Pain response of neonates to venipuncture
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《美国医学杂志》
Department of Pediatrics, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
Abstract
Objective: To study the physiological and behavioral response to pain. Methods: 80 healthy neonates requiring bilirubin estimation, blood sugar etc, were randomly assigned to receive a venous puncture. All parameters were recorded 10 minutes prior, during and 10 minutes after the procedure. Evaluated NIPS score and RR. HR, NIBP and O2 saturation observed on Datex-Ohmeda multimonitor. Results: After the venepuncture, heart rate (p<0.001) and blood pressure (p<0.001) were significantly increased in both the groups but more significant increase was present in Group I(>2.5kg) as compared to Group II (>2.5kg). Respiratory rate was also increased but more significant in Group II(p<0.001) whereas Oxygen saturation was decreased in both the groups but more significant in Group I (p<0.001). Median Neonatal Infant Pain Scale (NIPS) score was higher in both the Groups (p<0.001). Conclusion: The outcome measures appear to be reliable indices of term neonates responses to painful stimulation. NIPS are suitable instruments for neonatal pain evaluation.
Keywords: Newborn; Pain; Pain assessment
The subjectivity of pain causes enormous difficulties in evaluating neonatal pain with a single, practical and easy to apply tool. [1] The evaluation of pain in the human fetus and neonate is difficult because pain is generally defined as a subjective phenomenon.[2] Pain evaluation in the neonatal period should be performed by valid, safe, useful and feasible methods.[1] Previously, it was thought that neonates do not feel pain because of inadequate myelinization of the sensory nerves, immaturity of pain receptors and cortex and reduced localization of pain. [2]
Newborn babies experience pain similarly and probably more intensely than older children and adults. They are also at risk of adverse long term effects on behaviour and development. [3] Pain in the neonatal period is frequently experienced by 6-10% of newly born infants, who require neonatal intensive care. [4]
Behavior is the main source of information in nonverbal infants. [5] Female neonates of all gestational ages expressed more facial features of pain than male infants, during the capillary puncture.[6] NIPS are suitable instruments for neonatal pain evaluation. [1] Physiological responses to painful or stressful stimuli include increase in circulating catecholamines, increased heart rate and blood pressure and elevated intracranial pressure. The stress response of the immature fetus or preterm infant is less competent than that of the more mature infant or child. Therefore, in immature infant the classical vital signs of stress ( eg. Tachycardia, hypertension, agitation) are not reliable indicators of painful stimuli. [7] The focus of this prospective study was to evaluate the use of physiologic and behavioral parameters as valid assessment tools for acute pain in healthy term newborn infants.
Materials and Methods
Eighty term infants less than 7 days of age who required blood sampling for bilirubin estimation, blood sugar and workup were assessed for their responses to venipuncture performed in a standard manner. Healthy neonates between 37 weeks to 42 weeks gestational age were eligible. Babies with significant morbidity like septicemia, birth asphyxia, major congenital malformations and neurological involvement were excluded. The selected cases were divided into 2 groups: Group I: < 2.5kg and Group II:>2.5kg. The resident doctor rated infant's pain using NIPS at baseline (before the procedure) and during the period when maximal response was observed. The NIPS includes five behavioral groupings (facial expression, crying, movement of arms and legs, and state of arousal) and one physiological indicator (breathing pattern). The total score ranges from 0 to 7. [7] Heart rate, respiratory rate, blood pressure and oxygen saturation were monitored continuously from 10 minutes before to 10 minutes after the procedure. Non-invasive blood pressure and oxygen saturation was measured by Datex-Ohmeda multimoniter. The maximal change in the above parameters were noted. The data was statistically analyzed by using EPI-6.
Result
In the study group, there were total 80 neonates out of which 47 were males and 33 were females. The mean postnatal age in group I was 3.7 ± 1.4 days and group II 3.6 ± 1.61 days respectively. The time of last feed was 36 minutes in group I and 34.5 minutes in group II. The mean birth weight was 2.240 kg in group I and 2.852 kg group II.
The mean heart rate table1 increased during the procedure in both the groups and showed a significant differences (p < 0.001) when compared to that recorded prior to venepuncture. The non-invasive systolic blood pressure table4 also increased during the procedure in both the groups and showed a significant differences (p < 0.001) when compared to that recorded prior to venepuncture. There was significant increase in the respiratory rate table2 during the procedure in both the groups as compared to the baseline (p< 0.001). A significant decrease in oxygen saturation during the procedure (p <0.001) found in both group as compared to the baseline table3.
The mean Neonatal Infant Pain Scale (NIPS) table5 score during venipuncture was higher in both the groups as compared to baseline values (p<0.001) but more significantly increased in group II as compared to group I.
Discussion
Every year, millions of neonates require diagnostic blood sampling. Neonates undergoing these procedures cry and exhibit facial expression and body movements which are indicative of pain. Until recently, it was believed that infants and young children could not appreciate pain due to the immaturity of the central nervous system. However, now it is a well established fact that the anatomical, physiological and neurochemical structures which convey pain are well developed in neonates.[8]
Physiological changes in response to painful stimuli had been uniformly reported by previous studies.[8] The present study clearly indicates that all neonates responded to painful stimuli in one or the other way. A significant increases in heart rate was reported by Owen ME in the context of a tissue damaging stimulus.[10] The magnitude of changes in the heart rate was related to the intensity and duration of the stimulus and to the individual temperaments of the babies. [2] The study done by KJS Anand found that heart rate increased after circumcision or heel lancing in term neonates. [2]
McIntosh N et al[6], Van Cleve L et al[10], Harmesh Singh et al[11] and Gessler P et al[12] also reported that heart rate was significantly increased after venepuncture. These changes are comparable to that observed in the present study. Heart rate was significantly increased in both groups but more in group I (p<0.001).
Brown L[13] and Gessler P et al[12] showed that blood pressure increased after painful stimulation which was also recorded in these studies (p<0.001).
The statistically significant (p<0.001) rise in respiratory rate was recorded in the present study during the procedure which was also reported by Brown L,[13] McIntosh N et al[6], Harmesh Singh et al[11] and Gessler P et al.[12]
A significant decrease in oxygen saturation in response to painful stimuli was reported by KJS Anand[2], Van Cleve L et al[10], Harmesh Singh et al[11] and Gessler P et al.[12] Similar finding were recorded in the present study (p<0.001). Potentially injurious hypoxia occur even during essential routine care procedure.[11]
Johnston CC et al showed that full-term newborn is better equipped to interact with his caretakers and expresses his distress through specific facial actions.[14] Crying is the primary method of communication in newborn infants and is also elicited by stimuli other than pain. The pain cry has specific behavioral characteristics and spectrographic properties in healthy full-term neonates.[2] Rushforth JA et al found that thirty 5 (97%) term infants showed an increase in the number of behaviours in response to heel lance. Brow bulge and nasolabial furrow were seen most often, and occurred more often than crying.[15] Van Cleve L et al found that infants moved abruptly into a hyperalert or crying state in response to venipuncture, skipping several states without transition and showing disorganized behavior.[10] The motor responses of healthy full-term neonates to a pinprick in the leg were reported to be flexion and adduction of the upper and lower limbs associated with grimacing, crying, or both, and these responses were subsequently quantified.[2] The mean Neonatal Infant Pain Scale(NIPS) score was significantly higher in both the groups.
Conclusion
This study helps to validate the Neonatal Infant Pain Scale(NIPS) as suitable instruments for neonatal pain evaluation. Moreover Heart rate, Blood pressure, Respiratory rate and O2 saturation were good indicators for evaluating the neonatal pain. As behavioral pain score response during venipuncture and changes in physiologic parameters were uniformly present in both groups, it can be concluded that the weight of the term baby does not influence the pain response in newborn babies.
Key messages
The full-term newborn is better equipped to interact with his caretakers and express his distress through specific facial actions; a combination of physiological and behavioural changes provides a better estimate of infant pain.
The message of distress sent by the neonates through the cry sensitizes the adult, either the child's mother or another adult, who is taking care of it.
References
1. Pereira AL, Guinsburg, de Almeida MF, Montriro AC, dos Santos AM, Kopelmen BI et al. Validity of behavioral and physiologic parameters for acute pain assessment of term newborn infants. Sao Paulo Med J 1999; Mar 4; 117(2): 72-80.
2. Anand KJS, Hickey PR. Pain and its effects in the human neonates and fetus. New Eng J Med 1988; 317: 1321-1329.
3. Mathew PJ, Mathew JL. Assessment and management of pain in infants. Postgraduate Medical Journal 2003; 79: 438-443.
4. Dollberg S, Stolik-Dollberg O. Prevention and pain management in term and preterm infants. Harefuah 2004 Jan; 143 (1): 54-59, 84.
5. Bozzette M. Observation of pain behavior in the NICU: an exploratory study. J Perinat Neonatal Nurs 1993 Jun;7(1):76-87.
6. McIntosh N, Van Veen L, Brameyer H. The pain of heel prick and its measurement in preterm infants. Pain 1993 Jan; 52(1): 71-74.
7. Linda J, Van marter, Pryor CC. Management of pain and stress in the NICU. In Cloharty JP, Eichenwald EC, Stark AR, eds. Manual of Neonatal Care. 5th edn. Philadelphia; Lippincott, Williams and Wilkins, 2004; 703-715.
8. Shah V, Ohlsson. A Venepuncture versus heel lance for blood sampling in term neonates. The Cochrane Library, Issue 2, 2005. http://www.nichd.nih.gov/Cochrane/shah/shah.HTM.
9. Owens ME, Todt EH. Pain in infancy: Neonatal reaction to heel lance. Pain 1984; 20: 74-77.
10. Van Cleve L, Johnson L, Andrews S, Hawkins S, Newbold J. Pain response of hospitalized neonates to venipuncture. Neonatal Network 1995; 14: 31-36.
11. Harmesh Singh, Daljit Singh, R.K. Soni. Comparison of pain response to venepuncture between term and preterm neonates. Indian Pediatr 2000; 179-181.
12. Gessler P, Cignacco E et al. Measures for the assessment of pain in neonates as well as a comparison between the Bernese Pain Scale for Neonates (BPSN) with the Premature Infant Pain Profile (PIPP). Klin Pediatr 2004 Jan-Feb; 216(1): 16-20.
13. Brown L. Phsiologic responses to cutaneous pain in neonates. Neonatal Network 1987; 5: 18-23.
14. Johnston CC, Stevens B, Craig KD, Grunau RV. Developmental changes in pain expression in premature, full-term, two- and four-month-old infants. Pain 1993 Feb; 52(2): 201-208.
15. Rushforth JA, Levene MI. Behavioral responses to pain in healthy neonates. Arch Dis Child 1994; 70: 174-176.(Taksande Amar M, Vilhekar)
Abstract
Objective: To study the physiological and behavioral response to pain. Methods: 80 healthy neonates requiring bilirubin estimation, blood sugar etc, were randomly assigned to receive a venous puncture. All parameters were recorded 10 minutes prior, during and 10 minutes after the procedure. Evaluated NIPS score and RR. HR, NIBP and O2 saturation observed on Datex-Ohmeda multimonitor. Results: After the venepuncture, heart rate (p<0.001) and blood pressure (p<0.001) were significantly increased in both the groups but more significant increase was present in Group I(>2.5kg) as compared to Group II (>2.5kg). Respiratory rate was also increased but more significant in Group II(p<0.001) whereas Oxygen saturation was decreased in both the groups but more significant in Group I (p<0.001). Median Neonatal Infant Pain Scale (NIPS) score was higher in both the Groups (p<0.001). Conclusion: The outcome measures appear to be reliable indices of term neonates responses to painful stimulation. NIPS are suitable instruments for neonatal pain evaluation.
Keywords: Newborn; Pain; Pain assessment
The subjectivity of pain causes enormous difficulties in evaluating neonatal pain with a single, practical and easy to apply tool. [1] The evaluation of pain in the human fetus and neonate is difficult because pain is generally defined as a subjective phenomenon.[2] Pain evaluation in the neonatal period should be performed by valid, safe, useful and feasible methods.[1] Previously, it was thought that neonates do not feel pain because of inadequate myelinization of the sensory nerves, immaturity of pain receptors and cortex and reduced localization of pain. [2]
Newborn babies experience pain similarly and probably more intensely than older children and adults. They are also at risk of adverse long term effects on behaviour and development. [3] Pain in the neonatal period is frequently experienced by 6-10% of newly born infants, who require neonatal intensive care. [4]
Behavior is the main source of information in nonverbal infants. [5] Female neonates of all gestational ages expressed more facial features of pain than male infants, during the capillary puncture.[6] NIPS are suitable instruments for neonatal pain evaluation. [1] Physiological responses to painful or stressful stimuli include increase in circulating catecholamines, increased heart rate and blood pressure and elevated intracranial pressure. The stress response of the immature fetus or preterm infant is less competent than that of the more mature infant or child. Therefore, in immature infant the classical vital signs of stress ( eg. Tachycardia, hypertension, agitation) are not reliable indicators of painful stimuli. [7] The focus of this prospective study was to evaluate the use of physiologic and behavioral parameters as valid assessment tools for acute pain in healthy term newborn infants.
Materials and Methods
Eighty term infants less than 7 days of age who required blood sampling for bilirubin estimation, blood sugar and workup were assessed for their responses to venipuncture performed in a standard manner. Healthy neonates between 37 weeks to 42 weeks gestational age were eligible. Babies with significant morbidity like septicemia, birth asphyxia, major congenital malformations and neurological involvement were excluded. The selected cases were divided into 2 groups: Group I: < 2.5kg and Group II:>2.5kg. The resident doctor rated infant's pain using NIPS at baseline (before the procedure) and during the period when maximal response was observed. The NIPS includes five behavioral groupings (facial expression, crying, movement of arms and legs, and state of arousal) and one physiological indicator (breathing pattern). The total score ranges from 0 to 7. [7] Heart rate, respiratory rate, blood pressure and oxygen saturation were monitored continuously from 10 minutes before to 10 minutes after the procedure. Non-invasive blood pressure and oxygen saturation was measured by Datex-Ohmeda multimoniter. The maximal change in the above parameters were noted. The data was statistically analyzed by using EPI-6.
Result
In the study group, there were total 80 neonates out of which 47 were males and 33 were females. The mean postnatal age in group I was 3.7 ± 1.4 days and group II 3.6 ± 1.61 days respectively. The time of last feed was 36 minutes in group I and 34.5 minutes in group II. The mean birth weight was 2.240 kg in group I and 2.852 kg group II.
The mean heart rate table1 increased during the procedure in both the groups and showed a significant differences (p < 0.001) when compared to that recorded prior to venepuncture. The non-invasive systolic blood pressure table4 also increased during the procedure in both the groups and showed a significant differences (p < 0.001) when compared to that recorded prior to venepuncture. There was significant increase in the respiratory rate table2 during the procedure in both the groups as compared to the baseline (p< 0.001). A significant decrease in oxygen saturation during the procedure (p <0.001) found in both group as compared to the baseline table3.
The mean Neonatal Infant Pain Scale (NIPS) table5 score during venipuncture was higher in both the groups as compared to baseline values (p<0.001) but more significantly increased in group II as compared to group I.
Discussion
Every year, millions of neonates require diagnostic blood sampling. Neonates undergoing these procedures cry and exhibit facial expression and body movements which are indicative of pain. Until recently, it was believed that infants and young children could not appreciate pain due to the immaturity of the central nervous system. However, now it is a well established fact that the anatomical, physiological and neurochemical structures which convey pain are well developed in neonates.[8]
Physiological changes in response to painful stimuli had been uniformly reported by previous studies.[8] The present study clearly indicates that all neonates responded to painful stimuli in one or the other way. A significant increases in heart rate was reported by Owen ME in the context of a tissue damaging stimulus.[10] The magnitude of changes in the heart rate was related to the intensity and duration of the stimulus and to the individual temperaments of the babies. [2] The study done by KJS Anand found that heart rate increased after circumcision or heel lancing in term neonates. [2]
McIntosh N et al[6], Van Cleve L et al[10], Harmesh Singh et al[11] and Gessler P et al[12] also reported that heart rate was significantly increased after venepuncture. These changes are comparable to that observed in the present study. Heart rate was significantly increased in both groups but more in group I (p<0.001).
Brown L[13] and Gessler P et al[12] showed that blood pressure increased after painful stimulation which was also recorded in these studies (p<0.001).
The statistically significant (p<0.001) rise in respiratory rate was recorded in the present study during the procedure which was also reported by Brown L,[13] McIntosh N et al[6], Harmesh Singh et al[11] and Gessler P et al.[12]
A significant decrease in oxygen saturation in response to painful stimuli was reported by KJS Anand[2], Van Cleve L et al[10], Harmesh Singh et al[11] and Gessler P et al.[12] Similar finding were recorded in the present study (p<0.001). Potentially injurious hypoxia occur even during essential routine care procedure.[11]
Johnston CC et al showed that full-term newborn is better equipped to interact with his caretakers and expresses his distress through specific facial actions.[14] Crying is the primary method of communication in newborn infants and is also elicited by stimuli other than pain. The pain cry has specific behavioral characteristics and spectrographic properties in healthy full-term neonates.[2] Rushforth JA et al found that thirty 5 (97%) term infants showed an increase in the number of behaviours in response to heel lance. Brow bulge and nasolabial furrow were seen most often, and occurred more often than crying.[15] Van Cleve L et al found that infants moved abruptly into a hyperalert or crying state in response to venipuncture, skipping several states without transition and showing disorganized behavior.[10] The motor responses of healthy full-term neonates to a pinprick in the leg were reported to be flexion and adduction of the upper and lower limbs associated with grimacing, crying, or both, and these responses were subsequently quantified.[2] The mean Neonatal Infant Pain Scale(NIPS) score was significantly higher in both the groups.
Conclusion
This study helps to validate the Neonatal Infant Pain Scale(NIPS) as suitable instruments for neonatal pain evaluation. Moreover Heart rate, Blood pressure, Respiratory rate and O2 saturation were good indicators for evaluating the neonatal pain. As behavioral pain score response during venipuncture and changes in physiologic parameters were uniformly present in both groups, it can be concluded that the weight of the term baby does not influence the pain response in newborn babies.
Key messages
The full-term newborn is better equipped to interact with his caretakers and express his distress through specific facial actions; a combination of physiological and behavioural changes provides a better estimate of infant pain.
The message of distress sent by the neonates through the cry sensitizes the adult, either the child's mother or another adult, who is taking care of it.
References
1. Pereira AL, Guinsburg, de Almeida MF, Montriro AC, dos Santos AM, Kopelmen BI et al. Validity of behavioral and physiologic parameters for acute pain assessment of term newborn infants. Sao Paulo Med J 1999; Mar 4; 117(2): 72-80.
2. Anand KJS, Hickey PR. Pain and its effects in the human neonates and fetus. New Eng J Med 1988; 317: 1321-1329.
3. Mathew PJ, Mathew JL. Assessment and management of pain in infants. Postgraduate Medical Journal 2003; 79: 438-443.
4. Dollberg S, Stolik-Dollberg O. Prevention and pain management in term and preterm infants. Harefuah 2004 Jan; 143 (1): 54-59, 84.
5. Bozzette M. Observation of pain behavior in the NICU: an exploratory study. J Perinat Neonatal Nurs 1993 Jun;7(1):76-87.
6. McIntosh N, Van Veen L, Brameyer H. The pain of heel prick and its measurement in preterm infants. Pain 1993 Jan; 52(1): 71-74.
7. Linda J, Van marter, Pryor CC. Management of pain and stress in the NICU. In Cloharty JP, Eichenwald EC, Stark AR, eds. Manual of Neonatal Care. 5th edn. Philadelphia; Lippincott, Williams and Wilkins, 2004; 703-715.
8. Shah V, Ohlsson. A Venepuncture versus heel lance for blood sampling in term neonates. The Cochrane Library, Issue 2, 2005. http://www.nichd.nih.gov/Cochrane/shah/shah.HTM.
9. Owens ME, Todt EH. Pain in infancy: Neonatal reaction to heel lance. Pain 1984; 20: 74-77.
10. Van Cleve L, Johnson L, Andrews S, Hawkins S, Newbold J. Pain response of hospitalized neonates to venipuncture. Neonatal Network 1995; 14: 31-36.
11. Harmesh Singh, Daljit Singh, R.K. Soni. Comparison of pain response to venepuncture between term and preterm neonates. Indian Pediatr 2000; 179-181.
12. Gessler P, Cignacco E et al. Measures for the assessment of pain in neonates as well as a comparison between the Bernese Pain Scale for Neonates (BPSN) with the Premature Infant Pain Profile (PIPP). Klin Pediatr 2004 Jan-Feb; 216(1): 16-20.
13. Brown L. Phsiologic responses to cutaneous pain in neonates. Neonatal Network 1987; 5: 18-23.
14. Johnston CC, Stevens B, Craig KD, Grunau RV. Developmental changes in pain expression in premature, full-term, two- and four-month-old infants. Pain 1993 Feb; 52(2): 201-208.
15. Rushforth JA, Levene MI. Behavioral responses to pain in healthy neonates. Arch Dis Child 1994; 70: 174-176.(Taksande Amar M, Vilhekar)