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Meta-Analysis
. 2015 Dec 2;2015(12):CD006275.
doi: 10.1002/14651858.CD006275.pub3.

Non-pharmacological management of infant and young child procedural pain

Rebecca R Pillai Riddell  1 , Nicole M Racine, Hannah G Gennis, Kara Turcotte, Lindsay S Uman, Rachel E Horton, Sara Ahola Kohut, Jessica Hillgrove Stuart, Bonnie Stevens, Diana M Lisi
Affiliations
Meta-Analysis

Non-pharmacological management of infant and young child procedural pain

Rebecca R Pillai Riddell et al. Cochrane Database Syst Rev. .

Update in

  • Non-pharmacological management of infant and young child procedural pain.
    Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S, DiLorenzo-Klas M, Racine NM, Ahola Kohut S, Lisi D, Turcotte K, Stevens B, Uman LS. Pillai Riddell RR, et al. Cochrane Database Syst Rev. 2023 Jun 14;6(6):CD006275. doi: 10.1002/14651858.CD006275.pub4. Cochrane Database Syst Rev. 2023. PMID: 37314064 Free PMC article.

Abstract

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.

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Conflict of interest statement

Dr. Rebecca Pillai Riddell C.Psych.: No conflict to declare.

Nicole Racine, M.A.: No conflict to declare

Hannah Gennis, B.A.: No conflict to declare

Kara Turcotte, M.A.: No conflict to declare.

Dr. Lindsay Uman, R.Psych: No conflict to declare.

Dr. Rachel Horton, C.Psych (supervised practice): No conflict to declare.

Dr. Sara Ahola Kohut, C.Psych: No conflict to declare.

Jessica Hillgrove‐Stuart, M.A.: No conflict to declare.

Dr. Bonnie Stevens, RN, PhD: No conflict to declare.

Diana Lisi, B.A.: No conflict to declare.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Study flow diagram.
1.1
1.1. Analysis
Comparison 1 Non‐nutritive sucking‐related x preterm x pain reactivity, Outcome 1 Pain reactivity.
2.1
2.1. Analysis
Comparison 2 Non‐nutritive sucking‐related x preterm x immediate pain regulation, Outcome 1 Immediate pain regulation.
3.1
3.1. Analysis
Comparison 3 Non‐nutritive sucking‐related x neonate x pain reactivity, Outcome 1 Pain reactivity.
4.1
4.1. Analysis
Comparison 4 Non‐nutritive sucking‐related x older infants x immediate pain regulation, Outcome 1 Immediate pain regulation.
5.1
5.1. Analysis
Comparison 5 Swaddling/tucking‐related x preterm x pain reactivity, Outcome 1 Pain reactivity.
6.1
6.1. Analysis
Comparison 6 Toy distraction x older infants x pain reactivity, Outcome 1 Pain reactivity.
7.1
7.1. Analysis
Comparison 7 Structured parent involvement x older infant x pain reactivity, Outcome 1 Pain reactivity.
8.1
8.1. Analysis
Comparison 8 Structured parent involvement x older infants x immediate pain regulation, Outcome 1 Immediate pain regulation.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to studies excluded from this review

Abdallah 2013 {published data only}
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De Jong 2012 {published data only}
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de Sousa 2008 {published data only}
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Diego 2009 {published data only}
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Dilen 2010 {published data only}
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Gedaly‐Duff 1992 {published data only}
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Gonzalez 1989 {published data only}
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Gonzalez 1993 {published data only}
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Goubet 2007 {published data only}
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Hanson 2010 {published data only}
    1. Hanson D, Hall W, Mills LL, Au S, Bhagat R, Hernandez M, et al. Comparison of distress and pain in infants randomized to groups receiving standard versus multiple immunizations. Infant Behavior and Development 2010;33:289‐96. - PubMed
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    1. Harrison LL, Williams AK, Berbaum ML, Stem JT, Leeper J. Physiologic and behavioral effects of gentle human touch on preterm infants. Research in Nursing & Health 2000;23(6):435‐46. - PubMed
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Hsu 1995 {published data only}
    1. Hsu CY, Huang LM, Lee CY, Lin TY, Lee PI, Chen JM. Local massage after vaccination enhances the immunogenicity of diphtheria‐ tetanus‐pertussis vaccine. Pediatric Infectious Disease Journal 1995;14(7):567‐72. - PubMed
Huang 1999 {published data only}
    1. Huang FY, Huang LM. Effect of local massage on vaccination: DTP and DTPa. Acta Paediatrica Taiwanica 1999;40(3):166‐70. - PubMed
Huang 2004 {published data only}
    1. Huang CM, Tung WS, Kuo LL, Ying‐Ju C. Comparison of pain responses of premature infants to the heelstick between containment and swaddling. Journal of Nursing Research 2004;12(1):31‐40. - PubMed
Ida 2008 {published data only}
    1. Ida S, Yoshimura N, Nakacho M, Ota M, Mine H, Moriyama H, et al. Evaluation of the use of PenNeedle 32G Taper in children being treated with growth hormone. Clinical Pediatric Endocrinology 2008;17(1):1‐7. - PMC - PubMed
Ipp 2007 {published data only}
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Ipp 2009 {published data only}
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Jackson 2008 {published data only}
    1. Jackson LA, Starkovich P, Dunstan M, Yu O, Nelson J, Dunn J, et al. Prospective assessment of the effect of needle length and injection site on the risk of local reactions to the fifth diphtheria‐tetanus‐acellular pertussis vaccination. Pediatrics 2008;21(3):e646‐52. - PubMed
Jo 2007 {published data only}
    1. Jo SH, Mathiasen RA, Gurushanthaiah D. Prospective, randomized, controlled trial of a hemostatic sealant in children undergoing adenotonsillectomy. Otolaryngology ‐ Head & Neck Surgery 2007;137(3):154‐8. - PubMed
Johnston 2003 {published data only}
    1. Johnston CC, Stevens B, Pinelli J, Gibbins S, Filion F, Jack A, et al. Kangaroo care is effective in diminishing pain response in preterm neonates. Archives of Pediatrics & Adolescent Medicine 2003;157(11):1084‐8. - PubMed
Johnston 2007b {published data only}
    1. Johnston CC, Gagnon A, Rennick J, Rosmus C, Patenaude H, Ellis J, et al. One‐on‐one coaching to improve pain assessment and management practices of pediatric nurses. Pediatric Nursing 2007;22(6):467‐78. - PubMed
Johnston 2008a {published data only}
    1. Johnston CC, Filion F, Campbell‐Yeo M, Goulet C, Bell L, McNaughton K, et al. Kangaroo mother care diminishes pain from heel lance in very preterm neonates: a crossover trial. BMC Pediatrics 2008;8:13. [DOI: 10.1186/1471-2431-8-13] - DOI - PMC - PubMed
Johnston 2009 {published data only}
    1. Johnston CC, Filion F, Campbell‐Yeo M, Goulet C, Bell L, McNaughton K, et al. Enhanced kangaroo mother care for heel lance in preterm neonates: a crossover trial. Journal of Perinatology 2009;29:51‐6. [DOI: 10.1038/jp.2008.113] - DOI - PubMed
Kashaninia 2008 {published data only}
    1. Kashaninia Z, Sajedi F, Rahgozar M, Noghabi FA. The effect of kangaroo care on behavioral responses to pain of an intramuscular injection in neonates. Journal for Specialists in Pediatric Nursing 2008;13(4):275‐80. - PubMed
Kivijärvi 2008 {published data only}
    1. Kivijärvi R, Palviainen J. "Just like I had kicked my toe" ‐‐ Children's experiences of postsurgical pain. Sairaanhoitaja 2008;81(1):27‐9.
Koivusalo 2009 {published data only}
    1. Koivusalo AI, Korpela R, Wirtavuori K, Piiparinen S, Rintala RJ, Pakarinen MP. A single‐blinded, randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics 2009;123(1):332‐7. - PubMed
Kostandy 2008 {published data only}
    1. Kostandy RR, Ludington‐Hoe SM, Cong X, Abouelfettoh A, Bronson C, Stankus A, et al. Kangaroo care (skin contact) reduces crying response to pain in preterm neonates: pilot results. Pain Management Nursing 2008;9(2):55‐65. - PMC - PubMed
Leclair 2007 {published data only}
    1. Leclair MD, Plattner V, Mirallie E, Lejus C, Nguyen JM, Podevin G, et al. Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. Journal of Pediatric Surgery 2007;42(4):692‐8. - PubMed
Li 2007 {published data only}
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Lima 2013 {published data only}
    1. Lima AH, Hermont AP, Lima Friche AA. Analgesia in newborns: a case‐control study of the efficacy of nutritive and non‐nutritive sucking stimuli. CoDAS 2013;25(4):365‐368. - PubMed
Ludington‐Hoe 2005 {published data only}
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Luthy 2013 {published data only}
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MacLaren 2005 {published data only}
    1. MacLaren JE, Cohen LL. A comparison of distraction strategies for venipuncture distress in children. Journal of Pediatric Psychology 2005;30(5):387‐96. - PubMed
Manne 1990 {published data only}
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Marchisotti 2007 {published data only}
    1. Marchisotti FG, Carvalho LR, Berger K, Arnhold IJ, Mendonca BB. Growth hormone (GH) deficiency treatment in children: comparison between uses of pen versus bottles/syringes on GH administration. Arquivos Brasileiros de Endocrinologia e Metabologia 2007;51(7):1093‐6. - PubMed
Marec‐Berard 2009 {published data only}
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Marin Gabriel 2010 {published data only}
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Michel 2008 {published data only}
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Morelius 2009 {published data only}
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Mucignat 2004 {published data only}
    1. Mucignat V, Ducrocq S, Lebas F, Mochel F, Baudon JJ, Gold F. Analgesic effects of Emla cream and saccharose solution for subcutaneous injections in preterm newborns: a prospective study of 265 injections. Archives de Pediatrie 2004;11(8):921‐5. - PubMed
Okan 2010 {published data only}
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Phipps 2005 {published data only}
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Rattaz 2005 {published data only}
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    1. Slifer KJ, DeMore M, Vona‐Messersmith N, Pulbrook‐Vetter V, Beck M, Dalhquist L, et al. Comparison of two brief parent‐training interventions for child distress during parent‐administered needle procedures. Children's Health Care 2009;38:23‐48. [DOI: 10.1080/02739610802615831] - DOI - PMC - PubMed
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Vignochi 2010 {published data only}
    1. Vignochi C, Teixeira PP, Nader SS. Effect of aquatic physical therapy on pain and state of sleep and wakefulness among stable preterm newborns in neonatal intensive care units [Efeitos da fisioterapia aquatica na dor e no estado de sono e vigilia de recem‐nascidos pre‐termo estaveis internados em unidade de terapia intensiva neonatal]. Revista Brasileira de Fisioterapia (Brazilian Journal of Physical Therapy) 2010;14(3):214‐20. - PubMed
Vivancos 2010 {published data only}
    1. Vivancos RBZ, Leite AM, Scochi CGS, dos Santos CB. The skin to skin contact at birth and newborn crying during vaccination against hepatitis B [O contato pele a pele ao nascimento e o choro de recem‐nascidos durante vacinacao contra Hepatite B]. Acta Paul Enferm 2010;23(4):461‐5.
Weissman 2009 {published data only}
    1. Weissman A, Aranovitch M, Blazer S, Zimmer EZ. Heel‐lancing in newborns: behavioral and spectral analysis assessment of pain control methods. Pediatrics 2009;124:921‐6. [DOI: 10.1542/peds.2009-0598] - DOI - PubMed
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    1. Zun L, Downey L. The use of cartoon distraction in the reduction of pain. Pain Practice 2012;12(s1):1‐199.

References to studies awaiting assessment

Ho 2012 {published data only}
    1. Ho S, Ho L. Effects of facilitated swaddling for controlling procedural pain in premature neonates: a randomized controlled trial. Journal of Pain 2012;1:S59. [Author was contacted to get a copy of the article. There has not been a response to date]
Obeidat 2011 {published data only}
    1. Obeidat HM. The efficacy of containment for relieving painful responses among jordanian preterm infants during heel stick blood drawing. European Journal of Pain Supplements 2011;5(1):59. [Author was contacted to get a copy of the article. There has not been a response to date.]
Rozenfeld 2012 {published data only}
    1. Rozenfeld S, Mantin H, Mussafi H, Taizi T, Landau R, Kadosh D, et al. Effect of Snoezelen on pain perception and anxiety in CF infants during sputum suction. Pediatric Pulmonology 2012;47:41. [Author was contacted to get a copy of the article. There has not been a response to date.]
Taavoni 2013 {published data only}
    1. Taavoni S, Shahali S, Haghani H. Infants' vaccination pain management and effect of breast feeding, sucking the pacifier and mother's hug: A randomized control trial. European Psychiatry, Conference: 21st European Congress of Psychiatry 2013:28. [Author was contacted to get a copy of the article. There has not been a response to date.]

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