusion: The clinical practice guideline can be used by clinicians in varying settings such as the neonatal intensive care and special care unit. The document can be used to support existing practices or challenge clinicians to close the evidence practice gap for the management of newborn pain.     

Reducing pain in children with cancer: Methodology for the development of a clinical practice guideline

Although pain is one of the most prevalent and bothersome symptoms children with cancer experience, evidence‐based guidance regarding assessment and management is lacking. With 44 international, multidisciplinary healthcare professionals and nine patient representatives, we aimed to develop a clinical practice guideline (following GRADE methodology), addressing assessment and pharmacological, psychological, and physical management of tumor‐, treatment‐, and procedure‐related pain in children with cancer. In this paper, we present our thorough methodology for this development, including the challenges we faced and how we approached these. This lays the foundation for our clinical practice guideline, for which there is a high clinical demand.     

Diagnosis and management of childhood obesity: a survey of general practitioners in South West Sydney

Aim: To describe general practitioners' (GPs) diagnosis and management of overweight and obesity in children, their attitudes regarding obesity and their awareness of National Health and Medical Research Council (NHMRC) clinical practice guidelines. Method: A cross‐sectional written survey of members of the Liverpool Division of General Practice (located in South West Sydney, Australia). Results: Of 137 questionnaires sent, 85 (62%) were returned. Although the majority prescribed the correct interventions, there was variability in complications screening, ranging from 75% screening for psychosocial problems to 30% for fatty liver. Less than a third (28%) of GPs used NHMRC guidelines in their practice and only 9% used body mass index charts to correctly diagnose childhood obesity. GPs felt that childhood obesity was a significant issue and identified parental denial and lack of community support as barriers to treatment. Conclusion: Although NHMRC guideline adherence was far from universal, the GPs in our survey are motivated and aware of the importance of managing childhood obesity. If the primary care approach is to work, then GPs need support and education in an environment where there is greater community awareness of the impact of childhood obesity.     

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units

AIM: Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates. METHODS: A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both. RESULTS: Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents. CONCLUSION: Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.     

Needle and dread: Is it just a little poke? A call for implementation of evidence-based policies for the management of needle pain in clinical settings

The present commentary calls for the implementation of evidence-based policies to manage paediatric needle pain in clinical settings. While there have been fundamental advances in the treatment of needle pain over the past three decades, relevant techniques are often not used in clinical practice. Evidence indicates that needle procedures do hurt, are frequently cited as the most painful experience by children and a subset of children are terrified of them. Pain and distress from needle procedures can and must be addressed because needle procedures are frequently performed on both healthy (eg, immunizations) and ill (eg, bone marrow aspirations, lumbar punctures) children. An essential step in translating research knowledge into practice is the creation of evidence-based policies. Policy statements regarding the management of needle pain must be incorporated at the hospital, clinic and individual office levels to reduce the amount of pain and distress children suffer from needle procedures. Specific suggestions for policies to be incorporated in clinical settings are provided.     

Evaluation of a practice guideline for the management of respiratory distress syndrome in preterm infants: A quality improvement initiative

BACKGROUND:

The use of mechanical ventilation to treat respiratory distress syndrome in preterm infants has been associated with the development of bronchopulmonary dysplasia. As part of a quality improvement initiative to reduce the incidence of bronchopulmonary dysplasia in preterm infants, a new practice guideline for the management of respiratory distress syndrome was developed and adopted into practice in a neonatal intensive care unit in February 2012.

OBJECTIVE:

To evaluate the effects of implementing the new guideline in regard to the use of mechanical ventilation and surfactant, and the incidence of bronchopulmonary dypslasia.

METHODS:

An historical cohort of very preterm infants (gestational age 26⁰ to 32⁶ weeks) born one year before guideline implementation was compared with a similar cohort of infants born one year following guideline implementation. Data were collected retrospectively from the local neonatal intensive care unit database.

RESULTS:

A total of 272 preterm infants were included in the study: 129 in the preguideline cohort and 143 in the postguideline cohort. Following the implementation of the guideline, the proportion of infants treated with ongoing mechanical ventilation was reduced from 49% to 26% (P<0.001) and there was a trend toward a reduction in bronchopulmonary dysplasia (27% versus 18%; P=0.07). There was no difference in the proportion of infants treated with surfactant (54% versus 50%).

CONCLUSION:

The implementation of the practice guideline helped to minimize the use of ongoing mechanical ventilation in preterm infants.     

Variations in incubator temperature and humidity management: a survey of current practice

Aim: To describe and assess routine procedures and practices for incubator temperature and humidity management in France in 2009. Methods: A questionnaire was sent to all the 186 neonatal care units in France. Results: The questionnaire return rate was 86%. Seventy‐five per cent of the units preferred skin servo‐control to air temperature control in routine practice. Air temperature control was mainly used for infants with a gestational age of more than 28 weeks and aged over 7 days of life. In general, thermal management decisions did not depend on the infant’s age but were based on a protocol applied specifically by each unit. All units humidified the incubator air, but there was a large difference between the lowest and highest reported humidity values (45% and 100% assumed to be a maximal value, respectively). More than 65% of the units used a fixed humidity value, rather than a variable, protocol‐derived value. Conclusion: We observed large variations in incubator temperature and humidity management approaches from one neonatal care unit to another. There is a need for more evidence to better inform practice. A task force should be formed to guide clinical practice.     

The management of pain during pediatric hematopoietic stem cell transplantation: A qualitative study of contextual factors that influenced pain management practices

Background

Children hospitalized following hematopoietic stem cell transplantation (HSCT) experience complex and prolonged pain in response to the intensity of this treatment.

Objectives

To describe how pain was managed for children during HSCT therapy and how contextual factors related to the clinical environment influenced healthcare providers' and parents' pain management practices.

Methods

A qualitative case study was conducted and involved semi-structured interviews at two time points following transplantation (30 and 90 days) with parents (n = 10) and naturalistic observations of pain-related care provided to children (n = 29) during HSCT therapy by their healthcare providers (n = 10). Semi-structured interviews were also conducted with healthcare providers (n = 14).

Results

The effectiveness of pain management interventions was hindered by the multifactorial nature of pain children experienced, a gap in the provision of psychosocial interventions for pain and a lack of evidence-based guidelines for the sustained, and often long-term, administration of opioids and adjuvant medications. Misconceptions were demonstrated by healthcare providers about escalating pain management according to pain severity and differentiating between opioid tolerance and addiction. Parents were active in the management of pain for children, especially the provision of nonpharmacological interventions. Collaboration with external pain services and the impact of caring for children in protective isolation delayed timely management of pain.

Conclusions

There is a pressing need to create evidence-based supportive care guidelines for managing pain post transplantation to optimize children's relief from pain. If parents and children are to be involved in managing pain, greater efforts must be directed toward building their capacity to make informed decisions.     

A new method of blood sampling reduces pain for newborn infants: a prospective, randomized controlled clinical trial

BACKGROUND: Using a new simple blood glucose measurement device (Free Style), blood can thus be sampled from the forearm, which is less sensitive to pain than from the heel. Measuring the blood glucose levels in newborn infants using Free Style is therefore a potentially less painful testing modality than traditional blood sampling methods. OBJECTIVE: To compare the pain intensity at the time of blood sampling from the forearm using the Free Style with the conventional method from the heel. DESIGN: A prospective, randomized controlled clinical trial. PATIENTS AND METHODS: Sixty healthy neonates were randomized by the sealed envelope method into two groups-Group F, in which blood was sampled from the forearm using the Free Style, and Group H, in which blood was conventionally sampled from the heel using a lancet. The pain intensity was assessed based on their crying, the Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS). RESULTS: After skin puncture, 12 (40%) of the infants cried in Group F and 27 (90%) in Group H. The duration of crying was also significantly shorter in Group F than in Group H. Both of pain scores between the two groups differed significantly, these findings indicated less pain for Group F. CONCLUSION: The new blood sampling method from the forearm was found to be less painful than the conventional method, thus making it possible to clinically use this product as an innovative method for blood sampling in neonatal medicine.     

Effects of breast milk on pain severity during muscular injection of hepatitis B vaccine in neonates in a teaching hospital in Iran

Introduction and aims

Human breast milk is a natural pain reliever that contains endorphins. The aim of this study was to compare the effects of breast milk and powdered milk on pain severity after a muscular injection in 1-day-old neonates.

Expression of pain and distress in children during dental extractions through drawings as a projective measure: A clinical study

AIM: To evaluate the efficacy of drawings as a projective measure of pain and distress in children undergoing dental extractions.METHODS: Children in the age range of 4-13 years with existence of untreatable caries or over-retained primary teeth, indicated for extractions were included. Pain was assessed using one behavioral [faces, legs, activity, cry and consolability (FLACC)] scale; and a self report measure; faces pain scale-revised (FPS-R), at two points of time, after completion of local anesthetic administration and after extraction. The general behavior of children was assessed with Wright’s modification of Frankl rating scale. At the end of the session, children were instructed to represent, themselves along with the dentist and their experiences of the dental treatment through drawing. The drawings were scored utilizing Child drawing: Hospital scale (CD: H) manual and correlated with FLACC, FPS-R and Frankl using Pearson correlation test.RESULTS: A positive correlation, though statistically not significant, was observed between CD: H scores and all other considered parameters (Frankl, FPS-R and FLACC) in the present study.CONCLUSION: Drawings could not act as surrogate measure of child’s pain; however, they acted as a narrative of his/her experiences and reflection of inner emotions. Hence, drawings can be used as an additional dental armamentarium.     

Impact of a strategy to prevent the introduction of non-breast milk and complementary foods during the first 6 months of life: a randomized clinical trial with adolescent mothers and grandmothers

Introduction

Although the disadvantages of introducing non-breast milk and the early introduction of complementary foods are known, such practices are common worldwide.

Objective

To evaluate the efficacy of counseling about breastfeeding and complementary feeding in preventing the introduction of non-breast milk and complementary foods in the first 6 months.

Methods

This randomized clinical trial enrolled 323 adolescent mothers and their newborns and 169 maternal grandmothers; 163 mothers and 88 grandmothers received five counseling sessions on breastfeeding while in the hospital and at 7, 15, 30, and 60 days, and one session on complementary feeding at 120 days. Data about infant feeding were collected monthly. The impact was evaluated by comparing the Kaplan–Meier survival curves for the time of introduction of non-breast milk and complementary foods of the control and intervention groups. Median time of introduction of milk was calculated in the two groups.

Results

The survival curves showed that the intervention postponed the introduction of non-breast milk and complementary foods. At 4 months, 41% (95% CI, 32.8–49.2) of the infants in the control group received complementary foods in comparison to 22.8% (95% CI, 15.9–29.7) of the intervention group. Counseling postponed the introduction of non-breast milk, which occurred at 95 days (95% CI, 8.7–111.3) in the control group and at 153 days (95% CI, 114.6–191.4) in the intervention group.

Conclusions

Counseling sessions on infant's first 4 months were an efficacious strategy to prevent the introduction of non-breast milk and complementary foods in the 6 months of life.     

Provision of weight management advice for obese women during pregnancy: a survey of current practice and midwives' views on future approaches

A semi‐structured, web‐based questionnaire was developed to survey midwives (n = 241) employed by NHS Tayside, UK, to identify current practice and views on weight management of obese women during pregnancy and the puerperium. A total of 78 (32%) midwives submitted responses following email invitation. Most respondents (79%) reported always calculating women's body mass index (BMI) at booking, with 73% routinely explaining the BMI category. In terms of future practice for obese women, although few respondents (15%) currently offer personalised advice regarding weight management based on a woman's diet and physical activity levels, 77% of respondents thought such advice would be appropriate and 69% thought it could possibly be feasible to offer such advice. The respondents viewed weight management to be of importance and felt that universal advice is appropriate, but confidence in discussing weight management and knowledge of the subject was low. Strategies to improve midwife confidence and weight management services should include training, ongoing support and definition of the midwife's role within the multidisciplinary team to support practice in the future.