By Steven Lam
When our babies are in the NICU, it can be greatly stressful for everyone involved. Our babies may often be stressed due to maternal separation, noise and bright lights, procedures, and other events.
The types of pain that our babies can experience in the NICU include:
Like most infants, preterm infants also have pain responses, although they may be immature and less localized than in older infants. They often experience hyperalgesia (exaggerated pain responses), allodynia (pain from things that are not normally painful) and a longer latency in their responses.
These pain responses include physiological changes like heart rate, blood pressure, and oxygen levels, and hormone responses. They may also display behavioral signs of pain such as changes in their facial expression, body movements and of course crying.
However, it is important to note, that not all responses, like crying, moving, tachycardia, and perturbations in blood pressure are pain responses. Therefore it is important to properly assess infant pain.
Most Neonatal Pain tests usually evaluate for acute procedural pain, and not for discomfort or chronic pain because immature infants have inconsistent responses.
One such test is the Premature Infant Pain Profile or PIPP score. The PIPP score uses gestational age, behavioral state, heart rate, oxygen saturation and facial expressions such as the brow bulge, eye squeeze, and nasolabial furrow.
But how can pain affect our babies in the long-term?
It is possible that pain may affect long-term memory, pain perception and responses, and possibly alter social and cognitive development. Therefore it is obvious to try and address pain and stress in the NICU, especially acute and chronic pain.
Chronic Pain or Stress is much more difficult to assess, and often times may be superimposed by other types of pains like from procedures or inflammatory pain.
When addressing acute pain, due to procedures, it is important to look at the procedure itself and whether it is necessary but also if local anesthetics are available.
While morphine has been used for more serious procedures, the long-term risks may not be ideal. Other sedatives may also have other negative side effects and have been shown to show that there is insufficient evidence to recommend use of them during therapeutic hypothermia.
So if these aren’t working what can we do?
There has been a shift in approach in trying to limit the number of painful/stressful procedures and interventions as well as creating a less stressful NICU environment by involving the parents.
These includes many non-pharmacological approaches from swaddling, pacifiers, music, and family-centered care.
Sucrose has been used as a neonatal analgesia which did result in lower PIPP scores but no changes in pain specific cortical activity or reflexes indicating that it is not pain relief.
However, maternal holding of the infant has shown greater promise in reducing pain.
While this may lead to some issues where nursing staff may seem to be challenged by the parents, dialogue between nurse-parent collaboration may provide the best outcome for young ones. I
Parental participation may prove to be the one of the safest options that can be combined with other methods until more work is done in pharmacological methods where evidence supports positive outcomes.
By: Elizabeth Payne
Dr. Vincent Smith has practiced neonatal and perinatal medicine at Beth Israel Deaconess Medical Center in Boston for over ten years. Dr. Smith is a big proponent of family-centered care, an approach that encourages heavily involving the families of NICU patients in the care of their babies.
We had the pleasure of speaking with him recently on the value of family-centered care.
Tell me about your experience with family-centered care models.
Dr. Smith explained that one of the big advantages of family-centered care was having extra sets of eyes on each patient, watching just that patient.
Families, he said, “are getting a PhD in their baby”.
They oftentimes notice changes, both positive and negative, before the staff, and are able to notify their child’s providers about any such changes.
“Moms are the first to know,” he noted with a smile.
One of the ways he has tried to encourage family-centered care is having parents go on rounds with providers, making them a part of the healthcare team instead of an extension of the patient- this has resulted in a higher satisfaction rate among families.
Family-centered care encourages parent/child bonding, and gives the parents more understanding of what is going on and gives them some degree of control during a confusing, tumultuous time. With support and understanding of what is happening, parents become more confident in caring for their child.
"It’s a beautiful thing when people stop being scared and start enjoying their baby,” Dr. Smith said.
What are the best practices for family-centered care?
Dr. Smith believes that leadership starts from the top, and suggested that the leaders of a healthcare team teach by example.
"Staff want to do the right thing,” he explained, but often they are not aware of family-centered care and have not been trained in it.
We also discussed the role of “veteran” NICU parents in supporting parents whose child is currently being hospitalized. Dr. Smith believes that parents who are living proof that getting through the NICU can be done are an invaluable resource to parents whose children are currently in the NICU, providing them with hope, support and acting as a sounding board for questions that other parents may feel uncomfortable bringing up to healthcare providers.
Providing a welcoming environment and training on how to care for their child are also key in making parents feel comfortable. Learning how to care for their child and being reassured that they will not hurt the baby was especially valuable to parents and allowed them to feel more in control of the situation. Additionally, staff and parents should work collaboratively.
“Families will teach you a ton”, Dr. Smith noted.
What are some of the challenges of family-centered care?
One of the biggest challenges in the NICU in general is the previously mentioned parent apprehension about hurting their child; however, in family-centered care, parents are well-supported by staff in learning how to care for their child, helping them to “stop being scared and start enjoying their baby.”
There are some challenges when it comes to implementing family-centered care, as it is not always taken seriously and some providers dislike changing their way of practice.
When it comes to family-centered care itself, one important thing to remember is that it must be tailored to each family and family dynamic. The role of non-parent family members- such as siblings, aunts, uncles and grandparents--can vary from culture to culture and family to family. It is also important to remember patient’s perceptions of the roles of different healthcare providers--even if a team works collaboratively, parents tend to find it comforting to hear “big” news from the doctors and direct their basic questions to nurses.
What still needs to be done?
The mindset of “we’ve always done it this way” had to change in order for family-centered care to be implemented in a unit.
As previously discussed, the traditional view of doctors as planners and nurses as implementers is ineffective; the entire unit must work collaboratively. In some places family-centered care is considered a “squishy” approach and is pushed aside in favor of more traditional approaches.
Most importantly, the leadership of the unit and the administration must be on board for family-centered care to be implemented. In order for this to happen, awareness of effectiveness of family-centered care should be spread. Within family-centered care, parent apprehension needs to be addressed; staff need to address patient needs on a case-by-case basis and “nudge along” the parents as needed.
The biggest obstacle here is parents worrying that they are going to hurt their baby; staff needs to reassure them that this will not happen. “Babies are well-designed”, Dr. Smith pointed out.