Pain management in Swedish neonatal units – a national survey

Aim: The aim of this study was to investigate the degree to which Swedish neonatal units have adopted the national guidelines for prevention and treatment of pain in newborn infants.
Method: A survey was sent to all units in Sweden that provide neonatal care. For a list of potentially painful procedures, compiled from the national neonatal pain guidelines, the units were asked if they would use pharmacological and/or behavioural interventions, and in each case to specify the treatment.
Results: The response rate was 80.4%. Eighty-eight percent of the units had written guidelines for pain management, and 59% of these had been updated within the last 2 years. For almost every presented case, all units reported that they used either pharmacological or behavioural treatment or both. The survey showed a wide variation in morphine and paracetamol dosing and the absence of a paracetamol loading dose in a fourth of the units.
Conclusions: This study suggests that a majority of Swedish neonatal units have adopted pain management guidelines in concordance with the Swedish national guidelines, and kept them up-to-date. For most painful situations a variety of behavioural and pharmacological interventions are used, often in combination.     

Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland

BACKGROUND: Painful invasive procedures are frequently performed on preterm infants admitted to a neonatal intensive care unit (NICU). The aim of the present study was to investigate current pain management in Austrian, German and Swiss NICU and to identify factors associated with improved pain management in preterm infants. METHODS: A questionnaire was sent to all Austrian, German and Swiss pediatric hospitals with an NICU (n = 370). Pain assessment and documentation, use of analgesics for 13 painful procedures, presence of written guidelines for pain management and the use of 12 analgesics and sedatives were examined. RESULTS: A total of 225 units responded (61%). Pain assessment and documentation and frequent analgesic therapy for painful procedures were performed more often in units using written guidelines for pain management and in those treating >50 preterm infants at <32 weeks of gestation per year. This was also the case for the use of opioid analgesics and sucrose solution. Non-opioid analgesics were used more often in smaller units and in units with written guidelines. There was a broad variation in dosage of analgesics and sedatives within all groups. CONCLUSION: Pain assessment, documentation of pain and analgesic therapy are more frequently performed in NICU with written guidelines for pain management and in larger units with more than 50 preterm infants at <32 weeks of gestation per year.     

Skin‐to‐skin care in neonatal intensive care units in the Nordic countries: a survey of attitudes and practices

Aim: To investigate the application of skin‐to‐skin care (SSC) in the Nordic countries, the existence of guidelines for SSC and the attitudes of neonatal staff towards SSC. Methods: One questionnaire was distributed at unit level and one at staff level in all Nordic neonatal intensive care units (n = 109). Results: The unit questionnaire was answered by 95 (87%) units and the staff questionnaire by 1446 staff members (72%). All units offered SSC to various degrees, but guidelines only existed at 47% of them. Units in Denmark, Norway and Sweden seemed to use SSC earlier, longer and in more medically complicated situations than units in Finland and Iceland. Seventy‐seven per cent of the units had private rooms where parents and infants could stay together, still the physical environment of the units limited the use of SSC. Medical risks were considered the main barrier for further implementation of SSC, while general development and early interaction were the most frequently mentioned benefits. Conclusion: Skin‐to‐skin care is implemented in all Nordic neonatal units, but offered to various degrees, to various populations and to varying extents. Danish, Norwegian and Swedish units are offering SSC more extensively than units in Finland and Iceland.     

Pain assessment and procedural pain management practices in neonatal units in Australia

OBJECTIVE: To identify current pain assessment and procedural pain management practices in neonatal units in Australia. METHODS: Postal survey conducted during December 2003 and January 2004. The survey comprised questions relating to pain assessment scores, pain reduction strategies for minor painful procedures and the use of articulated policies relating to procedural pain management. Participants were the Nurse Unit Managers or their nominees of neonatal intensive care units, special care units and newborn emergency transport services in Australia. RESULTS: Surveys were sent to 181 eligible organizations, and 105 of these were returned (58%). Six units (6%) used pain assessment scores on a regular basis, and 16 units (15%) had an articulated policy directing pain management practices during painful procedures. Non-nutritive sucking and various nursing comfort measures were the pain reduction strategies most frequently used during minor painful procedures. Twenty-four units (23%) used sucrose or other sweet-tasting solutions during procedures; however, the reported frequency of their usage was low. Breast-feeding during venepuncture, heel lance and intramuscular or subcutaneous injection was infrequently practised and topical anaesthetic agents were rarely used. CONCLUSION: This survey demonstrates that the majority of Australian neonatal units have no articulated policy to guide pain management during painful procedures and do not regularly undertake pain assessments. Current evidence-based strategies to reduce procedural pain in hospitalized infants are used infrequently.     

Assessment of pain in newborn infants

Hospitalized newborn infants experience pain that can have negative short- and long-term consequences and thus should be prevented and treated. National and international guidelines state that adequate pain management requires valid pain assessment. Nociceptive signals cause a cascade of physical and behavioral reactions that alone or in combination can be observed and used to assess the presence and intensity of pain.Units that are caring for newborn infants must adopt sufficient pain assessment tools to cover the gestational ages and pain types that occurs in their setting. Pain assessment should be performed on a regular basis and any detection of pain should be acted on. Future research should focus on developing and validating pain assessment tools for specific situations.     

Pain management in Swedish neonatal units--a national survey.

AIM: The aim of this study was to investigate the degree to which Swedish neonatal units have adopted the national guidelines for prevention and treatment of pain in newborn infants. METHOD: A survey was sent to all units in Sweden that provide neonatal care. For a list of potentially painful procedures, compiled from the national neonatal pain guidelines, the units were asked if they would use pharmacological and/or behavioural interventions, and in each case to specify the treatment. RESULTS: The response rate was 80.4%. Eighty-eight percent of the units had written guidelines for pain management, and 59% of these had been updated within the last 2 years. For almost every presented case, all units reported that they used either pharmacological or behavioural treatment or both. The survey showed a wide variation in morphine and paracetamol dosing and the absence of a paracetamol loading dose in a fourth of the units. CONCLUSIONS: This study suggests that a majority of Swedish neonatal units have adopted pain management guidelines in concordance with the Swedish national guidelines, and kept them up-to-date. For most painful situations a variety of behavioural and pharmacological interventions are used, often in combination.     

Neonatal morbidity and care-seeking behaviour in rural Bangladesh

The present study was undertaken to assess the pattern of reported neonatal morbidity and the care-seeking behaviour for neonates in rural Bangladesh. Data were collected from 1511 women who had live births during January 1996-August 1998 in four rural subdistricts, which are the field sites of the Operations Research Project of the International Centre for Diarrhoeal Disease Research, Bangladesh. A structured questionnaire was used to collect information from the mothers who were interviewed in their homes. Forty-nine per cent of the neonates were reported to have suffered from some kind of morbidity. Fever was the most common morbidity reported in the study population (21 per cent), followed by breathing difficulty (11 per cent). Birth order, complications during pregnancy, and/or delivery and death of a sibling were found to be significantly associated with reported neonatal morbidity. Eighty-seven per cent of the mothers sought care for their newborns. Some were taken to several different providers, the commonest being homeopaths (38 per cent) and village doctors (37 per cent). Seventeen per cent were taken to trained providers, and only 5 per cent to government health facilities. Seeking care from trained providers was found to be associated with the gender of the neonate, birth order, antenatal care of the mother from trained providers, father's education and monthly expenditure of the family. The results of this study suggest that efforts should be made to raise community awareness regarding neonatal morbidity, the importance of seeking care from trained personnel and the availability of services for these conditions.     

新生儿重症监护病房医护人员对新生儿疼痛评估和镇痛管理的认知现状调查

目的 了解新生儿重症监护病房（neonatal intensive care unit，NICU）医护人员对新生儿疼痛评估和镇痛管理的认知现状。 方法 根据《新生儿疼痛评估与镇痛管理专家共识（2020版）》自制量表，采用此量表对江苏省新生儿科医疗质量控制中心成员单位的NICU医护人员发放问卷调查表，分析其对新生儿疼痛的基本知识、评估和管理的掌握水平。 结果 共收回有效问卷957份，其中医生383份，护士574份。医生与护士对新生儿疼痛基本知识的答题正确率的均值分别为38%和39%；对新生儿疼痛评估的答题正确率的中位值分别为0%和50%；对镇痛管理的答题正确率的均值分别为73%和68%。接受过疼痛相关培训的医护人员对新生儿疼痛基本知识和疼痛评估的答题正确率较未接受相关培训的医护人员显著增高（P<0.05）。三级医院医护人员对新生儿疼痛基本知识和疼痛评估的答题正确率较二级医院医护人员显著增高（P<0.05）。 结论 NICU医护人员对新生儿疼痛的认识不足，需开展有关新生儿疼痛知识的专项培训，建议侧重对《新生儿疼痛评估与镇痛管理专家共识（2020版）》的推广和临床应用，以提高医护人员对新生儿疼痛评估和镇痛管理的水平。     

Triage in the developing world--can it be done?

AIM: To assess guidelines for the emergency triage, assessment, and treatment (ETAT) of sick children presenting to hospitals in the developing world. This study pretested the guidelines in Malawi, assessing their performance when used by nurses compared to doctors trained in advanced paediatric life support (APLS). METHODS: Triage was performed simultaneously by a nurse and assessing doctor on 2281 children presenting to the under 5s clinic. Each patient was allocated one of three priorities, according to the ETAT guidelines. Any variation between nurse and assessor was recorded on the assessment forms. RESULTS: Nurses identified 92 children requiring emergency treatment and 661 with signs indicating a need for urgent medical assessment. One hundred and forty two (6.2%) had different priorities allocated by the APLS trained doctor, but these children did not tend to need subsequent admission. Eighty five per cent of admissions were prioritised to an emergency or urgent category. CONCLUSION: Although there are no gold standards for comparison the ETAT guidelines appear to reliably select out the majority of patients requiring admission.     

Current Italian practices regarding the management of hyperbilirubinaemia in preterm infants

Aim: To assess the current practices existing in Italy for the management of jaundice in preterm infants as preliminary achievement to a call for national guidelines and establishment of a kernicterus registry. Methods: A questionnaire (in Supporting Information online) was sent to the 109 level III neonatal units in Italy to ascertain existing guidelines for total bilirubin monitoring and treatment of hyperbilirubinaemia in preterm infants and occurrence of kernicterus. Results: There was a 61% (67/109) response rate. Eighty‐five per cent of responding units had either written guidelines coming from different literature sources or locally developed. The monitoring of bilirubin varied greatly in timing before, during and after jaundice development. Phototherapy and exchange transfusion were given to 56.0 ± 21.0% and 0.2 ± 0.4% of admitted preterm infants in participating centres. Five cases of kernicterus in preterm infants and eleven cases in term infants were documented over the last 10 years. Conclusion: The management of hyperbilirubinaemia in preterm infants is not uniform in Italy and would benefit from shared national guidance together with establishment of a kernicterus registry to guide therapy.     

Pain management in French neonatal intensive care units

The aim of this study was to investigate pain management in neonatal intensive care units (NICUs) in France and to identify factors associated with variability across units. A questionnaire sent to 143 heads of level II or III NICUs investigated the use of pain scores, pain management organization and pharmacological treatment in five clinical situations (endotracheal intubation, prolonged mechanical ventilation, acute stage of necrotizing enterocolitis, central venous catheter insertion and cephalhaematoma). The response rate was 81%. Among the 35 (30%) units that used no pain scores, 40% ascribed this to lack of knowledge. Factors associated with failure to use pain scores were level II status, no university affiliation, no surgical patients and neonatal patients only. Among the units that scored pain, 78% used valid scores for acute pain and 73% for prolonged pain. Written guidelines were available for acute pain in 65% of units and for prolonged pain in 36%. The rate of pharmacotherapy use varied widely across the five clinical situations studied (from 16 to 77%) and across units for a given clinical situation. Also extremely variable were the regimens used in each situation and the dosages of analgesics and sedatives. Only 11% of units adjusted dosages to gestational age. CONCLUSION: Pain assessment was performed in the most French NICUs, but a strong heterogeneity for pain treatment was observed. Reference to recently published pain management guidelines and new randomized trials could be useful to optimize pain treatment in NICUs.     

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.     

Survey of management of neonatal haemolytic jaundice in Australasia

Background: Haemolytic jaundice is an important entity in neonatal clinical practice. Because of the decrease in rhesus isoimmunisation since the advent of anti‐D immunoglobulin and improved antenatal management strategies, its management in the neonatal period has become less intensive and exchange transfusions rarely performed. Aim: We planned to review the practice of Australasian perinatal units in light of recent advances and recommendations. Methods: An electronic survey was sent to the directors of all 25 tertiary‐level perinatal units across Australasia. The questionnaire comprised 20 questions dealing with the management of haemolytic jaundice. Results: Twenty out of the 25 neonatal units responded. Most were aware of the recent American Academy of Pediatrics guidelines, but only eight (40%) based their practice on it. Fifty per cent of neonatal units had written protocols to manage such infants, but almost all had written guidelines for performing exchange transfusions. Seven (35%) units started prophylactic phototherapy; however, the criteria used for early exchange were variable, most related to cord haemoglobin or rate of rise of bilirubin. Few units used high‐dose intravenous immunoglobulin in haemolytic jaundice. Average exchange rates (based on the last 2 years) were 3.5/year (0–10). Conclusion: Variable practice was noted across the Australasian units. Written protocols form the backbone of management of jaundice in such babies. The use of intravenous immunoglobulin is minimal, and the information available on its use needs to be critically appraised.     

Differential trends in breastfeeding according to maternal and hospital characteristics: results from the French National Perinatal Surveys

AIM: To assess breastfeeding trends in hospital, between 1998 and 2003, according to several characteristics of mothers and maternity units. METHODS: Two representative national samples of births, comprising 13,600 live births in 1998 and 14,580 in 2003 were used. Data were collected during hospital stay. All newborns fed entirely or partly on breast milk were considered 'breastfed'. Univariate and multivariate analyses were used to compare the results for the 2 years. RESULTS: Breastfeeding increased in all groups, but this increase varied slightly according to maternal age and the size of the maternity unit. For example, high rates of breastfeeding tended to be concentrated in large maternity units (> or = 1500 deliveries per year) in 1998, but were also found in middle-size units (1000-1499 deliveries per year) in 2003. In 2003, women were more likely to breastfeed if they were at least 25 years old, primiparous, non-French or from a highly qualified occupational group, or if they gave birth in a university hospital or in a maternity unit with more than 1000 deliveries per year. CONCLUSION: Despite recent efforts to increase the breastfeeding rate, clear social disparities persist and further efforts are required, targeting particular groups of mothers less likely to breastfeed.     

Echocardiography on neonatal intensive care units in Australia and New Zealand

OBJECTIVE: To establish the number of neonatal intensive care units (NICU) in Australia and New Zealand where echocardiography is performed by neonatologists, and to establish attitudes to the training of neonatologists in echocardiography. METHODOLOGY: A survey was conducted of the directors of all 29 level 3 NICU in the Australian and New Zealand Neonatal Network. Replies were received from all NICU. RESULTS: In 41% of NICU, a neonatologist provides the primary echocardiography service, with half these units having more than one neonatologist with skills. Sixty-eight per cent of the other units would like a neonatologist to develop these skills in the future. Units without a neonatologist with echocardiographic skills were generally less satisfied with their service, benefits and problems for both types of unit are described. Eleven per cent of units felt neonatologists should not be doing echocardiography and 96% of units felt training guidelines should be established. CONCLUSIONS: Ultrasound in neonatology and other specialties is moving beyond its traditional boundaries and becoming part of the acute care doctors' diagnostic repertoire. This trend needs to be recognized in the specialty training and the ultrasound accreditation processes.     

Seeing through the blind! Ability of hospital staff to differentiate morphine from placebo, in neonates at a placebo controlled trial

AIM: To investigate whether professional training and/or clinical experience affect the ability of caregiver to assess clinical signs of pre-emptive morphine analgesia. METHODS: In the Neurological Outcomes & Pre-emptive Analgesia In Neonates trial preterm infants undergoing mechanical ventilation were randomized to receive continuous infusion, either of morphine or placebo blinded. Staff from centres in Sweden (Stockholm and Orebro) completed an assessment form. RESULTS: A total of 360 assessment forms were collected from 52 neonates. In 59% of the cases, caregivers correctly identified patients group. Comparable proportion of answers were correct between physicians, nurses and assistant nurses (63, 60 and 54%, respectively, p = 0.60). Staff with Neonatal intensive care unit experience <1 year identified 63%, as compared to 65% for working 1-5 year, and 55% that has been working >5 years (p = 0.28). Staff's ability to correctly identify group assignment was reduced by amount of additional morphine (p < 0.01) and severity of illness (p = 0.01). CONCLUSIONS: Clinical medical staffs, including neonatologists, have great difficulties in assessing the presence and severity of pain. Further studies should focus on the methods for assessment of prolonged pain in preterm neonates, define the effects of adequate analgesia, and investigate the clinical factors that may alter neonatal responses to acute and prolonged pain.     

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.     

Multicentric study on neonatal medical pain management in the Nord-Pas-de-Calais]

The aim of this study was to describe pain management for newborn infants in neonatal intensive care units and neonatal units in the Nord-Pas-de-Calais. PATIENTS AND METHODS: A questionnaire was distributed to the 52 physicians practising in the six neonatal intensive care units and six neonatal units. The questions were in reference to pain assessment, treatment and prevention. RESULTS: Forty questionnaires were completed (77%). Eleven units proclaimed an interest in neonatal pain management. The tool for assessing pain was the EDIN scale (Echelle Douleur Inconfort Nouveau-né, neonatal pain and discomfort scale). Analgesic treatment was administered in 100% of cases for the insertion of chest tube, in 92% of cases for the insertion of percutaneous central catheter in a ventilated newborn infant and in 91% of cases for necrotizing enterocolitis requiring a mechanical ventilation. Prescribed analgesic drugs were propacetamol, nalbuphin or fentanyl; a sedation by midazolam or diazepam was occasionally associated. Emla cream was used before lumbar puncture in 80% of cases in the neonatal intensive care units and in 92% of cases in the neonatal units. Three neonatal intensive care units and four neonatal units administered a sucrose solution for blood samples. CONCLUSION: At the time of study, the interest in the pain of the physicians working in neonatal intensive care units and neonatal units was inadequate to guarantee an optimum management of pain in newborn infants. Physicians' approach remained heterogeneous.     

Guidelines for procedural pain in the newborn

Despite accumulating evidence that procedural pain experienced by newborn infants may have acute and even long-term detrimental effects on their subsequent behaviour and neurological outcome, pain control and prevention remain controversial issues. Our aim was to develop guidelines based on evidence and clinical practice for preventing and controlling neonatal procedural pain in the light of the evidence-based recommendations contained in the SIGN classification. A panel of expert neonatologists used systematic review, data synthesis and open discussion to reach a consensus on the level of evidence supported by the literature or customs in clinical practice and to describe a global analgesic management, considering pharmacological, non-pharmacological, behavioural and environmental measures for each invasive procedure. There is strong evidence to support some analgesic measures, e.g. sucrose or breast milk for minor invasive procedures, and combinations of drugs for tracheal intubation. Many other pain control measures used during chest tube placement and removal, screening and treatment for ROP, or for postoperative pain, are still based not on evidence, but on good practice or expert opinions.
Conclusion: These guidelines should help improving the health care professional's awareness of the need to adequately manage procedural pain in neonates, based on the strongest evidence currently available.