Original ArticlePainful procedures and analgesia in hospitalized newborns: A prospective longitudinal study
Introduction
Newborns admitted to neonatal intensive care units (NICU) are exposed to a high numbers of painful skin breaking procedures such as heel lance and venipuncture, and stressful interventions such as handling. Early life exposure to untreated pain can negatively impact on postnatal growth and brain development, and may affect attention, cognitive, emotional and motor progress (Valeri et al., 2015). Furthermore, a cohort study demonstrated painful procedures were associated with decreased weight gain and head circumference gain in 78 very preterm newborns (<32 weeks of gestational age) hospitalized in an NICU (Vinall et al., 2012).
However a systematic review of studies conducted worldwide demonstrate that procedural pain prevention and management in newborns is suboptimal (Cruz et al., 2016), and studies published more recently continue to demonstrate similar results (Courtois et al., 2016a, 2016b). However there is little known about the epidemiology of neonatal pain in the Brazilian context (Bonutti et al., 2017; Linhares et al., 2012; Nóbrega et al., 2007; Sposito et al., 2017).
Although the length of hospitalization in NICU may vary from days to months according to newborns' clinical conditions, the majority of prior studies conducted in developed and developing countries have evaluate pain exposure and pain management practices during the first days of life only (Cruz et al., 2016). Therefore, examining the epidemiology of procedural pain and pain management and exploring the relation between painful procedures and neonatal demographic and clinical variables can contribute to the knowledge base concerning the true burden of pain for sick infants, and inform the creation and implementation of strategies to improve neonatal pain outcomes throughout the hospitalization.
The aims of this study were to identify the type and frequency of stressful and painful procedures, the use of analgesic and comforting strategies for newborn comfort and pain relief, and to identify relationships between demographic and clinical variables with frequency of procedures and pain management during the course of newborns' hospitalization.
Section snippets
Design
This is a prospective longitudinal study.
Setting, and ethics
This study was conducted in the NICUs of two different institutions, the Hospital Sofia Feldman and the Maternidade Odete Valadares. Both institutions are public teaching hospitals specialized in women and newborn health care, and located at the city of Belo Horizonte, Brazil. In 2014, a total of 1,104 newborns were admitted to the NICU at Hospital Sofia Feldman, with an average length of stay of 14 days. During the same year, a total of 894 newborns
Population characteristics
A total of 293 newborns were hospitalized in the two participating units during the study period. From the 255 newborns fulfilling the inclusion criteria, 140 were included in this study (Fig. 1). Most newborns were male (71/53.4%), born by cesarean section (68/52.7%), and born at <36 weeks gestational age (mean 32.8, ±3.6). Prematurity (60%) and respiratory distress syndrome (50%) were the most commonly registered reasons for NICU admission. The average length of stay was 26 days per newborn.
Discussion
This prospective, longitudinal study aimed to identify type and frequency of neonatal stressful and painful procedures, use of strategies for neonatal comfort and pain relief, and to identify factors related to frequency of procedures and pain management over the course of newborns' hospitalization.
Limitations of this study include data collection processes. Although trained, some of the staff did not include precise information on the data collection forms attached to the newborns' clinical
Conclusions
This study confirms newborns are exposed to a high number of stressful and painful procedures with infrequent use of effective recommended pain management strategies during the entire hospitalization. Tailoring and implementing knowledge translation strategies based on high quality synthesised evidence is crucial for improving neonatal pain management practices.
Funding
This study was supported by a grant from FAPEMIG #CDS APQ001140-13, project “Pain and analgesia in hospitalized newborns and their repercussions in the short term”. Funders had no participation or influence in data collection, analyses and report of the results.
Ethical statement
This study was approved by the local ethics committee at Federal University of Minas Gerais, protocol #14547613.5.1001.5149.
Conflicts of interest
None.
Acknowledgments
The authors gratefully acknowledge the families of included neonates for consenting their participation. We also acknowledge the health care providers, especially nursing staff, from the Sofia Feldman Hospital and Odete Valadares Maternity, for participating on data collection procedures for this study.
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