Background
Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.  This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'.

Objectives
To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). 

Search methods
For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added.

Selection criteria
Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update.

Data collection and analysis
Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method.

Main results
Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence.

Authors' conclusions
There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.

Non‐pharmacological management of infant and young child procedural pain

Vaccine injections are the most frequent painful medical procedure performed worldwide. Numerous interventions have been evaluated to combat the pain from vaccine injections.1 These interventions can be broadly divided into pharmacological, psychological, procedural, and physical approaches. But for the costs of training clinicians, the majority of procedural and physical interventions offer the advantage of being time and resource cost neutral when compared with other approaches, and hence can be applied across clinical settings.

In a previous knowledge synthesis on this topic, we found support for several different procedural and physical interventions.2 These interventions were subsequently incorporated in a clinical practice guideline about childhood vaccination pain management.1 Since the original guideline was developed, additional research has been undertaken that has the potential to impact previous conclusions. In addition, the original guideline excluded research in adults, leaving a gap in best practices for this population. The current systematic review was therefore undertaken to update and expand the knowledge synthesis on this topic.3

This manuscript reports the results for the effects of the following procedural and physical interventions: (1) aspiration during intramuscular (IM) vaccine injection, (2) order of injection for sequential vaccine injections, (3) simultaneous versus sequential injection of multiple vaccines, (4) positioning of the individual undergoing vaccination, (5) anatomic location for the vaccine injection, (6) non-nutritive sucking during vaccination, (7) tactile stimulation (manual and vibration) during vaccination, (8) warming the vaccine, and (9) muscle tension (for individuals with a history of fainting). Breastfeeding, which combines physical (positioning and non-nutritive sucking) and pharmacological (sweet-tasting substances) elements, is included in a separate manuscript in this series.4 Similarly, we also separately report on the effects of combined interventions that include physical interventions (eg, non-nutritive sucking and sweet-tasting substances together) and the effectiveness of muscle tension in individuals with high levels of needle fear and a history of fainting.4,5

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Procedural and Physical Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

Background

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.



Objectives

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation).



Search methods

We searched CENTRAL in The Cochrane Library (2011, Issue 1), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), PsycINFO (1967 to April 2011), Cumulative Index to Nursing and Allied Health Literature (1982 to 2011), Dissertation Abstracts International (1980 to 2011) and www.clinicaltrials.gov. We also searched reference lists and contacted researchers via electronic list-serves.



Selection criteria

Participants included infants from birth to three years. Only randomized controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results.



Data collection and analysis

We refined search strategies with three Cochrane-affiliated librarians. At least two review authors extracted and rated 51 articles. Study quality ratings were based on a scale by Yates and colleagues. We analyzed the standardized mean difference (SMD) using the generic inverse variance method. We also provided qualitative descriptions of 20 relevant but excluded studies.



Main results

Fifty-one studies, with 3396 participants, were analyzed. The most commonly studied acute procedures were heel-sticks (29 studies) and needles (n = 10 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (preterm: SMD -0.42; 95% CI -0.68 to -0.15; neonate: SMD -1.45, 95% CI -2.34 to -0.57), kangaroo care (preterm: SMD -1.12, 95% CI -2.04 to -0.21), and swaddling/facilitated tucking (preterm: SMD -0.97; 95% CI -1.63 to -0.31). For immediate pain-related regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.38; 95% CI -0.59 to -0.17; neonate: SMD -0.90, 95% CI -1.54 to -0.25), kangaroo care (SMD -0.77, 95% CI -1.50 to -0.03), swaddling/facilitated tucking (preterm: SMD -0.75; 95% CI -1.14 to -0.36), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30).The presence of significant heterogeneity limited our confidence in the lack of findings for certain analyses.



Authors' conclusions

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.



Plain Language Summary

Non-pharmacological interventions for acute pain in infants



We examined 13 different types of commonly investigated non-pharmacological treatments (excluding breastmilk, sucrose, and music) to determine their efficacy for pain reactions after an acutely painful procedure (right after the needle ('pain reactivity') and less immediate pain reactions ('immediate pain-related regulation').Fifty-one randomized controlled trials were included involving 3396 participants. For preterm infants, there was sufficient evidence to recommend kangaroo care, sucking-related interventions, and swaddling/facilitated tucking interventions for both pain reactivity and immediate pain-related regulation. For neonates, there was sufficient evidence to recommend sucking-related interventions as an effective treatment for pain reactivity and immediate pain-related regulation.Rocking/holding was also found to be efficacious for neonatal immediate pain-related regulation.For older infants, there were no treatments reviewed that demonstrated sufficient evidence. Due to significant differences in the magnitude of treatment effects among studies (heterogeneity), some analyses that found a lack of treatment effect need to be interpreted with caution.

Cochrane Review: Non-pharmacological management of infant and young child procedural pain

Introduction. This article aimed to investigate the effect of heat stress on cognitive performance and the blood concentration of stress hormones among workers of a foundry plant. Methods. Seventy workers within the exposed (35 people) and unexposed (35 people) groups were studied. The wet bulb globe temperature (WBGT) index was measured for heat stress assessment. The cognitive performance tests were conducted using the Stroop color word test (SCWT) before and during working hours. For the assessment of the serum level of cortisol and the plasma level of adrenaline and noradrenaline, blood samples were taken during working hours from both groups. Results. Only for SCWT III was there a significant relationship between heat stress and test duration, error rate and reaction time. The laboratory test results revealed significantly higher concentrations of cortisol, adrenaline and noradrenaline in the exposed subjects than in the unexposed group. There existed a positive correlation between cortisol, adrenali...

The influence of occupational heat exposure on cognitive performance and blood level of stress hormones: a field study report.

BACKGROUND & OBJECTIVE: Due to devastating effects of pain in neonates, it is very important to ease it though safe and feasible methods. This study was to determine the effect of familiar auditory stimuli on the arterial blood sampling (ABS) induced pain in term neonates . RESEARCH METHOD: This study was done on 30 newborns hospitalized in neonate intensive care unit (NICU) of a hospital in Tehran. Research samples were selected by using convenience sampling and randomly divided into two groups of control and test. In the test group, the recorded mothers' voices were played for the newborns before and after blood sampling procedure. Then, pain measures were recorded 10 minutes before, during and 10 minutes after blood collection based on Neonatal Infant Pain Scale (NIPS); then the pain level changes were reviewed and studied. FINDINGS: The findings showed significant differences between the control and test groups that indicating the effect of mother's voice on reducing the pain of neonates during the ABS (p<0.005). CONCLUSION: Research findings demonstrate that mother's voice reduces ABS induced pain in the term neonates .

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The Effect of Mother's Voice on Arterial Blood Sampling Induced Pain in Neonates Hospitalized in Neonate Intensive Care Unit.

This randomized controlled trial compared distress and pain in healthy 4-month-old infants receiving three different immunizations either sequentially (control, n=50) or simultaneously, two at the same time, followed by the third (experimental, n=51). Although both groups demonstrated a significant increase in cortisol from baseline levels, the lack of significant difference on salivary cortisol between groups post-immunization suggests the study was underpowered. On NIPS scores, the experimental group demonstrated significantly less pain (Mann-Whitney U=1648.0, p=0.003). Simultaneous injections appeared to be effective in reducing pain behavior responses in infants receiving their 4-month immunizations. Longitudinal studies could determine whether reduced exposure to pain in infancy, through simultaneous immunization injections, could contribute to a reduction in sensitivity to pain and physiologic stress responses.

Comparison of distress and pain in infants randomized to groups receiving standard versus multiple immunizations.

Objective To develop clinical leadership among front-line public health nurses (PHNs) Methods This paper describes a quality improvement process to develop clinical leadership among front-line PHNs Three activities were undertaken by a working group consisting mainly of front-line staff: engaging PHNs in an online change-readiness questionnaire, administering a survey to clients who had ever used public health services delivered by one Vancouver Community Infant, Child and Youth (ICY) program team and conducting three group interviews with public health providers The group interviews asked about PHN practice They were analyzed using thematic content analysis Results This quality improvement project suggests that PHNs (n=70) strongly believed in opportunities for system improvement Client surveys (n=429) and community partner surveys (n=79) revealed the importance of the PHN role Group interview data yielded three themes: PHNs were the "hub" of community care; PHNs lacked a common language to describe their work; PHNs envisioned their future practice encompassing their full scope of competencies PHNs developed the "ICY Public Health Nursing Model," which articulates 14 public health interventions and identifies the scope of their work Conclusion Developing and sustaining clinical leadership in front-line PHNs was accomplished through these various quality assurance activities

Leslie L. Mills

Papers

Comparison of distress and pain in infants randomized to groups receiving standard versus multiple immunizations.

Developing and Sustaining Leadership in Public Health Nursing: Findings from One British Columbia Health Authority