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Developmentally
Appropriate/Supportive
Interventions in the NICU
Many thanks to the
multi-disciplinary Sunnybrook
Team
Objectives
• To understand the various interventions that can
be implemented in the macro and micro-
environment within the NICU
• To appreciate the importance of these various
interventions
Interventions
• Environmental changes- macro and micro
• Cluster of care
• Non-nutritive sucking
• Positioning
• Skin to Skin Care
• Pain Management
• Family Centered Care
• Promote stability and reduce stress in the
infant
• Respond to the infant‟s cues
• Protect the family
Macro environment
• The NICU – design of the unit needs to be developmentally friendly
• The staff – needs to function as a team and be supportive of developmentally appropriate care
the staff needs also are taken into consideration
• Lights
• Sounds
Lighting
• Photometers to measure lighting
• <32wks GA
minimize ambient light exposure
use covers over isolettes
• Provide task lighting for staff and family
• Provide Night time staff exposure to adequate lighting
• Protect infants eyes from direct light exposure at:
Admission
Eye exams
Under phototherapy lights
Other procedures
In our unit
fully covered
isolettes until
approximately
32 weeks or while
critically ill
Cycled Lighting
• > 32 wks GA – cycled lighting:
210-270 lux from 7 AM to 7 PM
blankets are not permitted on top of the isolettes
infants are allowed 2 naps in dimness in
this 12-hour period
lighting is lower than 25 lux from7 PM to 7 AM.
• After 37 weeks GA – provide more complex
visual stimulation
Circadian rhythm
• In utero circadian rhythm of the fetus is set by mother by her activity level, eating, temperature, heart rate, blood pressure,melotonin and her cortisol levels
• Preterm infants in the NICU lack the maternal entrainment and are exposed to unpredictable lighting in the unit
• Cycled lighting may assist the preterm infant achieve some circadian rhythm in an appropriate timeline
Sound Levels
• average NICU is 70 - 80 dB
• recommended level is 50 dB
• well maintained and sealed empty isolette
should be 50 dB
• perceived loudness of sound doubles with
every 6 - 10 dB
• opening isolette doors gives perception of
sound 8 times louder
Sound
• Sound measurements to be done of the unit and
in the isolette and at the open bed space
• Sound reducing materials on surfaces in the unit
ie walls and floor
• Respond to monitors, equipment, pagers
• Attention to other noise producing equipment
• Traffic patterns in the unit – where high traffic,
keep babies away ( or at least the sickest)
• Reduce bedside conversations, other noises around bedside/isolette
• Want infant to hear mother‟s voice above background sounds
• Reduce lights – people talk quieter
• Reduce stress and crying of infants
• Naptime or quiet time
• Staff conversations
Noise Reduction
What doesn‟t work
• isolette covers
• infant foam ear covers
• curtains between baby areas
• “noise police” might work
Micro Environment
• Surrounding the infant:
Cluster of Care
Positioning
Touch- procedural / non-procedural
Pain management
• Use of expressed colostrum ( oral immune
therapy) and breastmilk
• Oral feeding = breastfeeding , bottle feeding
Cluster of Non-Emergent Care
• Should be according to infant‟s cues
• Should not be interrupting sleep
• Bedside nurse – the guardian: others to make an appointment as to when to handle ( other than a “hand-hug” by parent)
• Clustering of care is believed to support infant development by decreasing infant energy expenditure and promoting sleep.
•clustering of care with recovery time
•scheduled assessment times
•gentle, slow repositioning
•hand containment or nesting
Non-Nutritive Sucking (NNS)
• A reflex that is elicited when an infant sucks on a
pacifier, hand or any object that does not deliver
liquid
• NNS is important for infant‟s state regulation –
assists in calming the infant
• it is seen in utero as early as 11 - 13 weeks GA
• Use when there is maternal –infant separation
separation of mom & baby creates an
abnormal scenario
size appropriate, use during tube feeds
Cochrane Review (Pinelli and
Symington,2010
• NNS was found to decrease significantly the length of hospital stay in preterm infants.
• The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state).
• The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance.
• These infants showed less defensive
behaviors during tube feedings, spent less
time in fussy and active states during and
after tube feedings, and settled more
quickly into sleep.
Positioning the Preterm Infant
• Positioning is defined as “ a bodily posture
assumed by the patient or in which the
patient is placed to achieve comfort”
• “The particular disposition of the body and
extremities to facilitate the performance of
certain diagnostic or therapeutic postures”
Historical Perspective
• In the past, supine was the position of choice for infants,
• It allowed easy observation and easy access by caregivers
• The practice of supine positioning was challenged based on studies of respiratory function in adults.
• Attinger et al. (1956) studied preterm infants to determine the optimal position for care.
• Prone position was found to offer more benefits than supine or side lying positions. The findings of their hallmark study altered care in NICUs, wherein all infants were positioned prone.
• A 2001 review of 180 papers examined neuromotor
development and the physiological effects of
positioning and interventions in order to minimize or
prevent short and long tem negative outcomes
Emerging results indicated that:
• the development of posture and mobility in newborn
infants requires an optimal balance between active
and passive muscle tone
• prone position is physiologically more beneficial for
the preterm infant than supine and lateral positions
• prone position can lead to short and long term
postural and associated developmental problems
Why is Developmentally Appropriate
Positioning Important?
• Overall hypotonia (low muscle tone)
• Imbalance of active and passive muscle power
• Affects of gravity
• Lack of uterine containment
• Caudocephalic direction of neuromotor
development
Muscle Tone
what is it ?
Muscle tone
• The state of slight contraction usually present in muscles that contributes to posture and coordination
• Resistance of muscles to passive elongation or stretch
• Power and adaptability of the muscles during spontaneous movements
• Affected by state
• Factors affecting Muscle Tone in the Preterm population
Postural control
• Provides a basis for stability during movement
• Passive muscle power- slight, sustained contraction in anti-gravity muscles
• Supine posture – provides an overall impression of passive muscle tone
• Active muscle power- degree of vigour in spontaneous movements, fluent alterations in flex/ext – symmetrical, goal directed movements
Passive muscle tone
• Best observed when infant at rest – quiet
alert state
• State of slight muscle contraction that
contributes to postural control and co-
ordination of the extremity movements
• Begins approx 28 weeks gestation age
• Develops in a caudocephalic direction
28 week Gestational Age
Dubowitz et al, 1999
32 week Gestational Age
Dubowitz et al 1999
Posture: 36 - 37 weeks Gestational Age
Dubowitz et al 1999
36 weeks gestational age
Posture: Full Term
Dubowitz et al 1999
40 weeks
Active Muscle Power
• Is observed when an infant makes a movement in reaction to a situation
• As preterm infants have low muscle tone, they appear to develop exagerrated active muscle power
• Therefore increased extension with movements
Passive Muscle tone and active muscle
tone need to work in harmony to
provide stable postures and fluent
movements
The preterm infants have low muscle tone
and exagerrated active muscle power,
therefore very difficult to maintain a
posture or position without assistance
• Need to determine a position that is
medically effective and developmentally
supportive
“moving target”
• No long lasting perfect position
Positioning Goals
Goals of Positioning
Head Goals
• prevent head & neck hyperextension
• put neck in elongated position
• chin in neutral position or slightly flexed
downward
Nose Goals
• maintain normal nare shape
• prevent nasal notching and keep the
septum intact
• good alignment of tubing in the nostrils
Plastic surgery can‟t fix notches
please, spare the nares !
Eroded Caudal Septum
Columellar Transection
Columellar Notching
Upper Extremity Goals
• forward flexion of shoulders to prevent shoulder
retraction
• hands to midline
• hands to mouth
• grasp opportunities
Trunk & Lower Extremity Goals
• maintain a straight, aligned trunk
• hip and knee flexion to approx. 90 degrees
• prevent excessive abduction and external
rotation
• maintain knees in a midline (neutral) position
• feet - allow bracing, maintain a symmetrical
position
Principles of Positioning
• Flexion
• Midline
• Symmetry
• Alignment
• Weight bearing
• Containment
• Comfort and sleep
• Learning opportunities for the intimate caregiver
• Flexion: the act of bending or is the condition of
being bent
In utero, the fetus is maintained in a flexed position
by the uterine wall
In the NICU, the preterm infant should be positioned
in a flexed posture in order to imitate the intrauterine
posture and to enhance the development of flexor
muscle tone
• Midline :the line through the middle of the body ie
from the nose to the umbilicus.
• With positioning it is imperative to bring both the
upper and lower extremities towards the midline so
that the hands have easy access to the mouth,and
the hips and knees are towards the midline so
promote good alignment of the hips.
• As infant moves towards the midline, they are moving
into a position of flexion and as they move away from
the midline, they are moving into an extended
position which will increase stress and
disorganization.
• Symmetry is defined as “the
correspondence in size, form and
arrangement of parts on opposite sides of
a plane, line or point “ In positioning of the
preterm infant in the NICU this would
involve the placement of the extremities in
a similar position and direction
P
R
O
N
E
S
U
P
I
N
E
• Weight Bearing:It is important to be
cognizant of the body surfaces on which the
infant is lying hereby bearing their body
weight. These weight bearing surfaces are
also the pressure points from which the infant
is in contact with the surface of the external
support. Too much pressure or prolonged
weight bearing on one point can be a source
of pain and/ or discomfort.
• Movement occurs in the body parts that are
not bearing weight.
most of my weight
is on my head !
& that‟s not good
arm
knees
weight bearing
new weight bearing surfaces
side of face shoulder hip
• Alignment is the state of being in arranged in a line.
• Good postural alignment would mean that the ear is in line with the shoulder, in line with the hip, in line with the ankle.
• Good alignment in the infant will promote better quality movements ie the ability to move towards the midline into flexion, will enhance the development of age appropriate muscle tone and will decrease the likelihood to move away from the midline towards extension and therefore increasing the stress of the infant.
• Containment is defined as positioning the infant with the use of equipment to maintain the flexed midline position of the infant, giving the infant a sense of stability and security.
• The gentle pressure of the equipment will inhibit the big amplitude movements yet allow small movements which are normal in a fetus therefore a preterm infant.
• Promote comfort and sleep
• A multitude of learning opportunities for
the intimate caregiver
Good positioning is a positive oral experience
- hands to mouth, to midline
- gentle forward flexion
- Non- nutritive sucking
- reducing stress, allowing the infant to achieve
state regulation
- feeding readiness – cannot feed until achieve
systems stability in bed with handling and
then with holding
Passive and active positioning
• Containment is defined as assisting the infant
to achieve and maintain a flexed, midline
position by using blankets or equipment to
provide boundaries
• Blankets or positioning equipment provide
support and gentle inhibition of the large
amplitude movements of the extremities.
Containment does not restrain the infant.
Facilitated tuck:
• the tucked position is described as the infant being placed in
side lying, with the trunk being curled forward gently, with the
hips and knees flexed past 90 degrees and brought towards the
midline along with the shoulders and elbows flexed past 90
degrees thereby allowing the hands near the mouth or the face
(Ward-Larson et al, 2004)
• the gentle positioning of an infant‟s arms and legs in a flexed
midline position close to the infant‟s body while the infant is in
either a side-lying, supine or prone position (Hill et al, 2005)
• involves a caregiver providing the postural support with their
hands preferably on the head and feet while a second person
performs a procedure or routine care.
• These two studies demonstrated that the technique of facilitated
tucking during routine care and/or a painful procedure may be
an effective measure to reduce stress and/or pain for the infant.
Benefits: Positioning in Prone
• Gas exchange
• Chest wall synchrony with respirations
• Fewer episodes of apnea
• Sleep state improved
• Decreased energy expenditure
• Increased gastric emptying
• Decreased reflux episodes
Benefits: Positioning in Supine
• Visualize chest movement
• Chest movement with Oscillation or Jet
ventilation
• Umbilical lines, chest drain placement
• Less nare pressure when on Hudson Prong
CPAP
• Allows extremity movement
• “Back to Sleep”
Benefits: Positioning on Right and Left
Side!
• Head is in midline
• Hands to midline, mouth
• Sucking and grasping opportunities
• Left side decreases reflux episodes
• Pneumothorax treatment
• Post – op reasons
Equipment
• blanket rolls
• “headhuggers”
• “frogs”
• isolette covers
• “butterflies”
• prone pillow
• creative equipment
Long and short term
implications of positioning• Skull shaping
• Preference to face one way
• Increased trunk extension and shoulder
retraction
• Hips and other lower extremity postures
frequent right facing can lead to………
preferred right facing which can lead to……
weeks or months of therapy to return to midline
Skull Shapes
• Skull deformations occur after
embrogenesis
• Result from nondisruptive mechanical
forces ie postnatal positioning in the
NICU
• Skull weight bearing on the hard surface
Definitions• Dolichocephaly – having a cephalic index
<75%
common in premature infants usually caused by prone/ side lying positioning in the NICU
• Scaphocephaly – abnormal length and narrowness of skull, as a result of premature closure of the sagittal suture, usually accompanied by mental retardation
They will appear the same initially
• Central Occipital flattening –
Brachycephaly
( a Cranial Index >81% , indicates a
shortened anterior-posterior dimension
and widening of the bilateral eminences)
CI = 54%
• Plagiocephaly – asymmetric head
• known as Positional Plagiocephaly (
without synostosis) – deformation of the
skull(occiput) produced by extrinsic
forces acting on an intrinsically normal
skull
• from supine lying
• Right* ( most common)and Left occipital
flattening
Features of disorganized,organized
and self regulating behaviours
• Disorganized – tend to be jerky, frantic, flailing,
involve extension, repetitive movements that
tend to increase disorganization
• Self-regulating – start to calm, involve active
flexion, coming to the midline, jerkiness starts to
become more smooth,sucking
• Organized – smooth, flexion, hands and feet
together
Infant
Activities
Deep Sleep REM sleep Indeterminate
sleep
Quiet awake Active awake Crying Exhaustion
Heart rate Stable /
steady
Slight irregularity Irregular Irregular Irregular Irregular Bradycardia
Respiratory Regular
/smooth
Disruption of
regular breathing
pattern
Chaotic breathing
pattern
Regular /
smooth
pattern
Irregular Irregular Apnea
Colour Pink Pink Pink Pink Pink / red Red, dusky, circum-
oral cyanoses
Pale, mottled
dusky
Visceral none none none none Spit up Spit up Emesis, BM
Eyes Closed
& no
movement
lids closed or just
slightly parted, eye
moves under lids in
phasic patterns
‘heavy lids’ ‘fluttery
lids’
‘Dull’ eyes
‘Bright’
focused
Lids open, more
eye movement,
less focus
Eyes tightly closed
with grimace
Dull, unfocused
Face No
movement
Small twitch,
sucking motion
Twitches, brow
raise, smile,
Minimal
movement
Frequent
movements,
sucking, rooting,
grimace, hyper-
alert
Grimace, Gape face
Head &
Trunk
No
movement
Minimal to slow
rotation or lifting,
maintains tucked
flexed position
Larger smooth trunk
movement, diffuse
stretch
Minimal
movement
Mild arching,
extension,
Arching,
hyperextension,
Arching,
extension and
flaccid
• Red is stop, don‟t disturb, state is good:
• Green is „good to go‟ (i.e. capable of
feeding, interacting)
• Yellow is a state that needs assistance to
move into the red or green state
scent free in the NICU and in the isolette
Odours
• Cloth dolls “huggies”
• Perfume free zone
• Reduce exposure to noxious odours ( alcohol
hand wash)
• Protect from exposure to odour of cigarette
smoke
• Use of colostrum and breast milk
Maternal Scent Skin to Skin
Skin to Skin Care
(Kangaroo Care)
Skin To Skin Care
• Stable Infant placed upright with only a
diaper on mother or father‟s bare chest
• Willing caregivers – staff and
mother/father
• Transfer often the most difficult
• Length of time – a sleep cycle
Flexion
Midline
Symmetry
Alignment
Weight bearing
Containment
Comfort and sleep
Learning opportunities
& experiences
Infant Benefits of Skin to Skin
• Improves state organization, Increases the length of quiet sleep state (NREM) shorter periods of REM sleep
• Assists thermal regulation,
• Stabilizes respiratory patterns, oxygen saturation, reduces apnea, reduces bradycardia
• Increases rate of weight gain
• Functions as an analgesic during painful procedures
• Shortens hospital stay
• Positive impact on physiological and behavioral organization and later for mental health outcomes
• Positive impact on perceptual, cognitive and motor development
Maternal Benefits to Skin to Skin
• Increase mother‟s milk production
• Positive impact on breastfeeding outcomes
• Improves maternal adaptation to infant cues
• Positive impact on mother infant attachment
• Positive impact on maternal sense of
competence, during hospitalization and after
discharge
• Positive impact on paternal feelings
Infant Massage
• Numerous studies :
claim many short and long term benefits for infant and mother
• Can be a simple as a hand hug to infant massage
• Need to watch the infant‟s cues and reactions
• Probably best to teach the mother and closer to term age for the infant
Massage
• Massage has been found to soften scar
tissue by freeing restrictive fibrous bands
and increasing circulation
• Release the underlying adhesions
• Reasons: cosmetic
promote full lengthening of the
affected structures with
growth
Scars
• Surgical - PDA Ligation
- Abdominal
• Procedural - Central lines
- Chest tubes
- IV infitration
- tape removal
Pain Assessment &
Management:
Pharmacological and
Non-Pharmacological
Interventions in the
NICU
Sharyn Gibbins, RN, PhD
May 15, 2006
Pain
“Pain is an unpleasant sensory andemotional experience associated withactual or potential tissue damage ordescribed in terms of such damage”IASP
• Pain has been defined further as a subjective experience that is best understood through self-reports
• Verbal communication and self-report are considered the “gold standard” for pain assessment
Challenges to the Pain
Definition
In the absence of verbal communication, other indicators such as physiological, hormonal, biochemical and behavioral responses to painful stimuli should be considered forms of self-report that are surrogate markers to infer the existence of pain in high-risk populations (Warnock & Lander 2004)
Efforts should be directed towards increasing recognition of pain and developing broader sources of information to infer the subjective experience of pain in nonverbal neonates
PHYSIOLOGICAL
INDICATORS
BEHAVIOURAL
INDICATORS
BIOCHEMICAL/HORMONAL
INDICATORS
Increased Heart Rate Increased Facial Actions Increased Cortisol
Changes in Respiratory rate Cry Increased Epinephrine
Increased Intracranial Pressure Increased Body Movements Increased norepinepherine
Fluctuations in Blood Pressure Changes in State Increased Growth Hormones
Decreased Oxygen Saturation Fussiness/Sleeplessness Decreased Prolactin
Changes in Heart Rate Variability Flexor withdrawal reflex Decreased Insulin
Dilated Pupils Consolability/sleep patterns Protein Catabolism
Palmar Sweating Decreased Immune Responses
Summary of Pain Responses
Difficulties with Interpretation
of Individual Pain Responses
• Behavioral but not physiological indicators are predominant during painful procedures in preterm infants
• Repeated pain affects pain response
– preterm infants who were born at 28 weeks gestation and hospitalized in a NICU for 4 weeks (early preterm group) had significantly higher heart rates and lower oxygen saturation levels during heel lances than preterm infants born at 32 weeks (late preterm group)
– the more recently a preterm infant had experienced a painful procedure, the less likely he/she would demonstrate behavioral pain
responses to subsequent painful procedures
• Responses are influenced by gestational age, behavioral state and severity of illness
• Biological Factors
– gender differences
Myths of Pain
in Infants
“Infants Lack Myelination”
• The neural pathways for pain perception are present in newborn neonates (Anand, 1993; Fitzgerald, 2000;Humphrey, 1964 )
• The density of nociceptive nerve endings in the skin ofneonates is similar to or greater than that in adult skin(Anand 1993)
• Nociceptive pathways to the brainstem and thalamus are myelinated by 30 weeks gestation (Anand & Carr, 1989;
Anand et al.,1989; Fitzgerald, 1993; Rakic & Goldman-Rakic, 1982)
Myths of Pain
in Infants
“Capacity for fetal pain is limited”
• Fetal awareness of pain requires functional thalamocortical connections (Lee et al, 2005 )
• EEG patterns denoting wakefulness is present around 30 weeks
– Lack of surrogate markers
– Neuroanatomical evidence reports developmental ranges (21-30 weeks)
– Purpose was termination NOT preterm infant management
Pain in Infants
• Approximately 8.2% of the contacts in the NICU are comforting
• Stevens et al (1999) found that infants born between 27 to 31 weeks gestation received a mean of 134 painful procedures within the first two weeks of life and approximately 10% of the youngest and/or sickest infants received over 300 painful procedures
• Porter (1999) found that preterm infants experienced, on average, over 700 painful procedures during their hospitalization
• Gibbins et al. (2002;2005) found the mean number of painful procedures per day was greater than 5 (range 0 to 10) and 12/day if non-tissue damaging procedures were included
• Stevens et al. (2005) found the mean number of painful procedures per day was greater than 10
Measurement & Assessment
of Infant Pain
Assessment
• Assessment involves subjective judgment about the quality and significance of pain for a particular infant
• Assessment may include measurement but also involves clinical judgment based on observation
Measurement
• Measurement is used to
(a) quantify pain
(b) evaluate the effectiveness of pain relieving interventions and/or
(c) compare pain responses across situations with the same infant and between infants
Limitations in
Infant Pain Measures
• Plethora of infant pain measures– Limited psychometric analyses of existing pain measures
• Certain high-risk populations excluded– ELBW (<1000g) (Grunau et al., 2000; Morison et al., 2003)
– Cognitively impaired (i.e. Drug influence) (Stevens et al)
• Certain situations excluded– Chronic vs. Procedural vs. Disease related
ELBW
• Flexing and extending extremities, finger splaying,
fisting and mouthing (Grunau et al 2000, Holsti et al. 2004)
• Startles, twitches, jitters and tremors were not
associated with pain
• Decreased salivary cortisol in ELBW infants
• Pain responses in ELBW infants (Gibbins et al)
Neurologically impairedStevens et al. 2005
• Infants at highest risk for NI demonstrated less physiological and behavioral responses to painsignificant within-subject effect of phase was found with:
- facial activity (F(3,239) = 45.58, p <.0001)
- maximum HR (F(3,302) = 5.80 , p =.0007)
- minimum HR (F(3,302) = 6.81, p =.0002)
- minimum 02 (F(3,297) = 5.72 , p =.0008)
• Compared to cohorts B and C, significant between-subject effect with cohort A exhibiting:
- less facial activity (F(2,233) = 12.17, p=<.0001)
- lower maximum HR (F(2,302) = 14.4, p <.0001)
- lower minimum HR (F(2,302) = 5.52, p<.004)
- lower mean cry fundamental frequency (F(2,33)= 3.57, p<.039)
Procedural Pain
• Procedural pain in neonates still not treated
consistently
• Measures to manage neonatal pain can be both
pharmacological or non-pharmacological OR a
combination of both
Painful Procedures or
Conditions
• Heelsticks – (more painful than venipuncture (Shah,2002)
• Venipuncture/arterial puncture
• Skin lesions, abrasions, IV burns
• Rib,clavicle and extremity fractures
• Chest drain insertion
• Picc lines
• IM injections
• Surgical procedures
• Removal of adhesive tape/bandaids – may be the most frequent “painful” procedure (Franck,2006)
• Intubation
• Eye exams
• Pharmacological
– alleviate pain with drugs that are safe and effective
• Non-Pharmacological
– therapies, such as environmental or behavioral
interventions, that do not include pharmacological agents
One does not preclude the other
For the NICU infant, there should always be environmental
and behavioural strategies in place
Approaches to Pain
Management
Stevens, Gibbins, & Frank, 2000
Developmentally Sensitive
Strategies
• Environmental strategies can help by:
– Indirectly by reducing total amount of noxious stimuli
• Behavioural strategies may:
– Block nociceptive input along ascending fibers
– Activate descending endogenous opioid and non-opioid pathways-decrease nociceptive transmission
• Interventions-activate attention and arousal systems that help modulate pain
• Standard of Care for all painful procedures
NICU Environment
• Reduce noxious stimuli
– Multiple painful procedures, frequent handling
plus environmental factors increase the
infant‟s stress responses
• Promote calm environment ( macro & micro)
– Promote physiologic stability
– Individualize care – according to infant‟s cues
– Handle slowly –promote self regulatory
behaviours
– Provide adequate preparation and support esp
prior, during and following a painful procedure
Developmental Interventions
Comfort Measures
• Research examining
multiple
developmentally
sensitive measures to
reduce pain is limited
– positioning
– facilitated tucking ( using
hands)
– containment ( using
equipment)
– non-nutritive sucking
Non-nutritive sucking
• Mechanism unknown-
theory is that the release of serotonin (only when
sucking) may modulate, directly or indirectly the
transmission and processing of nociceptive stimuli (Blass,
1995)
• Studies-preterm and term
– Meta-analysis 3 studies significant reduction in heart
rate after heel prick (1997)
– Heelstick –decreased crying time (Field & Goldston, 1984)
Sucrose
• The most studied non-pharmacological pain relief treatment in newborns
• Sucrose-disaccharide consisting of fructose and glucose
• Hypothesis/Mechanism of action-sweet taste promotes analgesia through activation of the endogenous opioid release that attenuates nociceptive information
• Reduces heart rate and behavioural indicators of pain
• Initial data supported that sucrose was effective in reducing pain that led to studies evaluating the efficacy and safety of sucrose, as well as the most effective dose in reducing pain
Sucrose for management of neonatal
procedural pain
• Evidence has been available for several years that sucrose is effective in managing pain in newborns
• 30 RCTs, meta-analysis (Stevens et al, 1997) and systematic reviews (Stevens et al., 2002)
• CPS and AAP have recommended its use for treatment of procedural pain in neonates (AAP, Pediatrics, 2000)
• Consensus statement (Anand et al. 2001) that advocate for sucrose as frontline or adjunct therapy for most painful procedures
Dosage and Administration
• Dose dependent on Gestational Age
• Dose of 0.5mls used for preterm and up to 2 mls for term infants
• Must be administered on the anterior aspect of the tongue
• Most effective if administered 2 minutes prior to painful procedure; Lasts up to 5 minutes
• Dose can be divided to allow for re-administration for longer procedures
• Most effective in conjunction with pacifier-synergistic/additive effect
• No data on maximum dose
Conclusions
• Infants have a capacity for pain by mid gestation
• Pain has immediate and long term consequences
• Physiological, behavioral and biochemical indicators
are proxies for pain in infants
• Pain measures must be population/ and context specific
and have established psychometric properties
• Certain high-risk populations excluded– ELBW (<1000g) (Grunau et al., 2000; Morison et al., 2003)
– Cognitively impaired (i.e. Drug influence) (Stevens et al)
• Certain situations excluded– Chronic vs. Procedural vs. Disease related
Conclusions
• We need to use developmental strategies and non –pharmacological methods as much as possible
• We need to be judicious in our management of post operative pain and procedural pain.– When we chose pharmacological measures
• Chose the right drug
• Start low
• Use objective measures to evaluate and titrate to each baby‟s needs
• We need to develop guidelines for pain assessment and management
Infant Massage
• Numerous studies :
claim many short and long term benefits for infant and mother
• Can be a simple as a hand hug to infant massage
• Need to watch the infant‟s cues and reactions
• Probably best to teach the mother and closer to term age for the infant
Massage
• Massage has been found to soften scar
tissue by freeing restrictive fibrous bands
and increasing circulation
• Release the underlying adhesions
• Reasons: cosmetic
promote full lengthening of the affected
structures with growth
Scars
• Surgical - PDA Ligation
- Abdominal
• Procedural - Central lines
- Chest tubes
- IV infitration
- tape removal
Nothing about my babies, without
me
• Parents are not visitors
• Part of the team
• Involved in making decisions
• Participate in Rounds
• Participate in care
• Controlling infection in the unit is of utmost
importance but it does not mean excluding
parents from caring for their infants( Venkatesh et al, 2011)
• Many units now have a parent support position
as part of the team ( former NICU parent)