Interventional Pain and Non-Pharmacologic Management among Neonates and Infants

Abstract

The pain is a problem that directly affects the health status and leading to negative results in every domain of life when not controlled. All of the children receive a series of painful interventions since the moment of birth. The interventional procedures such as blood-letting and vaccination are the most important pain sources for the children. The trauma that pain creates might cause unconformity with the vaccination and the lack of adherence to therapy. These conditions might cause outbreaks in many preventable diseases, and leave the children defenseless. Especially in the infancy period, in which the brain development is fast, the pains arising from interventional procedures should be well-managed in order to eliminate the developmental and emotional effects of pain. In pain management, there are many approaches both pharmacological and non-pharmacological.  It is almost impossible to use the pharmacological methods due to the reasons such as the requirement of application by experienced personnel, the complication risk, and the costs. Some of the non-pharmacological methods used for neonates and infants are sucrose, holding in inclined position, kangaroo care, mother’s bosom, lactation, tactile stimulation, and swaddling. This paper was prepared in order to discuss the interventional procedure pains among the neonates and infants and the importance of non-pharmacological management of these pains.

Keywords

• Neonate
• infant
• interventional pain

Yenidoğan ve Süt Çocuklarında Girişimsel Ağrı ve Non-farmakolojik Yönetimi

Öz

Ağrı sağlık durumunu direk etkileyen kontrol edilmediğinde hayatın bütün alanlarında olumsuz sonuçlar doğuran bir sorundur. Tüm çocuklara doğumdan itibaren bir dizi girişimsel ağrılı işlem uygulanmaktadır. Kan alma, enjeksiyon, aşı gibi girişimsel işlemler çocukların en büyük ağrı kaynaklarındandır. Ağrının yarattığı travma çocuklarda başta iğne fobisi olmak üzere, aşı uygulamalarında aksaklık, tedaviye uyumda yetersizlik sebebi olabilir ve bu durumlar önlenebilir birçok hastalıkta salgınlara neden olarak çocukları savunmasız bırakabilir. Özellikle beyin gelişimin hızlı olduğu süt çocukluğu döneminde ağrının gelişimsel ve emosyonel etkilerini gidermek için girişimsel işlem ağrıları iyi yönetilmelidir. Ağrı yönetiminde farmakolojik ve non-farmakolojik pek çok yaklaşım vardır. Farmakolojik yöntemlerin deneyimli personel tarafından uygulanma zorunluluğu, komplikasyon riski ve maliyeti nedeniyle kullanımını nerdeyse imkansızdır. Sükroz, kıvırarak tutmak, anne kucağı, kanguru bakımı, emzik vermek, taktil uyarı, emzirme, kundaklama kullanılan yenidoğan ve süt çocukları için kullanılan non-farmakolojik yöntemlerdendir. Bu makale yenidoğan ve süt çocuğunda girişimsel işlem ağrıları ve bunun non-farmakolojik yönetiminin önemini vurgulamak için yazılmıştır.

Anahtar Kelimeler

• Yenidoğan
• süt çocuğu
• girişimsel ağrı

Kaynakça

1. 1. Aydın ON. Ağrı ve ağrı mekanizmalarına güncel bakış. Adnan Menderes Üniversitesi Tıp Fakültesi Dergisi. 2002; 3(2): 37-48.
2. 2. Melzack R, Wall P. Pain mechanism: a new theory. Pain Clinic. 1994; 7: 57-72.
3. 3. Coghill RC, McHaffie JG, Yen YF. Neural correlates of interindividual differences in the subjective experience of pain. Proc Natl Acad Sci U S A. 2003; 100: 8538-42.
4. 4. Puchalski M, Hummel P. The reality of neonatal pain. Advances in Neonatal Care. 2002; 2(5) 233-47.
5. 5. Uyar M. Çocukta ağrı ve tedavisi. Turkiye Klinikleri J Int Med Sci. 2006; 2(5) 36- 47.
6. 6. Goodenough B, Kampel L, Champion GD, Laubreaux L, Nicholas MK, Ziegler JB, McInerney M. An investigation of the placebo effect and age related factors in the report of needle pain from venipuncture in children. Pain. 1997; 72(3):383-91.
7. 7. Taddio A, Katz J. The effects of early pain experience in neonates on pain responses in infancy and childhood. Paediatr Drugs. 2005; 7,245–57.
8. 8. Batton DG, Barrington KJ, Wallman C. Prevention and management of pain in the neonate: an update. Pediatrics. 2006; 118:2231–41.

9. 9. Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J, Shah V. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline CMAJ. 2010 December 14;182(18): 843–55.
10. 10. Schechter NL, Zempsky WT, Cohen LL, McGrath PJ, McMurtry CM, Bright NS. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007;119(5):e1184-98.
11. 11. Tansky C, Lindberg EC. Breastfeeding as a pain intervention when immunizing infants. Journal for Nurse Practitioners. 2010;6(4):287-95.
12. 12. Zeltzer L, Schlank CB. Conquering Your Child’s Chronic Pain, Harper Resource. 2005, New York.
13. 13. Barnhill BJ, Holbert MD, Jackson NM, Erickson RS. (1996). Using pressure to decrease the pain of intramuscular injections. J Pain Symptom Manage. 1996; 12(1):52-8.
14. 14. Chung JW, Ng WM, Wong TK. An experimental study on the use of manual pressure to reduce pain in intramuscular injections. J Clin Nurs. 2002; 11(4):457-61.
15. 15. Yavuz DE, Karabacak U, Yavuz T, Ayhan Yİ. Applying manual pressure prior to benzathine penicillin injection for rheumatic fever prophylaxis reduces pain in children. Pain Manag Nurs. 2015;16 (3):328-35.
16. 16. Shah V, Taddio A, Rieder MJ for the HELPİNG KIDS Team. Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood iomunizations: Systematic review and metaanalyses. Clin Ther. 2009;31(B):104-51.
17. 17. Arnstein P. Multimodal approaches to pain management. Nursing. 2017 Mar; 41(3): 60-1.
18. 18. Young KD. Pediatric procedural pain. Ann Emerg Med. 2005 Feb;45(2):160-171.
19. 19. Anand K, Stevens B, McGrath PJ. Pain in neonates and infants: pain research and clinical management series. New York, USA: Elsevier; 2007.
20. 20. Fitzgerald M, Beggs S. The neurobiology of pain: developmental aspects. Neuroscientist. 2001 Jun;7(3):246-57.
21. 21. Davidson AJ. Neurotoxicity and the need for anesthesia in the newborn: does the emperor have no clothes? Anesthesiology. 2012 Mar;116(3):50750-9.
22. 22. Bhutta AT, Anand KJ. Vulnerability of the developing brain. Neuronal mechanisms. Clin Perinatol. 2002 Sep;29(3):357-72.
23. 23. Fitzgerald M. What do we really know about newborn infant pain? Exp Physiol. 2015 Dec;100(12):1451-7.
24. 24. Soriano SG, Anand KJ. Anesthetics and brain toxicity. Current Opinion in Anesthesiology 2005; 18:293–97.
25. 25. Lundeberg S, Lundeberg T. Pain in infants and children—Physiological background and clinical aspects. Acupuncture and Related Therapies 1 (2013) 46– 9.
26. 26. Fitzgerald M, Walker SM. Infant pain management: a developmental neurobiological approach. Nat Clin Pract Neurol. 2009 Jan;5(1):35-50
27. 27. Fabrizi L, Slater R, Worley A, et al. A Shift in Sensory Processing that Enables the Developing Human Brain to Discriminate Touch from Pain. Current Biology. 2011;21(18):1552-58.
28. 28. Talos DM, Follett PL, Folkerth RD, et al. Developmental regulation of AMPA receptor subunit expression in forebrain and relationship to regional susceptibility to hypoxic/ischemic injury: Part II. Human cerebral white matter and cortex. Steward O, ed. The Journal of comparative neurology. 2006; 497(1):61-77.
29. 29. Johnston CC, Stremler RL, Stevens BJ, Horton LJ. Effectiveness of oral sucrose and simulated rocking on pain response in preterm neonates. Pain. 1997 Aug;72(1-2):193-99.
30. 30. Ruda MA, Ling QD, Hohmann AG, Peng YB, Tachibana T. Altered nociceptive neuronal circuits after neonatal peripheral inflammation. Science. 2000 Jul 28;289(5479):628-31.
31. 31. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997 Mar 1;349(9052):599-603.
32. 32. Fabrizi L, Williams G, Lee A, Meek J, Slater R, Olhede S, Fitzgerald M. Cortical activity evoked by an acute painful tissue-damaging stimulus in healthy adult volunteers. J Neurophysiol. 2013 May;109(9):2393-403.
33. 33. Vinall J, Grunau RE. Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res. 2014 May;75(5):584-87.
34. 34. Buntinx M, Moreels M, Vandenabeele F, Lambrichts I, Raus J, Steels P, Stinissen P, Ameloot M. Cytokine-induced cell death in human oligodendroglial cell lines: I. Synergistic effects of IFN-gamma and TNF-alpha on apoptosis. J Neurosci Res. 2004 Jun 15;76(6):834-45.
35. 35. Slater L, Asmerom Y, Boskovic DS, Bahjri K, Plank MS, Angeles KR, Phillips R, Deming D, Ashwal S, Hougland K, Fayard E, Angeles DM. Procedural pain and oxidative stress in premature neonates. J Pain. 2012 Jun;13(6):590-97.
36. 36. Brummelte S, Grunau RE, Chau V, Poskitt KJ, Brant R, Vinall J, Gover A, Synnes AR, Miller SP. Procedural pain and brain development in premature newborns. Ann Neurol. 2012 Mar;71(3):385-96.
37. 37. Dührsen L, Simons SH, Dzietko M, Genz K, Bendix I, Boos V, Sifringer M, Tibboel D, Felderhoff-Mueser U. Effects of repetitive exposure to pain and morphine treatment on the neonatal rat brain. Neonatology. 2013;103(1):35-43.
38. 38. Ranger M, Chau CM, Garg A, Woodward TS, Beg MF, Bjornson B, Poskitt K, Fitzpatrick K, Synnes AR, Miller SP, Grunau RE. Neonatal pain-related stress predicts cortical thickness at age 7 years in children born very preterm. PloS One. 2013 Oct 18;8(10):76702.
39. 39. Ranger M, Grunau RE. Early repetitive pain in preterm infants in relation to the developing brain. Pain Manag. 2014 Jan;4(1):57-67.
40. 40. Doesburg SM, Chau CM, Cheung TP, Moiseev A, Ribary U, Herdman AT, Miller SP, Cepeda IL, Synnes A, Grunau RE. Neonatal pain-related stress, functional cortical activity and visual-perceptual abilities in school-age children born at extremely low gestational age. Pain. 2013 Oct;154(10):1946-52.
41. 41. Jacobson RM, Swan A, Adegbenro A, Ludington SL, Wollan PC, Poland GA; Vaccine Research Group. Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines. Vaccine. 2001 Mar 21;19(17-19):2418-27.
42. 42. Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V; HELPinKIDS Team. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin Ther. 2009;31 Suppl 2:48-76.
43. 43. Linking opportunıtıes generatıno ınter-professıonal collaboratıon. The official journal of the new zealand college of primary health care nurses, NZNO. June, 2016 15: 2. Avalible from http://www.who.int/immunization/sage/meetings/2014/october/1_Report_WOR
44. 44. Taddio A, Ipp M, Thivakaran S, Jamal A, Parikh C, Smart S, Sovran J, Stephens D, Katz J. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine. 2012 Jul 6;30(32):4807-12.
45. 45. Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics. 2011 May;127 Suppl 1:92-9.
46. 46. WHO position paper: Reducing pain at the time of vaccination. September 2015. Wkly Epidemiol Rec. 2015 Sep 25;90(39):505-10.
47. 47. Taddio A, Ho T, Vyas C, Thivakaran S, Jamal A, Ilersich AF, Hogan ME, Shah V. A randomized controlled trial of clinician-led tactile stimulation to reduce pain during vaccination in infants. Clin Pediatr (Phila). 2014 Jun;53(7):639-44.
48. 48. Beirne PV, Hennessy S, Cadogan SL, Shiely F, Fitzgerald T, MacLeod F. Needle size for vaccination procedures in children and adolescents. Cochrane Database Syst Rev. 2015 Jun 18;(6):CD010720.
49. 49. Taddio A, McMurtry CM, Shah V, Riddell RP, Chambers CT, Noel M, MacDonald NE, Rogers J, Bucci LM, Mousmanis P, Lang E, Halperin SA, Bowles S, Halpert C, Ipp M, Asmundson GJ, Rieder MJ, Robson K, Uleryk E, Antony MM, Dubey V, Hanrahan A, Lockett D, Scott J, Votta Bleeker E; HELPinKids&Adults. Reducing pain during vaccine injections: clinical practice guideline. CMAJ. 2015 Sep 22;187(13):975-82.
50. 50. Taddio A, Wong H, Welkovics B, Ilersich AL, Cole M, Goldbach M, Ipp M. A randomized trial of the effect of vaccine injection speed on acute pain in infants. Vaccine. 2016 Sep 7;34(39):4672-7.
51. 51. Slater R, Worley A, Fabrizi L, Roberts S, Meek J, Boyd S, Fitzgerald M. Evoked potentials generated by noxious stimulation in the human infant brain. Eur J Pain. 2010 Mar;14(3):321-26.
52. 52. Pillai Riddell RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, Ahola Kohut S, Hillgrove Stuart J, Stevens B, Lisi DM. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2015 Dec 2;(12): CD006275.
53. 53. Levene I. Question 2: does topical local anaesthetic reduce pain from vaccinations in infants? Arch Dis Child. 2014 Nov;99(11):1057-8.
54. 54. Gupta NK, Upadhyay A, Agarwal A, Goswami G, Kumar J, Sreenivas V. Randomized controlled trial of topical EMLA and breastfeeding for reducing pain during wDPT vaccination. Eur J Pediatr. 2013 Nov;172(11):1527-33.
55. 55. Vinall J, Miller SP, Synnes AR, Grunau RE. Parent behaviors moderate the relationship between neonatal pain and internalizing behaviors at 18 months corrected age in children born very prematurely. Pain. 2013 Sep;154(9):1831-39.
56. 56. Hall RW, Anand KJ. Pain management in newborns. Clin Perinatol. 2014 Dec;41(4):895-924.
57. 57. Johnston CC, Stevens B, Craig KD, Grunau RV. Developmental changes in pain expression in premature, full-term, two- and four-month-old infants. Pain. 1993 Feb;52(2):201-8.
58. 58. Johnston C, Campbell-Yeo M, Disher T, Benoit B, Fernandes A, Streiner D,Inglis D, Zee R. Skin-to-skin care for procedural pain in neonates. CochraneDatabase Syst Rev. 2017 Feb 16;2:CD008435.
59. 59. Fishman S, Ballantyne J, Bonica JJ.Bonica’s Management of Pain. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
60. 60. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov 19;150(3699):971-79.
61. 61. Purves D, Augustine G, Fitzpatrick D, et al.Neuroscience. 2nd ed. Sunderland, MA: Sinauer Associates; 2001.
62. 62. Romanò CL, Cecca E. A new method to reduce pin-prick pain of intra-muscular and subcutaneous injections. Minerva Anestesiol. 2005 Oct;71(10):609-15.
63. 63. Hogan ME, Probst J, Wong K, Riddell RP, Katz J, Taddio A. A randomized-controlled trial of parent-led tactile stimulation to reduce pain during infant immunization injections. Clin J Pain. 2014 Mar;30(3):259-65.
64. 64. Alavi NM. Effectiveness of acupressure to reduce pain in intramuscular injections. Acute Pain. 2007;9(4):201-5.
65. 65. Jain S, Kumar P, McMillan DD. Prior leg massage decreases pain responses to heel stick in preterm babies. J Paediatr Child Health. 2006 Sep;42(9):505-8.
66. 66. Gibbins S, Stevens B. Mechanisms of sucrose and non-nutritive sucking in procedural pain management in infants. Pain Res Manag. 2001 Spring;6(1):21-8 . 67. Barrett T, Kent S, Voudouris N. Does melatonin modulate beta-endorphin, corticosterone, and pain threshold? Life Sci. 2000;66(6):467-76.
67. 68. Blass EM. Milk-induced hypoalgesia in human newborns. Pediatrics. 1997 Jun;99(6):825-29.
68. 69. Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev. 2012 Dec 12;12:CD004950.
69. 70. Rosali L, Nesargi S, Mathew S, Vasu U, Rao SP, Bhat S. Efficacy of expressed breast milk in reducing pain during ROP screening--a randomized controlled trial. J Trop Pediatr. 2015 Apr;61(2):135-8.
70. 71. Liaw JJ, Zeng WP, Yang L, Yuh YS, Yin T, Yang MH. Nonnutritive sucking and oral sucrose relieve neonatal pain during intramuscular injection of hepatitis vaccine. J Pain Symptom Manage. 2011 Dec;42(6):918-30.
71. 72. Harrison D, Stevens B, Bueno M, Yamada J, Webber TA, Beyene J, Ohlsson A. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child. 2010 May; 2-8.
72. 73. Marín Gabriel MÁ, del Rey Hurtado de Mendoza B, Jiménez Figueroa L, Medina V, Iglesias Fernández B, Vázquez Rodríguez M, Escudero Huedo V, Medina Malagón L. Analgesia with breastfeeding in addition to skin-to-skin contact during heel prick. Arch Dis Child Fetal Neonatal Ed. 2013 Nov;98(6):F499-503.
73. 74. Yilmaz G, Caylan N, Oguz M, Karacan CD. Oral sucrose administration to reduce pain response during immunization in 16-19-month infants: a randomized, placebo-controlled trial. Eur J Pediatr. 2014 Nov;173(11):1527-32.
74. 75. Commıttee On Fetus And Newborn And Sectıon On Anesthesıology And Paın Medıcıne. Prevention and Management of Procedural Pain in the Neonate: An Update. Pediatrics. 2016 Feb;137(2):20154271.
75. 76. Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD001069.
76. 77. Anand K, Stevens B, McGrath PJ. Pain in neonates and infants: pain research and clinical management series. New York, USA: Elsevier; 2007.
77. 78. Guideline statement: management of procedure-related pain in children and adolescents. J Paediatr Child Health. 2006 Feb;42 Suppl 1:1-29.
78. 79. Taddio A, Manley J, Potash L, Ipp M, Sgro M, Shah V. Routine immunization practices: use of topical anesthetics and oral analgesics. Pediatrics. 2007 Sep;120(3): 637-43.