Article Information

Manali Shinde¹, Chhaya Valvi², Isha Deshmukh³*, AA Kinikar⁴

¹Resident in Pediatrics, BJGMC, Pune, India

²Professor, Pediatrics, BJGMC, Pune, India

³Assistant Professor, BJGMC, Pune, India

⁴Professor & HOD, BJGMC, Pune, India

^*Corresponding Author: Isha Deshmukh, Assistant Professor, BJGMC, Pune, India

Received: 12 August 2022; Accepted: 03 October 2022; Published: 31 October 2022

Citation: Manali Shinde, Chhaya Valvi, Isha Deshmukh, AA Kinikar. A Study of Assessment of Neonatal Pain and the Practices in Pain Management amongst Health Care Workers in An NICU of A Tertiary Care Center. Journal of Pediatrics, Perinatology and Child Health 6 (2022): 495-501.

Abstract

Keywords

Executive functions, Dietary fat intake, Perceived stress, prenatal distress, Emotion control

Article Details

Introduction

Socio-demographic Characteristics

86.8 % of respondents were females, 100 % of paramedic staff and 68.8 % residents. The highest numbers of respondents were between 20-30 years age group in case of residents (87.5%) whereas in 30-40 years of age group in paramedic staff (66.7%). Majority of staff had professional experience for more than 3 years of working in the NICU. (81%) whereas majority residents had experience of at least 1 year (50 %) (Figures 1-3).

The detailed socio-demographic characteristics of the study group are presented in Tables 1-4.

^{By Chi-square test, p = 0.016, p<0.05 Significant.}

Table 1: Demographic Data of the study population

Correlation Analysis:

^{By Pearson Correlation Co-efficient, r = -0.024, p = 0.889, p>0.05 Not Significant}

Table 2: Correlation of Age with Perception of Pain Management.

^{By Pearson Correlation Co-efficient, r = -0.016, p = 0.925, p>0.05 Not Significant.}

Table 3: Correlation of Gender with perception of pain management.

^{By Pearson Correlation Co-efficient, r = -0.019, p = 0.913, p>0.05 Not Significant.}

Table 4: Correlation of work experience with perception of pain management.

The p value was insignificant but if we take bigger sample size, we might find a significant value and results.

Figure 1: Profile of Gender Distribution among Study Cases.

Figure 2: Profile of Work Experience among Study Cases.

Figure 3: Profile of Age distribution among Study Cases.

Assessment of Health care professional’s perceptions of neonatal pain

 A detailed summary of 5 aspects of their perceptions of neonatal pain is presented in Table 5.

Table 5:  Aspects of their perceptions of neonatal pain.

Knowledge and Beliefs about Neonatal Pain

A significant number of participants in the study group (N=31; 86 %,) realized that neonates are capable of experiencing pain, the majority of those (N=2; 66.6%) also believed that pain in the neonatal period will have long term side effects. The nearly half of the health care workers (N=19; 52.7%) thought that preterm infants are less sensitive to pain than older children and adults because of the immature nervous system. A significant number of responders thought minor procedures like OGT insertion and oral suctioning can cause pain. (N=23, 63.8%). Moreover, the respondents agreed with the statement that pain experienced in the neonatal period has long-term adverse effects like impaired neurodevelopment due to repeated painful procedures in their NICU stay. (N=28, 77.7%)

Use of Pain Assessment Tools/scales

Majority of health care workers had not received any training while joining about neonatal pain assessment. Out of 37 workers, only 5 workers (13.8%) agreed that they use some scales and using protocols for neonatal pain assessment in daily practices but 15 (41.6%) % of all were confident about recognizing and assessing signs of neonatal pain out of which 3 (20%) were residents and 12 (80%) were paramedical staff. All 100 % residents and 76.7 % staffs agreed that they did not use the recommended tools for pain monitoring in this group of patients (Figure 4).

^{By Chi-square test, p = 0.013, p<0.05 Significant}

Figure 4: Profile of Pain Management as per protocol.

Use of Pharmacological and Non-Pharmacological methods

The respondents agreed that pharmacological and non-pharmacological interventions are necessary and they can efficiently reduce the pain, despite the fact that many invasive procedures may be carried out quickly. (N=35, 94%). The analysis of their responses demonstrated that neonatal pain is indeed treated in most of the centers in the form of injectable Midazolam during painful procedures and paracetamol suppositories in post OP patients. Most of the respondents (64.86%) agreed that non pharmacological methods including oral sucrose swabs would definitely help in alleviate the pain and they were confident in using them. According to 32 health care workers   (86.48%); non-pharmacological pain management like cuddling and giving sucrose swabs is effective in managing pain.

Family Involvement and Cultural Aspects

All 100 %participants agreed that parents are emotionally affected by the pain their infants face during painful procedures but 17 (45.94%) were of the opinion that parents shouldn’t be present and get involved in pain management during painful procedures considering emotional liability of mothers. On the contrary, all 100 % of the participating subjects agreed that kangaroo mother care and breast feedingis an efficient non-pharmacological method for neonatal pain relief after the painful procedure is completed.

Daily procedures and assessment of pain

When health care workers were told to rate the pain a neonate might be experiencing during routine procedures they face, it was observed that the average neonate was experiencing severe pain on daily basis especially in high dependency unit. Insertion of an IV access was graded as severe pain by 44.4% of the health care workers whereas 80.6 % labelled heel pricks as moderately severe for blood sugar level monitoring. Acts which might seem less painful but carried out daily like removal of IV catheter (80.6 %), removal of a micropore from skin (72.2 %) weregraded as moderately severe procedures. Hence planning the sampling in advance and minimum frequency of these procedures to reduce the pain is advisable.

Results

Our study analyzed the level of knowledge of medical personnel and observations regarding prophylaxis of pain and therapy in tertiary care neonatal intensive care units. The results clearly showed that the majority of participants have a sufficient level of knowledge of pain. However, in most of the hospitals there are no proper assessment tools. This is definitely an area where we can improvise. It should be emphasized that long-term chronic pain or long-lasting repetitive nociceptive impulses in this population may result in cognitive, motor, behavioral and personality disturbances [6, 7, 8]. Out of 28 (75.67%) confronted that they hadn’t undergone any lecture based on the neonatal pain assessment since joining / in past 3 years.

The results of our study show that the training for newly employed nurses/midwives was insufficient and that no adequate postgraduate educational programs were available [9, 10]. The level of knowledge and the skills of respondents who use pain assessment scales in their routine practice are also unsatisfactory. Almost half of the studied subjects were not confident in the identification of pain indicators (Figure 5).

Figure 5: Routine Procedures Causing Pain

Discussion

Newborn infants experience pain just as older children and adolescents experience pain; however, clinicians’ ability and approach to assessing and managing neonates is inadequate and controversial. Newborn infants experience acute measurable physiologic, metabolic, and hormonal, behavioral responses to pain [11]. They also experience long-term effects, including negative effects on neurologic and behavioral development. This is because they face pain during a very crucial time period of neurologic maturation [12]. In fact, preterm infants have demonstrated an exaggerated acute response to pain and behavioral and sensory long-term outcomes were worse when compared to term neonates [13, 14].  Available evidences have demonstrated that controlling pain in the newborn period improves physiological, behavioral, and hormonal outcomes. [11, 12]… Additionally, there is a lack of understanding of how neonates perceive pain and the resulting adverse outcomes that occur when pain remains untreated [12]. Thus, it is the need of today’s neonatologist to have some standard guidelines. There is lack of a universal method to assess pain. Objective measurements including heart rate, blood pressure, and levels of salivary cortisol can be used, but most care providers usually rely on grimace, crying and facial expressions. Objectives methods are inconvenient in resource limited settings. There are multiple validated pain scales utilized by NICUs to assess pain. For example for term neonates: neonatal facial coding system (NFCS); the neonatal infant pain scale (NIPS); cry, required oxygen, increased vital signs, expression, sleeplessness scale (CRIES); neonatal pain, agitation, and sedation scale (N-PASS); COMFORT Scale; and Douleur Aigue Nouveau-ne (DAN) scoring system have all been described in the literature .The premature infant pain profile (PIPP) is a validated pain scoring system which is used for preterm neonates.

Non-pharmacologic therapies, which include oral sucrose or glucose, breast or bottle feeding, Kangaroo mother Care, non-nutritive sucking, swaddling or facilitated tucking. Of all non-pharmacologic therapies the use of oral sucrose is the most discussed method. The proposed hypothesis is that glucose (and its alternative forms, such as sucrose) are responsible for endogenous opioid release, through an unknown mechanism [15–17]. The use of sucrose in neonates, when compared to breast milk or pacifier use is also associated with a reduction in behavioral indicators of pain, such as crying and grimacing seen in painful procedures [18]. Breast feeding was also found to be useful in alleviating pain.  Shah et al. demonstrated in a Cochrane review that breastfeeding can have an advantage for one-time painful procedures [19]. Careful positioning such as swaddling a neonate and facilitated tucking, which involves manually flexing a neonate’s arms and the legs have shown to be effective at reducing pain in neonates [20].

In pharmacological methods, EMLA which is a cream based formulation of lidocaine (2.5 %) and prilocaine (2.5 %) has been well established as effective in the neonatal population for reducing pain associated with minor procedures as a topical anesthetic agent. [21] Acetaminophen is one of the most commonly used systemic medications in the neonatal population due to its well-established effectiveness at pain reduction as well as its favorable side effect profile [21].

The optimization of pain management in the neonatal population is fundamentally aimed at reducing the total number of painful events. [22]. The clinicians reduce the number of painful events. The approach should include avoiding unnecessary painful procedures. Further, clinicians should reduce the number of bedside interruptions and daily examinations, if possible. Additionally, clinicians can anticipate the need for future studies and, with thoughtful planning, can coordinate studies to minimize the frequency pricks for withdrawing blood.

So, with help of this study it was proved that with a standardized approach to assess and manage pain, we hope to improve acute pain faced by the neonate, long-term neurologic and behavioral impairments, as well as parent and provider satisfaction. Ultimately, further research is needed regarding efficacy, safety profiles, and satisfaction scoring to better achieves these goals (Table 6).

Assessment of Training

^{By Chi-square test, p = 0.016, p<0.05 Significant}

Table 6: Profile of information on neonatal pain assessment.

Majority respondents wanted clinics every 3 monthly to update their knowledge and revise the scales to assess pain. So, it becomes very important to carry out adequate training on physiological and behavioral pain indicators in neonates considering these responses. The selection of an appropriate assessment tool depends on the clinical condition of the patient requiring intensive care. No single universal scale analyzing acute/procedure-related or chronic pain has been developed for this category of patients [9, 10]. Regardless of the type of measurement tool used, the percentage of personnel using it in routine clinical practice remains insufficient. This may result from inadequate training and a small number of staff responsible for carrying out such training [5]. Only 15.8% of respondents confirmed that the healthcare center where they are employed provided them a training session when they joined.

Conclusions

Our analyses indicate that health care workers obtained knowledge regarding neonatal pain by their own experience rather than proper training programs. According to the study subjects, pharmacological and non-pharmacological interventions undertaken in neonatal patients are effective in pain relief. The introduction of strategies to promote and extend the awareness among personnel of the neonatal pain monitoring scales is necessary. Implications of these practices with further studies concerning the control of neonatal pain evaluation, will allow the development of adequate training programs in this field. Unanimity in the pain scale will help by reducing chances of subjective assessment and will help in managing the pain without any discrepancy. Proper lectures creating awareness about assessment of pain, the long term effects on neonate in future and managing using adequate measures need to be scheduled every 3 monthly in our set up as rotation of residents and changing posting can be bothersome. We should try minimizing the procedures which can cause pain to a neonate by using proper techniques and planning. Pain, if managed adequately, can definitely help the baby to live a healthy and prosperous life in true senses.

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