Effectiveness of Reverse Kangaroo Mother Care Position in Decreasing Adverse Physiological Events and Pain during Screening of Premature Infants for Retinopathy of Prematurity

Background. Retinopathy of prematurity (ROP) screening is uncomfortable and even painful in preterm infants. Objective. To determine the effectiveness of the Reverse-Kangaroo Mother Care (R-KMC) position compared with the conventional position in decreasing adverse physiological events and pain during ROP screening. Methods. This was a parallel randomized controlled trial with two arms- R-KMC position and conventional position (control). The primary outcomes included increased oxygen saturation, decreased heart and respiratory rates, and decreased pain intensity measured by Prematurity Infant Pain Profile (PIPP). Results. There were 100 preterm infants recruited. There were no differences in baseline characteristics, mean ROP screening duration, mean physiological parameters after the mydriatic application and during ROP screening between the two. Only the mean respiratory rates were significantly lower among the R-KMC group during the application of mydriatric agent. (50.26 ± 6.18 vs. 51.6 ± 8.35; p=0.0191). Relative risk (RR) in the control group is 37 to 84 versus 40 to 68 in the R-KMC group. The R-KMC group had a significantly lower mean PIPP score (6.5±2.06 vs. 8.8±2.80; p<0.0001) after mydriatic application and during ROP screening (7.6±2.05 vs. 9.8±2.90; p<0.0001) compared with control. No apnea was observed after mydriatic application, but one apneic episode was in control during ROP screening. 26% of the ROP screeners recommended the R-KMC position during ROP screening, while a majority (70%) was neutral. Conclusion. R-KMC position, a low-cost intervention, significantly reduces pain during ROP screening. It is recommended as a position of choice during ROP screening.

Premedication with fentanyl for less invasive surfactant administration (LISA): A Randomized Controlled Trial

Currently, there is no consensus regarding analgesic premedication before the LISA procedure. In this randomized controlled trial, we compared the level of comfort of preterm infants receiving fentanyl as analgesic versus no fentanyl during LISA procedure. We randomized 34 preterm infants of 28+ 0 − 33+ 6 weeks of gestation with RDS within 6 h of birth to receive either fentanyl (1 µg /kg intravenous) or no premedication during LISA procedure. Primary objective was to assess the proportion of infants to be comfortable during the procedure (R-PIPP score < 10) and secondarily complications occurring during the procedure, hemodynamically significant patent ductus arteriosus (hsPDA), intraventricular hemorrhage (IVH) (≥ grade 3), bronchopulmonary dysplasia (BPD) and composite outcome of BPD/mortality. Proportion of infants with a R-PIPP score < 10 during LISA was significantly higher in the fentanyl group (13/17 (76.5%) vs 6/17 (35.3%); p value 0.036). There were no differences in secondary outcome parameters. Conclusion: Low dose fentanyl during LISA procedure resulted in more comfort in preterm infants and without increased complication of both the LISA procedure and fentanyl administration. Further studies are needed to determine the safest and most effective pharmacologic measures to prevent pain and discomfort during LISA. Trial registration: www.ctri.nic.in id CTRI/2020/08/027144, registration date August 14, 2020

Oral Sucrose Improves Analgesia During Retinopathy of Prematurity Screening

Purpose To determine whether sucrose provides significant analgesia during Retinopathy of Prematurity (ROP) screening Methods This was a prospective, randomized, sinlge masked audit. The examinations were performed by a single examiner. Forty-five (45) neonates were separated into two groups; Group 1 received oral sucrose while Group 2 received oral sucrose and non-nutritive suckling (NNS) at the discretion of the attending nurse. Pain was assessed using the Premature Infant Pain Profile (PIPP) score and recorded at baseline, immediately following lid speculum, at 3 minutes and 6 minutes following lid speculum insertion. Results The mean baseline PIPP score was 0.5. Fifteen (15) neonates (33%) received NNS. The mean PIPP scores at speculum insertion in both groups (Group 1: 7.24, Group 2: 5.50) were observed to be higher than at baseline and lower in Group 2 than in Group 1. In both groups, the scores at 3 minutes (Group 1: 4.70, Group 2: 4.20) and 6 minutes (Group 1 4.50, Group 2: 4.70) were observed to be higher than at baseline, lower than at speculum insertion, but not significantly different to each other. Conclusions Lid speculum insertion during ROP screening appears to be a significantly painful event. ROP examinations should be conducted with a combination of topical analgesia and sucrose and NNS for greatest pain-relieving effect.

Laser acupuncture versus oral glucose administration for pain prevention in term neonates: an observer-blinded non-inferiority randomized controlled clinical trial

Background: Neonates undergoing intensive care are routinely submitted to minor painful procedures such as heel lances. Pharmacological treatment is limited in neonatal care and not recommended for minor painful interventions. Hence, non-pharmacological acute pain management is an important subject. Acupuncture could be a new strategy for neonatal pain prevention. Accordingly, the aim of the present study was to investigate whether laser acupuncture is non-inferior to oral sweet solutions in pain prevention. Methods: In total, 96 healthy term neonates were randomly assigned to receive either laser acupuncture with 10 mW at LI4 bilaterally (AG, acupuncture group) or 30% oral glucose solution (GG, glucose group) before heel lance for metabolic screening. The primary outcome was the difference in premature infant pain profile (PIPP) score between groups in a non-inferiority concept. Secondary outcomes were changes in heart rate and crying time. Results: Median (interquartile range) PIPP scores were comparable in the AG and GG (12 (10–14) vs 12 (9–14), p = 0.981). Nevertheless, the 95% confidence interval (CI) of location shift exceeded the predefined margin for non-inferiority of 1 (95% CI: –1.000006 to 1.000059). Heart rate was found to be significantly lower after intervention (p = 0.048) and after heel lance (p = 0.015) in the AG versus GG. There was no difference in crying time between groups (p = 0.890). Conclusion: Laser acupuncture was not shown to be non-inferior to an oral glucose solution, possibly due to the higher than expected variability in PIPP scores within the studied groups. Future neonatal laser acupuncture studies for pain prevention with higher sample sizes are therefore warranted.

Skin-to-Skin Care by Mother vs. Father for Preterm Neonatal Pain: A Randomized Control Trial (ENVIRON Trial)

Objective. To compare skin-to-skin care (SSC) given by mother and father for preterm neonatal pain control by premature infant pain profile (PIPP) score. Methods. 64 stable preterm (28-36 weeks gestational age) neonates born at a level-3 neonatal intensive care unit were included in the trial. Random allocation with the help of a computer-generated sequence was done. In group A, SSC was given by the mother 15 minutes before the first heel-stick, and subsequently, SSC was given by the father before the second heel-stick. In group B, the sequence of SSC provider was reversed. Blinded PIPP score assessment at 0, 1, and 5 minutes of heel-stick were done by two independent assessors using video recording. Results. The mean (SD) birth weight was 1665.18 (339.35) grams, and mean (SD) gestational age was 34.28 (2.24) weeks. The PIPP score at 0, 1, and 5 minutes had no statistical or clinically significant differences between both groups (PIPP score mean (SD) at 0 minute = 3.20 (1.11) vs. 3.01 (1.29), p value = 0.38; 1 minute = 8.59 (4.27) vs. 8.26 (4.08), p value = 0.66; 5 minutes = 3.79 (1.40) vs. 3.93 (1.99), p value = 0.65 in SSC by mother and father group, respectively). Furthermore, there was no statistical difference between the groups for any components of the PIPP score (all p values > 0.05). The PIPP score at 5 minutes almost attained the 0-minute level in both the groups. Conclusion. Father is as effective as the mother for providing skin-to-skin care for preterm neonatal pain control. This trial is registered with CTRI/2018/01/016783.

Twenty-Five Percent Dextrose and EBM in Pain Relief During Heel Lance in Late Preterm Babies Using the PIPP Score: A Randomized Controlled Trial

Objective: To compare the analgesic effect of 25% dextrose and expressed breast milk (EBM) in pain relief during heel lance in late preterm babies using the premature infant pain profile (PIPP) score. Study Design: Prospective, double blind, randomized controlled trial. Setting: The neonatal intensive care unit of Jaipur Golden Hospital, Rohini, Delhi. Participants: One-hundred eleven late preterm babies who required heel lancing for glycemic control and who were on oral feeds and were hemodynamically stable. Methodology: The babies were randomized into 2 intervention groups (25% dextrose and EBM) and control group (sterile water). The test solution of 2mL was given to baby 2 minutes before heel lancing. The facial response to pain (brow bulge, eye squeeze, and nasolabial furrow) was analyzed from the video. Maximum heart rate (HR) and minimum blood oxygen saturation (SpO2) were also recorded at 30 seconds, 1 minute, 1.5 minutes, and 2.5 minutes after heel lancing by another camera. Outcome Variable: PIPP score, HR, SpO2 at 30 seconds, 1 minute, 1.5 minutes, and 2.5 minutes after heel lancing. Results: A total of 63 babies were considered for final analysis with 21 each in the 25% dextrose, EBM, and sterile water groups. The mean PIPP score in the 25% dextrose, EBM, and control groups at 30 seconds were 4.52, 6.86, and 10.14, respectively ( P < .001). At 1 minute, the PIPP scores were 3.24, 5.14, and 8.24, respectively, for the 25% dextrose, EBM, and control groups ( P < .001). Twenty-five percent dextrose gave better pain relief than EBM. Mean difference between the PIPP score in the 25% dextrose and EBM groups was –2.34 and –1.9 at 30 seconds and 1 minute, respectively, after the painful procedure ( P = .001). Babies in intervention groups had less increase in HR and less decrease in SpO2. Conclusions: Twenty-five percent dextrose and EBM significantly reduced procedural pain in neonates, though pain relief was better in the 25% dextrose group as compared to the EBM group.

Use of expressed breast milk for pain relief during venepuncture in neonates

Background: It is now known that repeated pain in neonatal period influences neurodevelopmental outcome. It is necessary to assess and manage neonatal pain with appropriate interventions. The objective is to study whether expressed breast milk effectively reduces neonatal pain after venepuncture in comparison to placebo using sterile water.Methods: In this randomised controlled trial, neonates were randomised into two groups-expressed breast milk group and placebo group with 40 neonates in each group. Two minutes before venepuncture, 2 ml of test solution was administered. Mean Premature Infant Pain Profile (PIPP) score and mean cry time were recorded in neonates of both groups after venepuncture and compared.Results: At 0-30 second, 1-1 ½ minute, 3-3 ½ minute, 5-5 ½ minute after venepuncture, neonates in placebo group had mean PIPP score of 11.475, 10.125, 9.125, 7.575 respectively. At the same time intervals, mean PIPP score was 9.375, 7.825, 6.475, 5.05 in neonates of expressed breast milk group. Mean cry time after venepuncture was 105.65 seconds and 75.825 seconds in the placebo group and expressed breast milk group respectively.Conclusions: Compared to placebo, expressed breast milk significantly reduced mean PIPP score and cry time in neonates.

Analgesic Effect of Maternal Human Milk Odor on Premature Neonates: A Randomized Controlled Trial

Background: Two studies have demonstrated an analgesic effect of maternal milk odor in preterm neonates, without specifying the method of olfactory stimulation. Research aim: This study aimed to assess the analgesic effect of maternal milk odor in preterm neonates by using a standardized method of olfactory stimulation. Methods: This trial was prospective, randomized, controlled, double blinded, and centrally administered. The inclusion criteria for breastfed infants included being born between 30 and 36 weeks + 6 days gestational age and being less than 10 days postnatal age. There were two groups: (a) A maternal milk odor group underwent a venipuncture with a diffuser emitting their own mother’s milk odor and (2) a control group underwent a venipuncture with an odorless diffuser. The primary outcome was the Premature Infant Pain Profile (PIPP) score, with secondary outcomes being the French scale of neonatal pain—Douleur Aiguë du Nouveau-né (DAN) scale—and crying duration. All neonates were given a dummy. Results: Our study included 16 neonates in the maternal milk odor group and 17 in the control group. Neonates exposed to their own mother’s milk odor had a significantly lower median PIPP score during venipuncture compared with the control group (6.3 [interquartile range (IQR) = 5-10] versus 12.0 [IQR = 7-13], p = .03). There was no significant difference between the DAN scores in the two groups ( p = .06). Maternal milk odor significantly reduced crying duration after venipuncture (0 [IQR = 0-0] versus 0 [IQR = 0-18], p = .04). Conclusion: Maternal milk odor has an analgesic effect on preterm neonates.