Pain assessment and management in the newborn: A systematized review

Table 1 Search strategy for PubMed

Search	Terms	Results
#1	“Pain” [Mesh]	390.237
#2	“Acute Pain” [Mesh]	2.063
#3	“Pain Management” [Mesh]	33.044
#4	#1 OR #2 OR #3	402.906
#5	“Infant, Newborn” [Mesh]	600.745
#6	"Intensive Care Units, Neonatal" [Mesh]	14.373
#7	“Nursing Care” [Mesh]	134.280
#8	#4 AND #5 AND #6 AND #7	48
#9	#8 Filters: Full text; published in the last 10 yr	19

Table 2 Studies characteristics included in the review

Ref.	Level of Evidence	Research Design	Pain Assessment	Pain Management	Painful Procedures	Aim
Gonzalez et al[3]	Ia	Systematic review	Scales: NIPS, PIPP, CRIES, NFCS, COMFORT	NPI: Environmental, behavioral and nutritional intervention: sucrose, dummy (non-nutritive suction), kangaroo method or skin to skin.PI: Paracetamol, morphine, ketamine, metamizole, thiopental, chloral hydrate…	Venipuncture, lumbar/heel puncture, peripheral/central venous catheter insertion, umbilical catheterization, injections, aspiration, orogastric catheterization	To know the neonatal pain impact and its treatment in painful procedures. Purpose: To sensitize health professionals about pain management in NBs
Avila-Alvarez et al[21]	III	Multicenter, observational, longitudinal and prospective study	NA	NPI: Sweet oral solution: Sucrose (most common) and glucose. PI: Fentanyl (most used), midazolam, morphine, paracetamol	Invasive and non-invasive mechanical ventilation	To determine the clinical practice in relation to sedation and analgesia in Spanish ICUs and to identify factors associated with the use of drugs
Guzmán et al[10]	III	Prospective-descriptive pilot study	Observational: Signs of pain (crying), contraction of facial muscles, heart rate and respiratory rate	Sentire method: Psychotherapeutic pain management through music and touch	Clinical procedures, separation from mother, ambient noise > 45 dB	Analyze the effectiveness of the Sentire method
San Martín et al[11]	III	Descriptive correlational cross-sectional study	Susan Givens-Bell Scale	NA	Venous and arterial puncture, orogastric catheterization, aspiration of secretions	Assess the pain intensity in NB against nursing procedures
Aguilar et al[22]	Ia	Systematic review	Most employed: PIPP and NIPS	NPI: Oral administration of sweet solutions, breastfeeding and kangaroo care	Heel puncture, injections and vaccines, venous lines cannulation	To analyze studies that assess the effectiveness of NPIs during painful procedures
Avila-Alvarez et al[5]	III	Observational longitudinal prospective study	Most used scales: NIPS, CRIES and Susan-Givens. Others: PIPP, NPASS, COMFORT	PI: Sedative or analgesic medication	Invasive mechanical ventilation	To determine the clinical practice in relation to the assessment of neonatal pain in Spain and the factors associated with the use of scales
Veronez et al[12]	III	Qualitative descriptive study	Observation: Crying, facial expression, irritability and agitation. Physiological alterations: Heart rate, blood pressure, respiratory parameters, etc	NPI(mild pain): Oral glucose administration, non-nutritive suction, group procedures, environmental measuresPI (severe pain): Non-opioid and opioid analgesics	Venous puncture, capillary glycemia, adhesive removal, tracheal aspiration, dressings…	Describe the perception of neonatal pain by ICU nursing professionals
Do Prado et al[13]	Ia	Systematic review	Physiological and behavioral alterations. Scales: NIPS, NFCS, PIPP, CRIES, N-PAS	NPI: Oral glucose and non-nutritive suction (most used), environmental and postural care, breastfeeding… PI: NSAIDs, opioids, sedatives, local anesthetics	Venipuncture, blood collection, gastric catheterization, intubation…	To analyze the Brazilian scientific production on the evaluation and therapeutic approach of pain in newborns admitted to NICU
Thomé et al[14]	III	Cross-sectional study	NIPS scale	NA	Orotracheal tube and airway aspiration, venipuncture, intubation and insertion of PICC	Assess pain in NBs admitted to the NICU during invasive procedures
Do Nascimento et al[15]	III	Descriptive exploratory study with a qualitative approach	Physiological and behavioral responses. Scales: NFCS, NIPS and PIPP	NPI: Non-nutritive suction, positioning and containment. PI: Opioids, topical analgesics and sedatives	Diagnostic, surgical and therapeutic procedures: Venipuncture, capillary blood glucose, improper management, orotracheal aspiration…	Identify how the nursing staff assesses and manages NB pain in the NICU
Costa et al[16]	III	Descriptive cross-sectional study	Scales: NIPS, CRIES. Physiological and behavioral alterations	NPI: Oral glucose, non-nutritive sucking and laying. PI: Paracetamol, fentanyl and morphine	Venous punctures, tracheal aspirations, surgeries	Verify the nurses knowledge and practices about NBs pain management admitted to the NICU
Bonolo et al[17]	III	Descriptive exploratory study	Physiological and behavioral indicators: Heart rate, facial expression, cryingScales: CRIES, PIPP, NIPS, NFCS, N-PASS	NPI: Positioning, non-nutritive suction, environmental measures. PI: Opioids, NSAIDs, local anesthetics	Venipuncture, overhandling, heel stick, blood draw, aspiration	To characterize the nursing staff and identify how it assesses and manages pain for preterm newborns
Alves et al[18]	III	Convergent care study	Escala: PASVital signs daily assessment	NPI: Reducing environmental stimulus, grouping procedures and promoting sleep, kangaroo mother care, containment during procedures, administration of oral glucose, non-nutritive sucking	Environmental stimulus and invasive procedures: Venous/arterial puncture, oro/nasogastric catheterization, endotracheal aspiration, lumbar puncture	Develop a nursing care plan based on non-pharmacological methods for neonatal pain treatment in ICUs.
Assunçao et al[19]	Ia	Exploratory qualitative bibliographic review	Physiological indicators (heart rate, respiratory rate, oxygen saturation) and behavioral (crying, facial expression and motor activity). Scales: NFCS, NIPS, PIPP	NPI: Non-nutritive suction, oral glucose/sucrose, positioning, skin-to-skin contact, environmental measures… PI: Opioids (morphine, fentanyl) non-opioids (acetaminophen, dipyrone) and sedatives (propofol, midazolam, diazepam)	Mechanical ventilation, postoperative period, insertion of central catheter and thoracic drains	Analyze the evaluation and intervention methods of neonatal pain and reflect on the nurse competence in the control and management of pain
Stevens et al[24]	Ia	Literature review of randomized control trials	Scales: PIPP, DAN, NIPS, NFCS, NAPI, N-PASS, BPSN. Physiological and behavioral indicators	NPI: Sucrose administration (most effective in combination with other interventions, such as non-nutritive sucking)	Heel puncture, venous/arterial puncture, injections, bladder and nasogastric catheterization, circumcision, retinopathy of prematurity eye exam	To determine the efficacy, dose and method of sucrose administration for pain relief during procedures in the NB
Desai et al[25]	III		Scales: N-PASS and NIPS	NA	Laboratory tests, venous/arterial puncture, intubation, aspirations…	To improve newborns acute and chronic pain measurements in a NICU by implementing the N-PASS scale
Santos et al[20]	III	Qualitative descriptive study	Physiological and behavioral indicators (heart rate, breath rate, crying, facial expression..)	NPI: Containment, environmental measures (light and noise), touch, skin-to-skin contact, non-nutritive suction and glucose	Venous punctures, orogastric and bladder catheterization, capillary blood glucose, dressings, airway aspiration, orotracheal intubation	Analyze the parameters used by the nursing team to assess pain and intervention in the premature newborn
Dionysakopoulo et al[23]	III	Cross-sectional study	Most used scales: NIPS, PIPP Others: CRIES, NFCS, OPS, PAT, N-PASS	NA	Venipuncture, airway aspiration, tube placement and removal…	Evaluation and validation of scales (NIPS-PIPP) in hospitalized newborns in two Greek ICUs

NA: Not appear; NIPS: Neonatal infant pain scales; PIPP: Premature infant pain profile; CRIES: Crying, requires oxygen saturation, increased vital signs, expression and sleeplessness; NFCS: Neonatal facing coding system; N-PASS: Pain, agitation and sedation scale; DAN: Douleur Aiguë du Nouveau-né Scale; NAPI: Neurobehavioural assessment of preterm infants; BPSN: Bernese pain scale for neonates; OPS: Objective pain scale; PAT: Patient assessment pain; NPI: Non-pharmacological interventions; PI: Pharmacological interventions; NICU: Neonatal intensive care unit; NB: Newborn.