Background
Physiological changes brought about by pain may contribute to the development of morbidity in neonates. Clinical studies have shown reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in situations where the neonate is experiencing pain or stress. Non-pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for this purpose.

Objectives
The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

Search methods
We performed a literature search using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 10), MEDLINE (1966 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), abstracts from the annual meetings of the Society for Pediatric Research (1994 to 2011), and major paediatric pain conference proceedings. We did not apply any language restrictions.

Selection criteria
Randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates were eligible for inclusion in this review. The study must have reported on either physiologic markers of pain or validated pain scores.

Data collection and analysis
We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a risk ratio (RR), risk difference (RD) and weighted mean difference (MD) as appropriate.

Main results
Of twenty eligible studies, ten evaluated breastfeeding and ten evaluated supplemental breast milk. Sixteen studies analysed used heel lance and four used venepuncture as procedure. We noted marked heterogeneity in control intervention and pain assessment measures among the studies. Neonates in the breastfeeding group had statistically a significantly lower increase in heart rate, reduced proportion of crying time and reduced duration of first cry and total crying time compared to positioning (swaddled and placed in a crib), holding by mother, placebo, pacifier use, no intervention or oral sucrose group, or both.

Premature Infant Pain Profile (PIPP) scores were significantly lower in the breastfeeding group compared to positioning, placebo or oral sucrose group, or both. However, there was no statistically significant difference in PIPP scores when compared to no intervention. Douleur Aigue Nouveau-ne scores (DAN) were significantly lower in the breastfeeding group compared to the placebo group and the group held in mother's arms, but not when compared to the glucose group. Neonatal Infant Pain Scale (NIPS) was significantly lower in the breastfeeding group compared to the no intervention group, but there was no difference when compared to the oral sucrose group. The Neonatal Facial Coding System (NFCS) was significantly lower in the breastfeeding group when compared to oral glucose, pacifier use, holding by mother and no intervention, but no difference was found when compared to formula feeding.

Supplemental breast milk yielded variable results. Neonates in the supplemental breast milk group had a significantly lower increase in heart rate, a reduction in duration of crying and a lower NFCS compared to the placebo group. Neonates in the supplemental breast milk group had a significantly higher increase in heart rate changes when compared to the sucrose group. Sucrose (in any concentration, i.e. 12.5%, 20%, 25%) was found to reduce the duration of cry when compared to breast milk, as did glycine, pacifier use, rocking, or no intervention. Breast milk was found not to be effective in reducing validated and non-validated pain scores such as NIPS, NFCS, and DAN; only being significantly better when compared to placebo (water) or massage. We did not identify any study that has evaluated safety/effectiveness of repeated administration of breastfeeding or supplemental breast milk for pain relief.

Authors' conclusions
If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure rather than placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for painful procedure should be studied in the preterm population, as there are currently a limited number of studies in the literature that have assessed it's effectiveness in this population.

Breastfeeding or breast milk for procedural pain in neonates

BACKGROUND
Physiological changes brought about by pain may contribute to the development of morbidity in neonates. Clinical studies have shown reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in situations where the neonate is experiencing pain or stress. Non-pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for this purpose.


OBJECTIVES
The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.


SEARCH METHODS
We performed a literature search using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 10), MEDLINE (1966 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), abstracts from the annual meetings of the Society for Pediatric Research (1994 to 2011), and major paediatric pain conference proceedings. We did not apply any language restrictions.


SELECTION CRITERIA
Randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates were eligible for inclusion in this review. The study must have reported on either physiologic markers of pain or validated pain scores.


DATA COLLECTION AND ANALYSIS
We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a risk ratio (RR), risk difference (RD) and weighted mean difference (MD) as appropriate.


MAIN RESULTS
Of twenty eligible studies, ten evaluated breastfeeding and ten evaluated supplemental breast milk. Sixteen studies analysed used heel lance and four used venepuncture as procedure. We noted marked heterogeneity in control intervention and pain assessment measures among the studies. Neonates in the breastfeeding group had statistically a significantly lower increase in heart rate, reduced proportion of crying time and reduced duration of first cry and total crying time compared to positioning (swaddled and placed in a crib), holding by mother, placebo, pacifier use, no intervention or oral sucrose group, or both.Premature Infant Pain Profile (PIPP) scores were significantly lower in the breastfeeding group compared to positioning, placebo or oral sucrose group, or both. However, there was no statistically significant difference in PIPP scores when compared to no intervention. Douleur Aigue Nouveau-ne scores (DAN) were significantly lower in the breastfeeding group compared to the placebo group and the group held in mother's arms, but not when compared to the glucose group. Neonatal Infant Pain Scale (NIPS) was significantly lower in the breastfeeding group compared to the no intervention group, but there was no difference when compared to the oral sucrose group. The Neonatal Facial Coding System (NFCS) was significantly lower in the breastfeeding group when compared to oral glucose, pacifier use, holding by mother and no intervention, but no difference was found when compared to formula feeding.Supplemental breast milk yielded variable results. Neonates in the supplemental breast milk group had a significantly lower increase in heart rate, a reduction in duration of crying and a lower NFCS compared to the placebo group. Neonates in the supplemental breast milk group had a significantly higher increase in heart rate changes when compared to the sucrose group. Sucrose (in any concentration, i.e. 12.5%, 20%, 25%) was found to reduce the duration of cry when compared to breast milk, as did glycine, pacifier use, rocking, or no intervention. Breast milk was found not to be effective in reducing validated and non-validated pain scores such as NIPS, NFCS, and DAN; only being significantly better when compared to placebo (water) or massage. We did not identify any study that has evaluated safety/effectiveness of repeated administration of breastfeeding or supplemental breast milk for pain relief.


AUTHORS' CONCLUSIONS
If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure rather than placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for painful procedure should be studied in the preterm population, as there are currently a limited number of studies in the literature that have assessed it's effectiveness in this population.

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Breastfeeding or breast milk for procedural pain in neonates (Review)

To determine the effect of Kangaroo Mother Care (KMC) of small duration of 15 min in decreasing pain in preterm neonates between 32–36 wk 6 d on heel prick by a 26 gauge needle. Randomized controlled double masked crossover trial involving 50 neonates, between 32 wk and 36 wk 6 d gestation and weighing less than 2500 g, within 10 d of birth, vitally stable, breathing without assistance or on Continuous positive airway pressure (CPAP), without any clinically evident neurological signs, not having received analgesics/sedatives within last 24 h and not fed within last 30 min and requiring heel pricking were eligible. Outcome measured was the Premature Infant Pain Profile (PIPP). Analysis was done using independent sample t test, with Bonferroni correction applied for comparing individual components of PIPP score. The heart rate, behaviour and facial scores were statistically significant and lower in KMC group. But there was no statistically significant difference in oxygen saturation (SpO2). The difference(4.85) in PIPP score was clinically and statistically significant (p < 0.0001). The findings suggest that short duration KMC (15 min) has stress reducing benefits. Preterm neonates above 32 wk gestational age can benefit from KMC to decrease pain from heel prick procedure.

Kangaroo Mother Care in Reducing Pain in Preterm Neonates on Heel Prick

Effects of white noise and holding on pain perception in newborns.

No activity can give you the joy that service does… . You should yearn for the chance to console, comfort, encourage, heal. See yourself as another, feel his joy to be yours, his sorrow to be yours.—Sri Sathya Sai Baba1

The drive for objective assessments and measurements in recent years has overshadowed some of the subjective aspects of medical care. Whereas evidence-based medicine informs “what” we can do for our patients, “how” we are providing this care may be equally important. This includes not only the actual details of care delivery but also the attitude, feelings, and emotional state of professional caregivers at the time of patient interactions. Interventions performed without empathy, mechanically, or while distracted by other concerns may be less effective than those imbued with love and care for the patient's well-being.2 Although we explore in this commentary the evidence for this principle related to neonates receiving care in an NICU, the same principle can be applied to other clinical populations and practice settings, especially intensive care.

During training, practitioners are encouraged to maintain objectivity and suppress their emotive reactions or emotional involvement in all clinical situations. Lack of objectivity is often cited as a reason for not treating close relatives, when emotional involvement is expected to occur. This habitual suppression of emotive behavior becomes second nature during the long years of clinical practice and is often seen as a component … 

Address correspondence to K.J.S. Anand, MBBS, DPhil, Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202. E-mail: anandsunny{at}uams.edu

Love, Pain, and Intensive Care : 早産児への共感と愛情がもたらすもの

Background: Evidence suggests that infants feel pain, and painful experiences may lead to subsequent increased pain sensitivity. Owing to concerns regarding the potential adverse effects of pharmacological interventions in newborns, effective alternatives for pain control are being sought. Aim: The Neonatal Infant Pain Scale (NIPS) was used to determine the analgesic effect of breastfeeding during venepuncture. Methods: The study was of cross-over design where each neonate served as his/her own control. Median pain scores during venepuncture when neonates were being breastfed (BF) were compared with those when neonates were not being breastfed (NBF). The site of venepuncture and number of previous venepunctures were noted. Pain was assessed using NIPS. Results: In all, 38 term neonates (25 male, 13 female) were recruited. Mean (SD) age and weight were 8.42 (8.74) days and 2.89 (0.67) kg, respectively. The median pain score (interquartile range) of the neonates when breastfed was 1.50 (1–2), and 4...

O. T. Adeoye

Papers

Effect of breastfeeding during venepuncture in neonates.