Acceptability and Usability of Smileyscope Virtual Reality for Paediatric Pain Management During Burn Procedures: Perspectives of Patients, Carers and Clinicians.

AIM: To explore clinician, child and parent acceptability and usability of the Smileyscope VR device in the context of addressing the unique pain and distress needs of young burn patients. DESIGN: A survey comprising closed and open-ended questions. METHOD: Descriptive statistics analysed participant characteristics, pain and analgesia. Qualitative content was collected from April 2022-August 2022 and analysed to identify barriers and enablers. Categories were then mapped onto the Capabilities, Opportunities and Motivation-Behaviour Wheel (COM-B) framework. RESULTS: Smileyscope was found to be effective for reducing pain and anxiety during dressing changes by both patients (n = 39) and parents (n = 37). Clinicians (n = 35) reported high self-efficacy and willingness to reuse the device. However, concerns arose regarding the device's fit and the need for age-appropriate programmes. CONCLUSION: Smileyscope demonstrated promise in reducing procedural pain and distress. The device is well accepted by all participants implying ease of implementation. Feedback suggests further program development and fitting optimisation is required. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Improved procedural pain has proven to decrease wound healing times, decreasing possible need for further scar management and long-term consequences after sustaining a burn injury. Smileyscope use in rural hospitals presents valuable opportunities for optimising early paediatric burn pain. IMPACT: Increased burn pain can delay wound healing and have long term physical and psychological impact on patients. Smileyscope was well received within this cohort; however, improvements in device design and programmes were suggested. This study shows the potential for use of Smileyscope as a non-pharmacological approach to improving paediatric burn pain and distress. PATIENT OR PUBLIC CONTRIBUTION: While our study included patients, parents and clinicians as research participants, there was no patient or public contribution in the design or conduct of the study, analysis or interpretation of the data.

Evaluation of the Relationship between Pain Exposure and Somatosensory Evoked Potentials in Preterm Infants: A Prospective Cohort Study.

BACKGROUND AND AIM: First, to compare somatosensory evoked potentials (SEPs) in preterm newborns without major brain injury studied at term equivalent age (TEA) with a term historical control group. Second, to investigate the impact of pain exposure during the first 28 days after birth on SEPs. Third, to evaluate the association between SEPs and Bayley-III at 2 years corrected age (CA). METHODS: Infants born at <32 weeks' gestational age (GA) were studied with continuous-SEPs. First, SEP differences between preterm and term infants were analyzed. Second, regression analyses were conducted to explore the association between SEPs and painful procedures, and then between SEPs and neurodevelopment. RESULTS: 86 preterm infants were prospectively enrolled. Preterm infants exhibited prolonged N1 latencies, central conduction times (CCTs), lower N1-P1 amplitudes, and more recurrently abnormal SEPs compared to term infants. Higher pain exposure predicted longer N1 latency and slower CCT (all p < 0.005), adjusting for clinical risk factors. Younger GA and postmenstrual age (PMA) at SEP recording were associated with longer N1 latency and lower N1-P1 amplitude (all p < 0.005). A normal SEP at TEA positively predicted cognitive outcome at 2 years CA (p < 0.005). CONCLUSION: Pain exposure and prematurity were risk factors for altered SEP parameters at TEA. SEPs predicted cognitive outcome.

Scientific and technical assistance on welfare aspects related to housing and health of cats and dogs in commercial breeding establishments.

This Scientific Report addresses a mandate from the European Commission according to Article 31 of Regulation (EC) No 178/2002 on the welfare of cats and dogs in commercial breeding establishments kept for sport, hunting and companion purposes. The aim was to scrutinise recent recommendations made by the EU Platform on Animal Welfare Voluntary Initiative on measures to assist the preparation of policy options for the legal framework of commercial breeding of cats and dogs. Specifically, the main question addressed was if there is scientific evidence to support the measures for protection of cats and dogs in commercial breeding related to housing, health considerations and painful procedures. Three judgements were carried out based on scientific literature reviews and, where possible a review of national regulations. The first judgement addressed housing and included: type of accommodation, outdoor access, exercise, social behaviour, housing temperature and light requirements. The second judgement addressed health and included: age at first and last breeding, and breeding frequency. Judgement 3 addressed painful procedures (mutilations or convenience surgeries) and included: ear cropping, tail docking and vocal cord resections in dogs and declawing in cats. For each of these judgements, considerations were provided indicating where scientific literature is available to support recommendations on providing or avoiding specific housing, health or painful surgical interventions. Areas where evidence is lacking are indicated.

Effects of multimodal pain management strategies on acute physiological and behavioral response to cautery disbudding in neonatal goat kids.

Dairy goat kids are commonly disbudded in the United States without pain relief. Our objective was to identify an efficient pain management strategy by monitoring changes in plasma biomarkers and behavior of disbudded goat kids. A total of 42 kids (5-18 d old at the time of disbudding) were randomly allocated to 1 of 7 treatments (n = 6/treatment): sham treatment; 0.05 mg/kg i.m. xylazine (X); 4 mg/kg subcutaneous buffered lidocaine (L); 1 mg/kg oral meloxicam (M); xylazine and lidocaine (XL); xylazine and meloxicam (XM); and xylazine, meloxicam, and lidocaine together (XML). Treatments were administered 20 min before disbudding. One trained individual, blinded to treatment, disbudded all kids; sham-treated kids were handled similarly except the iron was cold. Jugular blood samples (3 mL) were obtained before (-20, -10, and -1 min) and after (1, 15, and 30 min, and 1, 2, 4, 6, 12, 24, 36, 48 h) disbudding and analyzed for cortisol and prostaglandin E2 (PGE2). Mechanical nociceptive threshold (MNT) testing was performed at 4, 12, 24, and 48 h after disbudding, and kids were weighed daily until 2 d post-disbudding. Vocalizations, tail flicks, and struggle behavior during disbudding were recorded. Cameras were mounted over home pens; continuous and scan observations over 12 periods of 10 min each, in the 48 h after disbudding, captured frequency of locomotion and pain-specific behaviors. Repeated measures and linear mixed models assessed treatment effects on outcome measures during and after disbudding. Models accounted for sex, breed, and age as random effects, and Bonferroni adjustments accounted for multiple comparisons. At 15 min after disbudding, XML kids had lower plasma cortisol concentrations compared with L (50.0 ± 13.2 vs. 132.8 ± 13.6 mmol/L) and M kids (50.0 ± 13.2 vs. 145.4 ± 15.7 mmol/L). Cortisol was also lower in XML kids over the first hour after disbudding compared with L kids (43.4 ± 9 vs. 80.2 ± 9 mmol/L). Change from baseline PGE2 was not affected by treatment. Behaviors observed during disbudding did not differ by treatment group. Treatment affected MNT such that M kids were more sensitive overall compared with sham kids (0.93 ± 0.11 kgf vs. 1.35 ± 0.12 kgf). None of the recorded post-disbudding behaviors were affected by treatment, but study activities did influence behavior over time, with kid activity levels declining in the first day after disbudding but largely recovering thereafter. We conclude that none of the drug combinations investigated here appeared to fully attenuate pain indicators during or after disbudding, but triple modality seems to have offered partial relief compared with some of the single-modality treatments.

Oxytocin Levels Increase and Anxiety Decreases in Mothers Who Sing and Talk to Their Premature Infants during a Painful Procedure.

(1) Background: Preterm infants spend their first weeks of life in the hospital partially separated from their parents and subjected to frequent potentially painful clinical procedures. Previous research has found that early vocal contact reduces infant pain perception while simultaneously increasing oxytocin (OXT) levels. The current study aims to assess the effect of maternal singing and speaking on mothers. (2) Methods: During a painful procedure over two days, twenty preterm infants were randomly exposed to their mother's live voice (speaking or singing). Maternal OXT levels were measured twice: before and after singing, as well as before and after speaking. The anxiety and resilience responses of mothers were studied before and after the two-day interventions, regardless of the speaking/singing condition. OXT levels in mothers increased in response to both singing and speech. Concurrently, anxiety levels decreased, but no significant effects on maternal resilience were found. (3) Conclusions: OXT could be identified as a key mechanism for anxiety regulation in parents, even in sensitive care situations, such as when their infant is in pain. Active involvement of parents in the care of their preterm infants can have a positive effect on their anxiety as well as potential benefits to their sensitivity and care abilities through OXT.

Effects of kangaroo care on pain relief in premature infants during painful procedures: A meta-analysis.

AIM: This study aimed to evaluate effects of kangaroo care on pain relief in premature infants during painful procedures. DESIGN: A meta-analysis. METHODS: Eight databases (Cochrane Library, PubMed, Embase, Web of Science, China Biology Medicine [CBM], China Science and Technology Journal Database [CSTJ], China National Knowledge Infrastructure [CNKI], and WanFang Data) were systematically reviewed from inception to November 2021 for randomized controlled and crossover trials. RESULTS: Thirteen studies, including 2311 infants (kangaroo care: 1153, control: 1158) were analyzed. Kangaroo care had a moderate effect on pain relief during painful procedures in premature infants at a gestational age of 32-36 + 6 weeks but no effect at 28-31 + 6 weeks. Furthermore, 15 or 30 min of kangaroo care had a moderate effect and could markedly relieve pain at the instant of and 30/60 s after, had a small effect at 90 s after, and no effect at 120 s after the procedure. PRACTICE IMPLICATIONS: Kangaroo care may be an effective nonpharmacologic alternative therapy to relieve procedural pain in premature infants born at a gestational age of 32-36 + 6 weeks.

The practice of procedural pain assessment and management in neonatal intensive care unit in Ethiopia: Cross-sectional study.

BACKGROUND AND AIMS: Neonates in intensive care units undergo frequent painful procedures for diagnostic or care-related purposes. Untreated pain has serious short-term and long-term complications. This study aims to evaluate the frequency of painful procedures, pain assessment, and their analgesic management practice among neonates admitted to the NICU. METHODS: The present study is a hospital-based cross-sectional study of neonates admitted at level II NICU of St. Paul hospital millennium medical college in Ethiopia between March and August 2019. Data were collected from medical charts of neonates and bedside observation using a checklist. The parameters included were demographic characteristics, types of painful procedures, pain assessment practice, and analgesic intervention provided during painful procedures. Descriptive statistics, Mann-Whitney U-test, and Kruskal-Wallis test were used to compare the number of painful procedures and influencing factors. P-value < .05 was considered statistically significant. RESULTS: Of the 325 neonates included in this study, a median of 4 (3-7) painful procedures were performed per neonate in the first 24 hours of NICU stay. Heel lance 280 (20.7%) and Venipuncture 249 (18.41%) were the most commonly performed painful procedures. Of the 1352 painful procedures, none of the neonates received any form of analgesic intervention and none of the neonate's pain scores were documented on their medical chart. The higher number of painful procedures were associated with gestational age between 28 and 31 weeks, birth weight less than 1500 g, and use of CPAP respiratory support P-value <.001, <.001, and .0015, respectively. CONCLUSION: Painful procedures were frequently performed in NICU without any form of analgesic intervention. Strategies to introduce neonatal pain assessment and their analgesic management for clinical practice are necessary.

Parental Preference for Treatment Location and Inclusion in Decision Making in Painful Pediatric Procedures: Towards an Evidence-Based Clinical Guideline.

PURPOSE: To determine parental preference for treatment location of painful procedures for pediatric patients, and the involvement of parents in decision-making about procedure location. DESIGN AND METHOD: A descriptive survey design was applied. Parents of hospitalized children were asked what procedures their child had undergone, where the procedures were performed, who decided on the location, what their preference was, and why. Data was collected over a twelve-day period in seven wards of a tertiary pediatric hospital. RESULTS: Of 312 different procedures, 244 (78%) were performed in the patient's room. The treatment room was reserved for complex procedures such as lumbar punctures. Seventy-three percent of parents surveyed indicated a strong preference for procedures to be performed in the patient's room, with the most common reason being 'comfortability'. Parents were only involved in procedure location decision-making in 50% of the reported cases. CONCLUSIONS: For parents, the patient's room is the preferred location for many procedures. The opinion of parents was not always taken into consideration by health care professionals, in contrary to the principles of patient-centered care. These findings are important for health care professionals in pediatric settings to reconsider the location of procedures and how parents are involved in decision making.

Stress and Perception of Procedural Pain Management in Chinese Parents of Children With Cancer.

OBJECTIVES: Children with cancer are exposed to repeated painful and invasive procedures. This study examines Chinese parents' stress and perception toward their children's procedural pain control. METHODS: We recruited 265 parents of children (aged <18 years) diagnosed with hematological cancer (74.7%) and solid tumors (25.3%) from two major public hospitals. Parents used a scale (0-10) to rate perceived pain experienced by their child when undergoing lumbar puncture (LP), bone marrow aspirate, or/and biopsy. They reported their stress level and attitudes toward analgesics using the adapted Pain Flexibility Scale for Parents and Parental Medication Attitude Questionnaire. General linear modeling was used to identify factors associated with perception outcomes. RESULTS: Parents (72.8% mothers, age 36.5 [6.8] years) expressed that they were worried (31.7%) and had difficulty with concentration (57.7%) when the child was in pain. Among parents whose children had undergone LP (n = 207), 39.1% perceived that their child still experienced severe pain (pain score >7) even with existing pain control measures. Parents reported concerns over side effects of analgesics (69.4%) and addiction (35.1%). Half of the parents (47.2%) perceived that analgesics should only be reserved for severe pain. Parents who were older (estimate = 2.07, SE = 0.87; P = 0.0054) and had lower education attainment (estimate = -3.38, SE = 1.09; P = 0.0021) had a more negative attitude toward analgesics use. Higher parental distress was associated with avoidance of analgesics use (rs = 0.17, P = 0.0052). CONCLUSION: Our findings suggested that subgroups of Chinese parents demonstrated distress with their child's pain and harbored misconceptions over analgesics use. Future work includes devising targeted psychoeducation interventions for these parents.

Pain control in neonatal male circumcision: A best evidence review.

OBJECTIVE: Routine male infant circumcision (RMIC) is a common procedure that inadvertently causes significant but preventable pain. In this best evidence review, we examine the available pain management options and their effectiveness for RMIC. MATERIAL AND METHODS: The Medline (OVID) and Cochrane library were searched for randomized controlled trials investigating pain control for RMIC. Only trials that included newborns younger than 45 days of age were included. The articles generated in the initial search were screened independently by two of the authors. A third reviewer settled any discrepancies about the inclusion. Then, trials were categorized based on the type of intervention: topical anesthetics, oral sucrose, oral acetaminophen, nerve blocks, caudal blocks, circumcision device, non-pharmacological adjuncts, and multiple combinations. RESULTS: Twenty-nine randomized clinical trials (RCTs) were found to address pain preventative measures in RMIC. As single agent, nerve blocks outperformed topical anesthetics and oral sucrose, as the latter two proved to be insufficient for proper pain control. Additionally, dorsal penile nerve block and ring blocks have a reasonable safety profile. The use of caudal blocks in RMIC was uncommon. Oral sucrose in association with swaddling or music are helpful and can be easily combined with other methods of pain management. Moreover, oral acetaminophen given perioperatively helps the patient recover. Ultimately, pain control should rely on a combination of anesthetics, analgesics, and kinesthetic methods to be administered before, during, and after the procedure for optimal outcome. CONCLUSION: RMIC is a painful procedure in need of proper pain control. Different interventions and agents have various abilities in controlling pain; however, developing a protocol centered around multimodal pain control proves to be the most effective.

Cuidados não traumáticos em contexto pediátrico: a intervenção de enfermagem na gestão dos medos associados aos procedimentos dolorosos / Non-traumatic care in a pediatric context: nursing intervention in the management of fears associated with painful procedures

Ao longo do processo de crescimento e desenvolvimento, a criança e família, contactam com os cuidados de saúde, vivenciando processos emocionalmente intensos. Estas experiências representam, muitas vezes, momentos de sofrimento emocional e, por esse motivo, o ato de cuidar em enfermagem não pode ser indiferente às emoções das crianças e famílias sendo o enfermeiro um gestor emocional (Watson, 2002; Diogo, 2015, 2019). No que diz respeito à experiência emocional das crianças, relacionada com a realização de procedimentos dolorosos, sabemos que a emoção "medo" está presente em todas as faixas etárias sendo transversal a todos os contextos da prestação de cuidados. A evidência científica demonstra que caso o medo não seja superado ou transformado positivamente (resignificar a experiência emocional) poderá ter consequências futuras, podendo, em casos mais graves, evoluir para uma psicopatologia (Diogo et al., 2016). Assim, no sentido de responder à problemática identificada, foi definido como objeto de estudo a intervenção de enfermagem na gestão dos medos da criança relacionados com a realização de procedimentos dolorosos. Este relatório tem como objetivo refletir sobre a experiência formativa que visou o desenvolvimento de competências de enfermeira especialista em enfermagem de saúde infantil e pediátrica, tendo como pilar a temática da gestão dos medos da criança relacionados com a realização de procedimentos dolorosos. Este percurso teve por base uma metodologia reflexiva que foi essencial para a transformação do conhecimento alicerçado em conceções teorias norteadoras, como a Teoria do Cuidar Humano de Jean Watson e o Modelo do Trabalho emocional em Enfermagem Pediátrica de Paula Diogo. As intervenções autónomas de enfermagem na gestão dos medos da criança, relacionados com a realização de procedimentos dolorosos, são essenciais para a prestação de cuidados não traumáticos, permitindo a prestação de cuidados centrados na família e emocionalmente sensíveis.

Throughout the process of growth and development, the child and family are in contact with health care, experiencing emotionally intense processes. These experiences often represent moments of emotional suffering and, for this reason the act of caring in nursing can not be indifferent to the emotions of children and families, with nurses being an emotional manager (Watson, 2002; Diogo, 2015, 2019). Regarding the children's emotional experience, related to the performance of painful procedures, we know that the emotion "fear" is present in all age groups and is transversal to all contexts of care. Scientific evidence shows that if fear is not overcome or transformed positively (reframing the emotional experience), it may have future consequences and may, in more severe cases, evolve into psychopathology (Diogo et al., 2016). Thus, in order to respond to the identified problem, nursing intervention in the management of children's fears related to the performance of painful procedures was defined as the object of study. This report aims to reflect on the training experience that aimed at developing the skills of a specialist nurse in child and pediatric health nursing, having as a pillar the theme of the management of children's fears related to the performance of painful procedures. This path was based on a reflective methodology that was essential for the transformation of knowledge based on guiding theories and conceptions, such as Jean Watson's Theory of Human Caring and Paula Diogo's Model of Emotional Work in Pediatric Nursing. Autonomous nursing interventions in the management of children's fears, related to the performance of painful procedures, are essential for the provision of non-traumatic care, allowing the provision of family-centered and emotionally sensitive care.

"WE do it together!" An Ethnographic Study of the Alliance Between Child and Hospital Clown During Venipunctures.

PURPOSE: Hospital clowns are widely used as a means of non-pharmacological intervention in the treatment of hospitalized children. However, little research has examined the impact of clowns on common painful needle-related procedures. This study explored children's pain experience and their ability to cope during a venipuncture while interacting with a clown in the acute admission unit. DESIGN AND METHODS: An ethnographic fieldwork study was conducted. Data were collected over a 10-month period through participant observation and informal interviews, supplemented by video recordings. The participants comprised 38 acutely admitted children aged 4 to 15 years undergoing a venipuncture in the presence of a hospital clown. Analysis was structured in three stages: before venipuncture; during venipuncture; and after venipuncture. RESULTS: The development of a responsive interaction between child and clown, identified as a WE, was found to be beneficial to the child during venipuncture procedure. The WE was characterized by three themes "How do WE do this together?"; "WE are together"; and "I/WE did it!" CONCLUSIONS: The study emphasizes the importance of a WE established between child and hospital clown from the first encounter until a final evaluation. This WE was verbalized repeatedly by the clown and the child and was essential in shaping a tailored approach which met the needs of each child. This approach seemed to strengthen the child's competence in pain management and ability to cope, thus building competence for future venipunctures. PRACTICE IMPLICATIONS: Establishing a WE might advance the psychosocial care of hospitalized children undergoing acute painful procedures.

Exploring distraction and the impact of a child life specialist: Perceptions from nurses in a pediatric setting.

PURPOSE: The purpose of this study is to explore perceptions held by nurses on the use of distraction and the role of a child life specialist in caring for children undergoing painful procedures. DESIGN AND METHODS: A qualitative focus-group design was conducted with 18 nurses from a 24-bed pediatric unit in New South Wales, Australia; this represented 51% of the staff from the unit. Three focus groups were conducted and transcribed verbatim followed by thematic analysis. RESULTS: Findings revealed five main themes that reflected the perceptions of the nurses' use of distraction and the impact of the child life specialist. The theme "Distraction as part of everyday nursing practice" was viewed by nurses as an integral component of nursing practice. The theme "Influence of child life specialist" revealed that the child life specialist created a feeling of ease during procedures. Differences were acknowledged between the two roles, "Contrast of roles" the child life specialist was seen as positive for children and families, whereas nurses viewed themselves as mean and unkind due to the nature of their work. The theme "The value of collaboration for positive healthcare experiences" acknowledged distraction as a contributing factor in ensuring the child and their family had a positive healthcare experience. The types of "nurses perception of the child's experience with distraction" shared in each of the focus groups identified nurses felt their techniques for distraction were much more simplified than the child life specialist; nurses felt disadvantaged at times in not having access to the same tools. PRACTICE IMPLICATIONS: The findings indicate the positive impact that a child life specialist has on a nurse's role while caring for children undergoing painful procedures. Nurses felt they were able to focus on the procedure, therefore ensuring the physician received the right amount of assistance. This reassured the nurses in knowing the child and their families emotional needs were being taken care of. The child life specialist was viewed as being able to provide a positive healthcare experience for the child and families, nurses felt this added to the value of care provided in the pediatric unit. Recommendations include further exploration of the child life specialist role in the pediatric inpatient setting.

General anesthesia, conscious sedation, or nothing: Decision-making by children during painful procedures.

BACKGROUND: Following diagnosis, children with cancer suddenly find themselves in an unknown world where unfamiliar adults make all the important decisions. Children typically experience increasing levels of anxiety with repeated invasive procedures and do not adapt to the discomfort. The aim of the present study is to explore the possibility of asking children directly about their medical support preferences during invasive procedures. PROCEDURE: Each patient was offered a choice of medical support on the day of the procedure, specifically general anesthesia (GA), conscious sedation (CS), or nothing. An ad hoc assessment tool was prepared in order to measure child discomfort before, during, and after each procedure, and caregiver adequacy was measured. Both instruments were completed at each procedure by the attending psychologist. RESULTS: We monitored 247 consecutive invasive procedures in 85 children and found that children in the 4 to 7 year age group showed significantly higher distress levels. GA was chosen 66 times (26.7%), CS was chosen 97 times (39.3%), and nothing was chosen 5 times and exclusively by adolescents. The child did not choose in 79 procedures (32%). The selection of medical support differed between age groups and distress level was reduced at succeeding procedures. CONCLUSIONS: Offering children the choice of medical support during invasive procedures allows for tailored support based on individual needs and is an effective modality to return active control to young patients, limiting the emotional trauma of cancer and treatment.

Allostatic Load and Biomarkers of Stress in the Preterm Infant: An Integrative Review.

BACKGROUND: Every year, an estimated 15 million babies are born preterm (<37 weeks' gestational age) globally. These preterm infants are exposed to repeated stressful and often painful procedures as part of routine life-saving care within the neonatal intensive care unit (NICU). Low thresholds for tactile and nociceptive input make it more difficult for neonates to discriminate between noxious and nonnoxious stimuli, which can result in continuous activation of stress responses in an attempt to achieve stability through adaptation, or allostasis. Rapidly reoccurring stressors can render stress-response systems over- or underactive, creating wear and tear, or allostatic load. A better understanding of biomarkers related to allostatic load might aid in early detection and prevention/alleviation of allostatic load in this population. PURPOSE: To identify stress biomarkers that have been studied in preterm infants at different time points in the NICU and as long-term outcome measures. METHOD/SEARCH STRATEGY: Systematic searches were conducted of PubMed, CINAHL, SCOPUS, and PsychInfo databases. FINDINGS/RESULTS: Twenty-one studies met inclusion criteria for this review. Several putative biomarkers were identified, including cortisol levels, epigenetic markers, brain microstructure, markers of oxidative stress, and the brain-gut-microbiome axis. CONCLUSION: The interaction of disease with therapeutic interventions may inadvertently increase infant allostatic load. In addition to human studies, future research should leverage newly available large data sets to conduct additional analyses.

"Keeping pace according to the child" during procedures in the paediatric intensive care unit: A grounded theory study.

OBJECTIVE: The goal was to explore how nurses interact with children in the paediatric intensive care unit during potentially painful procedures. RESEARCH METHODOLOGY/DESIGN: This was a qualitative research study that used grounded theory approach. Data were collected through participant observation and interviews. Nurse-child interactions were observed and recorded during potentially painful procedures performed by nurses. Following observation of a procedure, nurses were interviewed about their intentions, feelings and emotions during the procedure. SETTING: The study took place in a seven-bed paediatric intensive care unit in an academic teaching hospital in Japan. FINDINGS: Children's acceptance of a procedure was induced by nurses' pacing, particularly in a pattern of "keeping pace according to the child." Such pacing involved soothing the child, explaining what was being done to the child at each step and acknowledging the child's emotions. All of these child-centred procedures provoked cooperation from the children even during painful procedures. CONCLUSIONS: Our study suggests that a collaborative practice approach, in which nurses use a series of calming tactics, might improve children's perceptions of painful procedures.

Preterm newborn pain research review.

This narrative review is based on a literature search of PubMed and PsycINFO for research on preterm newborn pain published during the last ten years. The high prevalence of painful procedures being performed with preterm newborns without analgesia (79%), with a median of 75 painful procedures being received during hospitalization and as many as 51 painful procedures per day highlights the importance of this problem. This review covers the pain assessments that have been developed, the short-term effects of the painful procedures, the longer-term developmental outcomes and the pharmacological and alternative therapies that have been researched. The most immediate effects reported for repeated painful procedures include increased heart rate, oxidative stress and cortisol as well as decreased vagal activity. Lower body weight and head circumference have been noted at 32 weeks gestation. Blunted cortisol reactivity to stressors has been reported for three-month-olds and thinner gray matter in 21 of 66 cerebral regions and motor and cognitive developmental delays have been noted as early as eight months. Longer-term outcomes have been reported at school age including less cortical thickness, lower vagal activity, delayed visual- perceptual development, lower IQs and internalizing behavior. Pharmacological interventions and their side effects and non-pharmacological therapies are also reviewed including sucrose, milk and nonnutritive sucking which have been effective but thought to negatively affect breast-feeding. Full-body interventions have included tucking, swaddling, kangaroo care and massage therapy. Although these have been effective for alleviating immediate pain during invasive procedures, research is lacking on the routine use of these therapies for reducing long-term pain effects. Further, additional randomized controlled replication studies are needed.

Neonatal pain and reduced maternal care: Early-life stressors interacting to impact brain and behavioral development.

Advances in neonatal intensive care units (NICUs) have drastically increased the survival chances of preterm infants. However, preterm infants are still exposed to a wide range of stressors during their stay in the NICU, which include painful procedures and reduced maternal contact. The activation of the hypothalamic-pituitary-adrenal (HPA) axis, in response to these stressors during this critical period of brain development, has been associated with many acute and long-term adverse biobehavioral outcomes. Recent research has shown that Kangaroo care, a non-pharmacological analgesic based on increased skin-to-skin contact between the neonate and the mother, negates the adverse outcomes associated with neonatal pain and reduced maternal care, however the biological mechanism remains widely unknown. This review summarizes findings from both human and rodent literature investigating neonatal pain and reduced maternal care independently, primarily focusing on the role of the HPA axis and biobehavioral outcomes. The physiological and positive outcomes of Kangaroo care will also be discussed in terms of how dampening of the HPA axis response to neonatal pain and increased maternal care may account for positive outcomes associated with Kangaroo care.

The Experiences of Professionals Regarding Involvement of Parents in Neonatal Pain Management.

OBJECTIVE: To explore the experiences of health care professionals related to parent involvement during painful procedures carried out on their infants and to describe contextual facilitators and barriers that influence parent involvement during evidence-based, nonpharmacologic pain relief. DESIGN: Qualitative study with focus group interviews. SETTING: Two Level III NICUs and one Level II NICU in the German-speaking part of Switzerland. PARTICIPANTS: Convenience sample of 17 NICU nurses and six neonatologists. METHODS: Three interprofessional focus group interviews were conducted. Data were analyzed by thematic analysis. RESULTS: Contextual factors among professionals, such as know-how and communication skills regarding neonatal pain management; reflective and collaborative practice; and an attitude of partnership with parents and organizational resources, such as time and staffing, promoted a working atmosphere in which it was possible to talk about neonatal pain with parents. Within this context, parents could be successfully involved in their infant's pain management. In contrast, lack of the aforementioned contextual factors, including an attitude of paternalism toward parents, resulted in a working atmosphere in which professionals "kept silent about pain" and hindered parent involvement during painful procedures. CONCLUSION: The work culture and organizational features of a NICU facilitate or hinder parent involvement in neonatal pain management. Facilitators and barriers should be identified from the individual, team, and system perspectives. Facilitation of parent-centered pain management in infants should be promoted by the organization.