Medical professionals underestimate parents' role in alleviating newborns' pain

Medical professionals underestimate parents' role in alleviating newborns' pain A recent doctoral dissertation found that parents — one of the most effective sources of pain relief for infants — are still not routinely involved during painful procedures. Newborns frequently undergo painful procedures in the hospital, including blood draws, injections, IV catheter insertion and airway suctioning. A doctoral dissertation defended at the University of Tartu found that while nurses in Estonian hospitals consider pain management for infants important, pain assessment is often not systematic and guidance for parents depends largely on the experience of individual staff members. At the same time, parents themselves want more information and confidence about how to help their child during painful procedures. The study included 111 neonatal and intensive care nurses and 189 parents. In addition, 12 parents were interviewed about their experiences. Author Airin Treiman-Kiveste said she first noticed years ago that although hospitals devote considerable attention to medications, much less emphasis is placed on how pain should be assessed in the first place and how it can be reduced using simple, non-pharmacological methods. "When we were developing postoperative pain management guidelines, I realized we hadn't discussed pain assessment scales or non-pharmacological pain relief. Yet those are especially important for newborns," she said. Pain doesn't just disappear As recently as two decades ago, it was widely believed that newborns did not experience pain in the same way as older children. Scientific evidence has since disproved that view. The dissertation explains that both preterm and full-term infants activate nearly the same brain regions in response to pain as adults. Repeated untreated pain can alter brain development, lower pain thresholds later in life and increase the risk of anxiety, behavioral problems and developmental disorders. Treiman-Kiveste said it is a misconception that early painful experiences leave no lasting memory. "These painful procedures leave their mark on the still-developing brain. Later in life, the child may experience pain more intensely than someone who has not had these kinds of experiences," she said. According to Treiman-Kiveste, premature infants receiving intensive care may undergo several painful procedures in a single day, adding up to hundreds over the course of their hospital stay. Nurses place more trust in experience than pain scales One of the dissertation's more surprising findings concerns pain assessment. Although most nurses consider assessing pain important, they rarely use standardized pain assessment scales. In the study, 71 percent of nurses said pain assessment directly affects pain management. At the same time, 61 percent of respondents said they could reliably assess a newborn's pain without using any pain assessment scale. More than half, 56 percent, even believed that systematic documentation of pain was unnecessary. Knowledge of internationally recognized pain assessment scales also proved limited. For example, only 13 percent of nurses said they were thoroughly familiar with the Neonatal Infant Pain Scale (NIPS) and most did not use it in their daily work. NIPS is a pain assessment tool for newborns and young infants. It is widely used by healthcare professionals to assess postoperative and procedural pain in both preterm and full-term newborns. The scale evaluates six behavioral and physiological indicators, including the infant's facial expression — whether the baby is smiling, relaxed or grimacing — whether the baby is crying and the nature of the cry, breathing patterns, body posture and other observable signs. Treiman-Kiveste said the findings do not mean nurses fail to recognize when infants are in pain. "They do recognize it. The issue is that the assessment is often based on experience. But when everyone uses the same pain assessment scale, pain is evaluated according to the same criteria and it then becomes possible to determine whether the pain relief measures actually worked," she said. The problem begins with workplace practices. The study found that nearly four out of five nurses were unaware of the pain management guidelines in place in their unit, while nine out of 10 had not received continuing education on infant pain during the previous year. Written guidance for parents was available in only a handful of units. Parent as the most effective pain relief One of the dissertation's central findings is that many of the most effective methods of relieving pain do not require medication. International research shows that breastfeeding, skin-to-skin contact, holding the infant in a supportive position, gentle touch and administering a sweet sugar solution before a procedure all significantly reduce infants' pain responses. Methods that provide multiple soothing sensory stimuli at the same time are especially effective. During breastfeeding, for example, the infant is simultaneously comforted by the mother's heartbeat, scent, voice, touch and breast milk. "When the baby is at the breast, the mother's scent, heartbeat, touch and breast milk all work together. It is actually one of the most effective methods of pain relief," she said. Treiman-Kiveste noted, however, that these approaches are often used inconsistently and largely depend on whether parents know to offer this kind of support themselves or whether a nurse encourages them to do so. Parents want to help but don't always know how The dissertation found the clearest discrepancy when comparing the views of nurses and parents. Nurses generally believed they provided parents with sufficient guidance before painful procedures. Parents, however, reported a very different experience. Treiman-Kiveste said this does not necessarily mean nurses fail to provide guidance. Rather, parents may not recognize the information they receive as such. "Nurses themselves believe they guide parents well, but parents don't experience it that way. They may be told to hold the baby a certain way or place a hand on the baby, but it may not be explained that these are evidence-based methods of pain relief," she said. Interviews conducted as part of the dissertation showed that parents wanted to know much more before procedures than simply what was going to be done to their child. They wanted to understand why the procedure was necessary, how long it would take, how painful it might be and what they themselves could do to help. They also wanted nurses to clearly explain what role they were expected to play. Several parents described feeling more like bystanders during procedures. "Parents should not simply be bystanders. They need to know what their role is during the procedure," Treiman-Kiveste said. According to the dissertation, involving parents does more than increase a child's sense of security. The scientific literature shows it also reduces the child's pain, strengthens parents' confidence and improves trust in the healthcare system. Yet parental involvement remains limited in many hospitals because parents lack the necessary knowledge or experience, or do not receive sufficient encouragement from healthcare professionals. Sometimes very simple methods do the trick Treiman-Kiveste emphasized that the most effective methods of pain relief are neither complicated nor expensive. Often, all that is needed is to prepare for the procedure a few minutes in advance. For example, a sugar solution should be given to the infant before the procedure, not during it. "It needs to be administered two to three minutes before the procedure. Only then does it have time to take effect," she said. The same applies to breastfeeding. "If a baby is receiving a vaccination, for example, the infant should be breastfed during the injection. That also makes it easier for the nurse to administer the shot, while the baby experiences less pain," she said. The dissertation's literature review confirms that breastfeeding, skin-to-skin contact and the simultaneous use of multiple soothing stimuli are among the most effective non-pharmacological methods of pain relief. The best results are achieved by combining these approaches so that the infant simultaneously feels a parent's touch, hears a familiar voice and receives breast milk or a sweet sugar solution. Parents not the only ones who need to change According to the dissertation's author, responsibility cannot rest solely with parents. If they are to help their child, hospitals must create the conditions that allow them to do so. The study found that written guidance for parents was available in only a few hospital units, while most nurses had not received continuing education on infant pain during the previous year. Many were also unaware of the pain management guidelines in place in their own unit. Treiman-Kiveste said standardized guidelines are needed for both pain assessment and parental involvement. "Parents are the people best able to help their child. But to do that, they need to know what to do and someone has to teach them," she said. According to Treiman-Kiveste, most of the recommended changes would require neither additional funding nor new equipment. "These are mainly organizational changes in how we train nurses, how we guide parents and how we think about children's pain," she said. Treiman-Kiveste said this shift in mindset is the dissertation's most important message. While infant pain was often considered unavoidable or insignificant just a few decades ago, current scientific evidence shows that every unnecessary painful experience can affect a child's development. For that reason, she said, every painful procedure should, whenever possible, be anticipated, assessed and managed, with the child's parents serving not as bystanders but as active participants alongside healthcare professionals. Airin Treiman-Kiveste defended her doctoral dissertation, "Infants' Procedural Pain Management With Non-Pharmacological Methods in Estonian Hospitals: Parents' and Nurses' Perspectives," on June 17. -- Editor: Marcus Turovski