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ARTICLE:
Maria Gradin, Mats Eriksson, Gunilla Holmqvist, Åsa Holstein, and Jens Schollin
Pain Reduction at Venipuncture in Newborns: Oral Glucose Compared With Local Anesthetic Cream
Pediatrics 2002; 110: 1053-1057 [Abstract] [Full text] [PDF]
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P3Rs published:

[Read P3R] Pain Management at Venipuncture in Newborn
Sunil Jain   (11 December 2002)
[Read P3R] Methodological issues in neonatal pain management
Maria Gradin, Mats Eriksson and Jens Schollin   (17 December 2002)

Pain Management at Venipuncture in Newborn 11 December 2002
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Sunil Jain,
Physician
Southern Illinois University School of Medicine, Springfield IL

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Re: Pain Management at Venipuncture in Newborn

jainsunil{at}hotmail.com Sunil Jain

Inadequate means of assessing pain in the newborn infants is unresolved clinical area. The multidimensionality of pain as explained by Gate Control Theory (1) suggests that physiological, behavioral, and modifying components of the experience should be included in any pain measure. Premature Infant Pain Profile (PIPP) can be considered multidimensional as it consists of contextual, physiological activity, and behavioral state. But most of the parameters included in PIPP are subject in nature. I think Neonatal Infant Pain Scale (NIPS) could be a better scale because it provides clinician with an objective measure of intensity of response that can be used to compare pain relief measures. What was the protocol as far as feeding was concerned? Blood collectors may inflict more painful stress depending on their experience. Did you limit the number of blood collectors? How long analgesic effect of glucose lasts? Can we use it do other short procedures like lumbar puncture or arterial puncture in the newborn infants?

References 1. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971 -9.

Methodological issues in neonatal pain management 17 December 2002
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Maria Gradin,
RN
Orebro University Hospital,
Mats Eriksson and Jens Schollin

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Re: Methodological issues in neonatal pain management

maria.gradin{at}orebroll.se Maria Gradin, et al.

We thank dr Jain for his comments on our article. It is clear that pain assessment in infants is a question with many answers. There exists a big amount of pain assessment instruments using physiological and/or behavioural parameters. Due to the multidimensional nature of pain an ideal pain tool should take more than one body system into account (1). This is done by the Premature Infant Pain Profile (PIPP), that combines physiological (heart rate, oxygen saturation) and behavioural (facial expressions) variables with contextual factors like sleeping state and gestational age. This is also done by the Neonatal Infant Pain Scale (NIPS) with different behavioural parameters including face activity and body movement as well as one physiological indicator (breathing pattern).

If one wants to describe these scoring systems in terms of subjectivity and objectivity, one also have to define which of the included variables that are considered subjective. It is tempting to assume that many people would call behavioural parameters subjective (which they don’t have to be) and in that case NIPS would be more subjective than PIPP. This classification however, is not a fruitful way in choosing the ideal pain assessment tool. Both PIPP and NIPS have their place in research, and in the clinical setting.

Time since last feeding varied in both groups, but there was no difference between the groups. The number of blood collectors was limited, and all the nurses that performed the blood sampling were experienced neonatal nurses with clear instructions about the methods in the actual study.

The pain relieving effect of sucrose lasts about five minutes with the most intense effect at two minutes (2); Clinical observations reveals that the effect of glucose seems to have the same duration. Smaller doses can be given in a repeated administration if the procedure takes longer time. The international consensus document about pain in neonates (3) suggests that sweet solutions should be given as a complement to other treatment during procedures like lumbar puncture or percutaneous arterial catheter insertion.

Maria Gradin, Mats Eriksson, Jens Schollin Department of Paediatrics, Orebro University Hospital

References

1. Abu-Saad HH, Bours GJ, Stevens B, Hamers JP. Assessment of pain in the neonate. Semin Perinatol 1998;22(5):402-16. 2. Blass EM, Shah A. Pain-reducing properties of sucrose in human newborns. Chem Senses 1995;20(1):29-35. 3. Anand KJ, International Evidence-Based Group for Neonatal P. Consensus statement for the prevention and management of pain in the newborn. Archives of Pediatrics & Adolescent Medicine 2001;155(2):173-80.