Repetitive acute pain in infants born preterm: an age-specific nonpharmacological approach

Purpose of the study: to examine the age-related effectiveness of simple non-pharmacological interventions in reducing procedural pain in ex-preterm infants during a series of repetitive immunizations. Background: Infant pain is of critical interest, especially with respect to premature infants often exposed to protracted pain and recurring painful procedures. Despite the accumulating evidence that preterm neonates are highly sensitive to pain and that neonatal procedural pain is harmful and may lead to changes in neural development, treatment for painful procedures is limited. Children born preterm routinely undergo a series of monthly immunizations in order to prevent upper respiratory infections. These painful immunizations impact on an infant that experienced a mean of 14 stressful and painful procedures a day, during the period of hospitalization, which may have lasted for months. Given this, special attention is required to the development and use of age appropriate approaches that reduce the impact of painful procedures and to improve the treatment of repetitive pain in this particular group of vulnerable neonates. Methods: A Single Case Experimental Desing was used. 37 Italian children born pre-term were assigned to four non-pharmacological interventions (1: 25% sucrose solution in combination with oral stimulation by a pacifier; 2: visual–auditory distraction; 3: play interaction and 4: blowing soap bubbles). Reflecting the maturational level of the infants, considering age corrected for gestational age, each infant received the first intervention at his first immunization (out of five) and whenever no pain relieve was obtained, the next immunization was performed with the second intervention. Assessment of video-taped behaviour and crying, time to first cry, time to stop cry and total time required for the immunization procedure were used as outcome measures and assess by six independent observers. Results and Conclusions: following the maturation of the infant, visual-auditory distraction (using the more complex capacity of visual auditory integration), play interaction and blowing soap bubbles (using the capacity to participate in interactive play) all proved to be effective in delaying distress, reducing the facial display of pain and especially in reducing the time necessary to calm and console the infant. In addition, negative hospital experiences, length of stay together with gestational age and weight at birth should be considered important factors that influence the initial reaction to the first immunization. Sucrose in the presence of a pacifier significantly reduced pain and distress up to an age of 60 weeks corrected for gestational age. Furthermore these factors may underlie the extended efficacy of oral sucrose combined with a pacifier by altering the responsiveness of the immature nervous system to adverse events. This observation extends the effects of sucrose plus pacifier much beyond the period in which they are effective in term neonates. Finally, adjusting the method of non-pharmacological intervention according to age and maturational level will not only lead to the highest efficacy of pain management but will also lead to a reduction in stress as well as in time spend for the medical staff.