Breastfeeding preterm infants as the initial oral feeding: An integrative review

BackgroundAlthough breastfeeding up to six months of age is strongly encouraged, the preterm infant is challenged to orally feed. Breastfeeding should be encouraged as the initial oral feeding, then offered as the preferred method as tolerated by the infant.MethodsThe study used an integrative review method that included articles between 2017 and 2022 related to direct breastfeeding preterm infants and methods to support initiation of oral feedings.ResultsEleven articles met the criteria for review. Six themes emerged: medically stable infant to start and/or continue oral feedings, skin-to-skin/kangaroo mother care, breastfeeding benefits, cue-based feedings, increased weight gain, and non-nutritive sucking.ConclusionsCaregivers support preterm infants with transitioning from gavage to breast by implementing skin-to-skin, non-nutritive sucking, and cue-based feeding. Direct breastfeeding increased exclusive breastfeeding rates at discharge. The interventions should start on medically stable infants and continue as long as there is demonstrated physiologic stability.     

The Indonesian version of the Premature Infant Pain Profile–Revised: Translation and adaptation of a neonatal pain assessment

PurposePain assessment is a key component of good pain management in hospitalized infants. This study aimed to translate and adapt a version of pain measurement in infants, the Premature Infant Pain Profile Revised (PIPP-R) into Indonesian.MethodThe adaptation process of the measuring instrument used a modified Brislin method which included forward translation, back translation 1, group discussion 1, back translation 2, group discussion 2, and pilot testing on neonatal nurses: feasibility test, inter-rater reliability using intraclass correlation (ICC), and internal consistency using Cronbach's α coefficient.ResultsThe PIPP-R version in English has been translated into Indonesian. In general, nurses assessed this measuring instrument as feasible. The inter-rater reliability showed a high agreement (ICC = 0.968, P = 0.001) and this measuring instrument had good internal consistency (Cronbach's α = 0.856).ConclusionThe Indonesian version of PIPP-R is easy to use and shows good psychometric properties. The use of this measuring instrument will help nurses and researchers obtain accurate infant pain intensity measurement values.     

Pain assessment and management in the newborn: A systematized review

BACKGROUNDNeonatal pain has been underdiagnosed due to several false beliefs.AIMTo determine the status of neonatal pain in newborns who are admitted to intensive care units.METHODSDifferent databases were searched. Literature reviews and research reports conducted in newborns that were written in English, Spanish, or Portuguese, published between 2010 and 2020, and having free access to the full text were selected. A total of 135 articles were found, and 18 articles were finally reviewed.RESULTSNewborns are exposed to numerous painful procedures. In order to assess their pain levels, several scales have been used, although they are sometimes not correctly interpreted. In terms of pain management, the nursing team plays a very important role based mainly on both pharmacological and non-pharmacological approaches. CONCLUSIONNursing staff members must be well trained in order to identify pain and to interpret the scales correctly. Besides, they have an important role in performing non-pharmacological procedures for pain management.     

Virtual visitation in the NICU: A scoping literature review

ObjectiveThis scoping literature review aims to identify how virtual visitation (VV) is currently being used in the Neonatal Intensive Care Unit (NICU), with a specific focus on the experiences and perceptions of parents and neonatal nurses, as well as research gaps.MethodGuided by the Joanna Briggs Institute method for conducting a scoping literature review, the PubMed, CINAHL, and Web of Science databases were utilized to identify articles answering the research questions. Gray literature was also identified through ProQuest, and the home websites of the two largest commercial virtual visitation vendors were explored for additional relevant information.ResultsFollowing a comprehensive search, 12 articles were identified for inclusion in this scoping literature review. Overall, parents report positive experiences with VV, welcoming this technology in connecting to their infant. The experiences and perceptions of NICU nurses regarding the addition of VV to their practice environment are generally negative. With a paucity of research exploring the questions guiding this scoping review, research gaps are evident.ConclusionVirtual visitation in the NICU aids in connecting parents to their hospitalized infants. However, published literature reveals significant differences in the experiences and perceptions of parents and neonatal nurses for the use of VV in the NICU. Further research is warranted to understand the impact of VV in this specialized environment fully.     

Quality Assessment of Neonatal Pain Scales Translated and Validated to Brazilian Portuguese: A Systematic Review of Psychometric Properties

ObjectivesThe objective of this systematic review was to identify and describe the psychometric properties of neonatal pain scales that were translated into Brazilian Portuguese and to verify the methodological quality of these translation, transcultural adaptations and validation.DesignThe present study is a systematic review. A systematic search in the literature included studies of development, validation, and transcultural adaptation of neonatal pain scales to Brazilian Portuguese. The instruments must have been developed for health care professionals to evaluate neonatal pain and stress in full-term and preterm newborns.Data SourcesThe search strategy was conducted in PubMed, Web of Science, Scopus, and Scielo databases following The PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).Review /Analysis MethodsA total of 1,479 publications were identified and 5 fulfilled the inclusion criteria, with 4 instruments evaluated. For the methodological quality analysis of the measurement properties of the instruments the Consensus-based Standards for Health Measurement Instruments (COSMIN) Risk of Bias checklist was used. The psychometric properties verified were internal consistency, content validity, reliability, and construct validity.ResultsThree instruments reviewed were inadequate and one was doubtful.ConclusionsThe neonatal pain scales wich were cross culturally adapted to Brazilian Portuguese were shown to be of low methodological quality based on COSMIM checklist. Caution should be considered for clinical decisions about pain management judgment coming from these instruments.     

Physiological measures of assessing infant pain: a literature review

Neonatal pain assessment is not standardized. Clinicians may use various parameters in the measurement of pain which can lead to different interpretations. Currently, there is no validated biological marker for assessing infant pain in any age group. However, in the non-verbal patient, the most feasible way to assess pain may be by evaluation of physiological parameters. The author conducted a systematic review of the literature using qualitative methods and seven research papers were selected for review, in which physiological measures were used in the assessment of neonatal pain. Heart rate was the most frequently used physiological pain measure in these studies. Oxygen saturation, blood pressure and respiratory rate lacked sensitivity and specificity and cannot be used independently. These measures may detect pain but cannot quantify it and are, therefore, not useful assessments of chronic pain. The multidimensional approach to pain assessment may be the most appropriate owing to the correlation between behavioural and physiological indicators of pain in the neonate.     

Development and preliminary validation of the Neonatal Infant Acute Pain Assessment Scale (NIAPAS)

BackgroundSeveral pain scales are available for neonates, but, unfortunately they are only rarely used in clinical practice. To help with the current situation of unrecognized and under-treated pain in neonatal intensive care units (NICUs), we developed an assessment tool in close collaboration with clinical staff.ObjectivesTo develop a multidimensional scale, NIAPAS (the Neonatal Infant Acute Pain Assessment Scale), that is sensitive to the needs of infants in neonatal intensive care units, and to test the validity, reliability, feasibility and clinical utility of the scale for this population.DesignInstrument development and psychometric analysis.MethodsPain assessments (n = 180) were made of 34 neonates born between 23 and 42 weeks gestational age who were undergoing 60 painful procedures (heel lance 77%, tracheal suctioning 23%) in the NICU. Using bedside video recordings, each neonate was observed through three phases of the procedure: 1 min before the procedure, during the procedure (lasting from 0.6 to 11.2 min, mean 2.6), and 1 min after the procedure. In addition, an expert panel (n = 5) and nurses (n = 26) participated in the validation of the scale.ResultsA pool of 8 pain indicators (5 behavioral and 3 physiological indicators), including the gestational age of neonates as a contextual factor, was identified based on the nurses’ expertise in neonatal intensive care. Scores on the NIAPAS changed significantly across the phases (p < 0.001), indicating a good construct validity of the scale. Correlations between the NIAPAS and NIPS (the Neonatal Infant Pain Score) were high (0.751–0.873). The study also demonstrated high coefficients for inter-rater (r = 0.991–0.997) and intra-rater reliability (r = 0.992–1.00), with an internal consistency of 0.723. The content validity was very good (Mean I-CVI 1.00), as evaluated by the expert group. The nurses agreed that the scale was easy to administer and that it helped decision-making in the pain management of infants.ConclusionsThe NIAPAS was shown to be a valid and reliable scale for assessing acute pain in preterm and full-term infants in the NICU. It allows nurses to evaluate infants’ acute pain especially during painful procedures and help to provide pain relief for the infants.     

Neonatal nurses’ self-reported practices,knowledge and attitudes toward premature infant pain assessment and management

AimTo identify neonatal nurses’ self-reported practices, knowledge and attitudes toward premature infant pain assessment and management.MethodAn exploratory cross sectional mixed methods survey.FindingsOf the 127 surveys distributed, 86 were returned (68% response rate). Those with postgraduate education had higher knowledge and reported more positive attitudes. Comfort measures and analgesia for painful procedures were reported as used more often in term infants. Analgesia was not used for endotracheal intubation. This was attributed to non-prescribing of analgesia by doctors.ConclusionNurses reported a positive attitude toward infant pain assessment and management but a low level of knowledge about premature infants’ response to pain. The non-use of analgesia for painful procedures presents a formidable challenge to changing practice. Evidenced based strategies may overcome barriers.     

State of the art: Pain assessment and management in high-risk infants

Despite the increased understanding of neurophysiology of pain in infants, there are still wide variations in pain management practices across neonatal intensive care units. Fundamental to effective pain management is the ability to assess pain in a variety of high-risk infants. Pain assessment is influenced by personal beliefs and experiences. Unlike measurement, which refers to the application of a specific tool to quantify an aspect of pain (physiologic or behavioral), assessment involves subjective judgment about the quality and significance of pain for a particular infant. Over the past decade, several pain measures have been developed to assist clinicians and researchers quantify pain, evaluate the effectiveness of pain-relieving interventions, and compare pain responses across situations with the same infant and between infants. Although the quality of pain measures varies tremendously in its psychometric properties, feasibility, and clinical usefulness, the pain measures provide a framework for infant pain assessment and management. This review highlights the importance of infant pain assessment and examines various measures of infant pain. Interventions to manage acute procedural pain in high-risk preterm infants also is addressed briefly. Copyright © 2001 by W.B. Saunders Company     

Multidimensional Pain Assessment Tools for Ambulatory and Inpatient Nursing Practice

BackgroundOne of the critical components in pain management is the assessment of pain. Multidimensional measurement tools capture multiple aspects of a patient's pain experience but can be cumbersome to administer in busy clinical settings.AimWe conducted a systematic review to identify brief multidimensional pain assessment tools that nurses can use in both ambulatory and acute care settings.MethodsWe searched PUBMED/MEDLINE, PsychInfo, and CINAHL databases from January 1977 through December 2019. Eligible English-language articles were systematically screened and data were extracted independently by two raters. Main outcomes included the number and types of domains captured by each instrument (e.g., sensory, impact on function, temporal components) and tool characteristics (e.g., administration time, validity) that may affect instrument uptake in practice.ResultsOur search identified eight multidimensional assessment tools, all of which measured sensory or affective qualities of pain and its impact on functioning. Most tools measured impact of pain on affective functioning, mood, or enjoyment of life. One tool used ecological momentary assessment via a web-based app to assess pain symptoms. Time to administer the varying tools ranged from less than 2 minutes to 10 minutes, and evidence of validity was reported for seven of the eight tools.ConclusionsOur review identified eight multidimensional pain measurement tools that nurses can use in ambulatory or acute care settings to capture patients’ experience of pain. The most important element in selecting a multidimensional pain measure, though, is that one tool is selected that best fits the practice and is used consistently over time.     

Neonatal end-of-life care: a review of the research literature

While advances in neonatal medicine have increased the possibility of sustaining life for many infants, more infants still die in the neonatal period (birth to 27 days of life) than those in any other time in childhood. Despite this statistic, there still remains much that is unknown about both the needs and the care of these critically ill babies. Palliative care is a viable option for many of these infants and their families. However, palliative care is rarely provided as an option for families. To provide healthcare providers with an overview of palliative and end-of-life care for infants in the neonatal period, we conducted an integrative review of the current research literature. A total of 10 articles were selected for the review. Findings from these studies were summarized in 1 of 4 categories: practices of withdrawing or withholding life-sustaining treatment, pain management during ventilator withdrawal, parents and the decision-making process, and the dying process.     

Management of an Extremely Premature Infant in the Out-of-Hospital Environment

Abstract

The rate of premature infant mortality has decreased over the last several decades, with an accompanying decrease in the gestational age of premature infants who survive to hospital discharge. Emergency medical services (EMS) providers are sometimes called to provide prehospital care for infants born at the edge of viability. Such extremely premature infants (EPIs) present medical and ethical challenges. In this case report, we describe an infant born at 24 weeks into a toilet by a mother who thought she had miscarried. The EMS providers evaluated the infant as nonviable and placed him in a plastic bag for transport to a local emergency department (ED). The ED staff found the infant to have a bradycardic rhythm, initiated resuscitation, and admitted him to the neonatal intensive care unit. The infant died seven days later. We review the literature for recommendations in resuscitation of EPIs and discuss the ethics regarding their management in the prehospital setting.     

Nurses’ experiences of caring for preterm infants in pain: A meta-ethnography

ObjectivePreterm infants are subjected to numerous painful procedures during their neonatal intensive care unit (NICU) hospitalization. Despite advancements in pain alleviation, nurses remain challenged to provide timely and effective pain management for preterm infants. Greater understanding of the lived experience of nurses caring for preterm infants in pain could provide novel insights to improve pain management for this vulnerable population. The aim of this meta-ethnography was to synthesize and interpret qualitative findings of nurses’ experiences of taking care of preterm infants in pain.MethodsAn extensive literature search in PubMed, CINAHL, PsycINFO, Scopus, BIOSIS and ProQuest Dissertation and Theses Database was conducted, including studies within the past 10 years. Two nursing researchers conducted data extraction and analysis independently. Inclusion criteria were applied to search for qualitative studies of nurse participants who worked in the NICU taking care of preterm infants. Studies published in a language other than English, articles that did not include qualitative data and qualitative data that could not be extracted from the findings or did not discuss nurses’ experiences were excluded. Critical Appraisal Skills Programme was used for literature quality evaluation.ResultsEight studies remained after further screening according to inclusion and exclusion criteria. These eight studies were conducted from 2013 to 2018 and totally enrolled 205 nurses from Iran, Canada, the United States, Finland, Sweden, Switzerland, and Australia. Five themes emerged on the nurses’ perspectives of taking care of preterm infants in pain: 1) They sense the neonatal pain; 2) Adverse consequences of unrelieved pain; 3) Barriers of managing pain; 4) Concerns of available approaches for pain relief; 5) Failure to work with parents.ConclusionsThis meta-ethnography identified nurses’ understanding of pain in preterm infants that can be assessed, and they acknowledged that unrelieved pain could cause developmental deficits in infants. The barriers are lack of training and support on pain assessment and intervention in preterm infants. Optimizing workload and environment, developing age-specified pain assessment and intervention, receiving emotional support and training, and building up a rapport with parents are urgent needs for nurses to provide better care to infants having pain.     

The newborn infant parasympathetic evaluation in pediatric and neonatology: a literature review

Purpose

The Newborn Infant Parasympathetic Evaluation (NIPE) is a heart rate variability-based technology for assessing pain and comfort in neonates and infants under 2-years-old. This review aims to investigate the clinical utility of the NIPE.

Methods

Two investigators screened Pubmed/Medline and Google Scholar for relevant studies, independently. One investigator extracted data, which were reviewed by a second investigator.

Results

The NIPE was used during/after painful stimuli (6 studies), in the context of general anaesthesia (2 studies), and for comfort assessment (6 studies). A) Evaluation of procedural pain/distress: 2 studies reported that the mean-NIPE could be used for reliable monitoring of prolonged pain, and one study reported the association between instant-NIPE and pain after a stimulus but the instant-NIPE represents the NIPE average over 3 min. Two studies found no correlation between the NIPE and comfort behavior/pain scales, but they mainly differed in patients’ gestational age and evaluation methodology. B) There are only 2 studies for the evaluation of nociception during surgery under general anaesthesia with contradictory results. C) Studies assessing neonates’ comfort reported increased NIPE scores during skin-to-skin contact and during facilitated tucking associated with a human voice. No effect on NIPE scores of facilitated tucking during echocardiography was reported in preterm infants. One study reported significantly different NIPE scores with 2 surfactant therapy protocols. Overall, study populations were small and heterogeneous.

Conclusion

The results regarding NIPE’s performances differ between studies. Given the limited number of studies and the heterogeneous outcomes, more studies are required to confirm the NIPE usefulness in the different clinical settings.

     

The effects of massage therapy in hospitalized preterm neonates: A systematic review

ObjectiveThe aim of this study was to perform a systematic review to identify, evaluate and summarise studies on the administration of therapeutic massage to preterm neonates during their stay in the NICU, and to assess their methodological quality.Designsystematic review following PRISMA statements guidelines.Data sourcesA comprehensive search was performed including relevant articles between January 2004 and December 2013, using the following electronic databases: Medline, PEDro, Web of Science and Scopus.Review methodsTwo reviewers conducted a review of the selected articles: one evaluated the methodological quality of the studies and performed data extraction and the other performed a cross-check. Divergences of opinion were resolved by discussion with a third reviewer.The studies reviewed implemented a wide variety of interventions and evaluation methods, and therefore it was not possible to perform a meta-analysis. The following data were extracted from each article: year of publication, study design, participants and main measurements of outcomes obtained through the intervention. A non-quantitative synthesis of the extracted data was performed. Level of evidence was graded using the Jadad Scale.ResultsA total of 23 articles met the inclusion criteria and were thus included in the review; these presented a methodological quality ranging from 1 to 5 points (with a mean of 3 points). Most studies reported that the administration of various forms of therapeutic massage exerted a beneficial effect on factors related to the growth of preterm infants. The causes indicated by the researchers for these anthropometric benefits included increased vagal activity, increased gastric activity and increased serum insulin levels. Other demonstrated benefits of massage therapy when administered to hospitalised preterm infants included better neurodevelopment, a positive effect on brain development, a reduced risk of neonatal sepsis, a reduction in length of hospital stay and reduced neonatal stress.ConclusionsAlthough based on a qualitative analysis of heterogeneous data, the present review suggests that a clear benefit is obtained from the administration of massage therapy in hospitalised preterm infants, a finding which should encourage the more generalised use of massotherapy in NICU clinical practice.     

An Integrated Review of Cannabis and Cannabinoids in Adult Oncologic Pain Management

ObjectiveThe objective of this paper is to review the available literature regarding the use of cannabis and cannabinoids in adult oncologic pain management.Design and Data SourcesA integrative review was conducted on March 1, 2018 using PubMed, MEDLINE, CINAHL, Embase, and Scopus. A snowball method was used to extract studies included in systematic reviews that were not included in the primary literature search.Review MethodArticles reviewed address the use of cannabinoids or cannabis for pain management in oncology patients, either as stand- alone or adjuvant therapy.ResultsThe final number of articles included is nine articles. Of the nine studies reviewed, eight reviewed the effect of the cannabinoid THC on cancer pain, and one study reviewed the use of medicinally available whole plant cannabis. The following study types were included: multiple multi-center, randomized, placebo- controlled trials and two prospective observational survey studies.Results and ConclusionsOf the eight studies that reviewed the effect of the cannabinoid THC, five found THC to be more effective than placebo, one found THC to be more effective than placebo in American patients but ineffective in patients from other countries, and two found THC to be no more effective than placebo. The study that reviewed the effect of the whole plant cannabis found that there was a significant decrease in pain among those patients smoking cannabis.Nursing Practice ImplicationsThe lack of evidence in this field of research suggests a need to change policy surrounding cannabis research.     

Evidence for best practices in the neonatal period

The purpose of this article is to provide a review of current nursing research that supports best practices during the newborn period. The literature review of peer-reviewed research articles published between January 2000 and October 2004 was conducted via keyword searches using the databases of the Cochrane Library, CINAHL, and MEDLINE. Key words included neonatal nursing, newborn, neonate, premature infant, preterm infant, and low birthweight. Content analysis revealed the following primary categories of studies that provide solid evidence for nursing practice: developmentally focused nursing care, neonatal skin care, feeding, skin-to-skin care, and pain management. Neonatal nurse researchers have made many important contributions to the research literature. Future research should expand the findings to date on the effective use of pain scales, the outcomes of skin-to-skin care and infant massage as standard practice for all neonates, and the effectiveness of nursing interventions to support the developmental sequelae of prematurity. Neonatal nurses should become familiar with and implement those findings from nursing research that strongly support evidence-based nursing practice.