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I would consider myself fairly open minded when it comes to care in the NICU. I wouldn’t call myself a maverick or careless but I certainly am open to new techniques or technologies that may offer a better level of care for the babies in our unit. When it comes to “non-Western” concepts though such as therapeutic touch, chiropractic manipulations of infants and acupuncture (needle or otherwise) I have generally been a skeptic. I have written about such topics before with the most popular post being Laser acupuncture for neonatal abstinence syndrome. My conclusion there was that I was not a fan of the strategy but perhaps I could be more open to non traditional therapies. Magnetic Acupuncture This would appear to be the newest and perhaps strangest (to me at least) approach to pain relief that I have seen. I do love name of this study; the MAGNIFIC trial consisted of a pilot study on the use of auricular magnetic acupuncture to alleviate pain in the NICU from heel lances. The study was published in Acta Paediatrica this month; Magnetic Non-Invasive Acupuncture for Infant Comfort (MAGNIFIC) – A single-blinded randomized controlled pilot trial. The goal here was to measure pain scores using the PIPP scoring system for pain in the neonate before during and after a painful experience (heel lance) in the NICU. Being a pilot study it was small with only 20 needed per arm based on the power calculation to detect a 20% difference in scores. The intervention used small magnets placed at specific locations on the ear of the infant at least two hours before the heel lance was to occur. Before I get into the results, the authors of the study provide references to explain how the therapy works. Looking at the references I have to admit I was not able to obtain complete papers but the evidence is generally it would appear from adult patients. The explanation has to do with the magnetic field increasing blood flow to the area the magnet is applied to and in addition another reference suggests that there are affects the orbitofrontal and limbic regions which then impacts neurohormonal responses as seen in functional MRI. The evidence to support this is I would have thought would be pretty sparse but I was surprised to find a literature review on the subject that looked at 42 studies on the topic. The finding was that 88% of the studies reported a therapeutic effect. The conclusion though of the review was that the quality of the included studies was a bit sketchy for the most part so was not able to find that this should be a recommended therapy. So what were the results? Despite my clear skepticism what this study did well was that aside from the magnets, the intervention was the same. Twenty one babies received the magnetic treatments vs 19 placebo. There was a difference in the gestational ages of the babies with the magnet treated infants being about two weeks older (35 vs 33 weeks). What difference that might in and of itself have on the PIPPs scoring I am not sure. The stickers were applied to the ears with and without magnets in a randomized fashion and the nurses instructed to score them using the PIPP scoring system. Interestingly, as per their unit policy all babies received sucrose as well before the intervention of a heel lance so I suppose the information gleaned here would be the use of magnets as an adjunctive treatment. No difference was noted in the two groups before and after the heel lance but during the procedure the magnet treated infants had a difference in means (SD): 5.9 (3.7) v 8.3 (4.7), p=0.04). No differences were found in secondary measures such as HR or saturation and no adverse effects were noted. The authors conclusions were that it was feasible and appears safe and as with most pilot studies warrants further larger studies to verify the results. Should we run out and buy it? One of the issues I have with the study is that in the introduction they mention that this treatment might be useful where kangaroo care (KC) is not such as a critically ill infant. Having placed infants who are quite sick in KC and watched wonderful stability arise I am not sure if the unit in question under utilizes this important modality for comfort. The second and perhaps biggest issue I have here is that although the primary outcome was reached it does seem that there was some fishing going on here. By that I mean there were three PIPP scores examined (before, during and after) and one barely reached statistical significance. My hunch is that indeed this was reached by chance rather than it being a real difference. The last concern is that while the intervention was done in a blinded and randomized fashion, the evidence supporting the use of this in the first place is not strong. Taking this into account and adding the previous concern in as well and I have strong doubts that this is indeed “for real”. I doubt this will be the last we will hear about it and while my skepticism continues I have to admit if a larger study is produced I will be willing and interested to read it.
Several scales to assess pain in newbrns exist: both for acute and for postsurgical pain. Scales for postsurgical or chronical pain are few and easy to use. I recently wondered if pain scales for acute pain are really necessary: they seem scarcely used in clinical practice though they are more than 40(!), they are often complicated, and -above all- they give a pain score when the procedure is over, i.e., when (I fear) it is too late. Acute pain scales do not consider the context of the procedure, but only babies' reactions; therefore they should simultaneously use and combineseveral indicators. I proposed to settle for pain detection instead of pain scoring. It is easy: you should first wonder if your procedure can actually stimulate nociceptors, then you should see if it provokes a sudden reaction: this is a contextual detection of pain: easy, reliable and useful. What is your opinion about this idea? Acta Paediatr. 2015 Mar;104(3):221-4. doi: 10.1111/apa.12882. Epub 2015 Jan 7. Should we assess pain in newborn infants using a scoring system or just a detection method? Bellieni CV1, Tei M, Buonocore G. Author information Abstract Newborn infants' pain should be scored indirectly using dedicated pain scales. Unfortunately, while some scales for prolonged pain have given good results, a gold standard to assess acute pain does not exist. Acute pain scales still have weak points, most are complex and are scarcely used in neonatal departments. Moreover, carefully scoring pain in clinical practice seems redundant, because any avoidable pain is a concern. This suggests that researchers must find new ways to assess acute pain. A possible approach is to settle for pain detection instead of pain scoring in selected cases. Here, we describe a two-point method that illustrates this approach. CONCLUSION: For everyday practice, detecting pain is more useful than scoring it; acute pain scales should be reserved for research, for those clinical settings where the personnel has received a careful training and where overcrowding and hurry are absent.
Dear fellow-members! Together with a student, Isa Sundell, I try to collect national guidelines for neonatal pain management. With helpful support from many professionals in neonatology worldwide, we have received several examples, and have compiled a list of the result so far (see short list below). I now turn to you: maybe there are new guideIines or updates we are not aware of. It would be a great help to us if you could send information about such guidelines in your country. Absolutely best would be to recieve an electronic copy or a web-link, or in printed form to adress below, but second best would be a reply to the following questions: 1 Country: 2 Year of publication of national neonatal pain guidelines: 3 Who issued the guidelines (goverment, professional society etc)? 4 The guidelines have suggestions for a) post-operative pain Yes / No other ongoing pain (ventilator etc) Yes / No c) procedural pain Yes / No d) pain assessement Yes / No e) pharmacological pain treatment Yes / No f) non-pharmacologica pain treatment Yes / No The results will published in a report / scientific publication in 2012. Thank you in advance! Yours sincerely Mats Eriksson & Isa Sundell e-mail: firstname.lastname@example.org mail: Isa Sundell, VFC, Örebro university hospital, S-70185 Sweden List of guidelines Australia and New Zeeland - 2005 - Royal Australasian College of Physicians Australia and New Zeeland - 2007 - Australian and New Zeeland Neonatal Network Brazil - 2011 - Ministry of Health Canada and USA - 2000/2007 - Canadian Paediatric Society, Fetus and Newborn Committee Denmark - (summer 2012, ongoing work) - Special Interest Group in Neonatal Nursing France - 2009/2011 - Agence francais de sécurité sanitarire des produits de santé Great Britain and Ireland - 2008 - Association of Paediatric Anaesthetists of Great Britain and Ireland Great Britain - 2000/2009 - Royal College of Nursing Iceland - 2004 - Local guidelines on the only NICU Ireland - 2008 - Association of Paediatric Anaesthetists Italy - 2005/2008 - Pain Study Group of the Italian Society of Neonatology The Netherlands - 2007 - Dutch Society of Pediatrics The Netherlands - 1995 - National Studygroup for Pain in NICU's Norway - 2003 (part of general guidelines) - The Norwegian Physician Society Poland - 2008 Sweden - 2002/2009 - Swedish Paediatric Pain Association