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Background: Worldwide, oral sucrose is standard of care in many neonatal intensive care units to relieve procedural pain in neonates. This study aims to determine if time interval between sucrose administration and heelstick correlates with pain scores., Methods: Neonates were prospectively studied with variable time intervals and assessed with the Premature Infant Pain Profile-Revised (PIPP-R)., Results: 150 neonates were included with a median gestational age of 30 +6 (IQR 27 +6 -33 +2 ) weeks and a median time interval of 72 (IQR 39-115) seconds between sucrose administration and heelstick. In multiple regression analysis, this time interval was not significantly related to the PIPP-R (B=0.004, 95% CI -0.005 to 0.013, p=0.37). Providing non-nutritive sucking combined with sucrose was significantly related to lower PIPP-R scores (B=-3.50, 95% CI -4.7 to -2.3, p<0.001)., Conclusions: Our study suggests that there is no need to wait 2 min after sucrose administration before a painful procedure. Sucrose-induced non-nutritive sucking shows a fast pain-relieving effect in neonates., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To investigate the analgesic effect (measured with Neonatal Infant Pain Scale (NIPS)) of breastfeeding (BF) in addition to skin-to-skin contact (SSC) versus other methods of non-pharmacological analgesia during blood sampling through heel lance in healthy term neonates., Design: Randomised controlled trial., Setting: Tertiary level maternity ward., Patients: One hundred thirty-six healthy term newborns., Inclusion Criteria: healthy term neonates, wish to breastfeed and absence of feeding during the previous 60 min., Intervention: Neonates were randomly assigned to four groups: Group breastfed with SSC (BF+SSC Group) (n=35); Group sucrose with SSC (Sucrose+SSC Group) (n=35); SSC Group (n=33); or Sucrose Group (n=33). Babies were recorded with a video camera., Outcome Measures: Three observers watched the videos and measured NIPS score at three time points (t0: 2 min before heel prick; t1: During heel prick; and t2: 2 min after the heel prick). The influences of non-pharmacological methods on crying time, percentage of crying while sampling, heart rate, number of attempts and duration of sampling were also studied., Results: BF+SSC Group achieved a significant lower median NIPS score (value=1) compared with other groups (value=2, 4 and 4, respectively). The percentage of neonates with moderate-to-severe pain was also lower in the BF+SSC Group. Both groups BF+SSC and Sucrose+SSC achieved a significant lower percentage of crying compared with SSC Group., Conclusions: This study suggests that BF in addition to SSC provides superior analgesia to other kinds of non-pharmacological analgesia in healthy term neonates during heel prick.

Unlabelled: BACKGROUND Neonatal pain assessment generally requires access to facial expression. Improved neonatology practices, such as greater protection against bright lights and non-invasive mask ventilation, have made facial observation more difficult., Objective: To validate a 'faceless' acute neonatal pain scale (FANS), which does not depend on facial expression., Methods: In a prospective, multicentre study, 24-40-week-old neonates were videotaped during a painful procedure (heel prick). Three investigators then scored the pain using FANS and a previously validated scale: DAN (Douleur aiguë du Nouveau-né). FANS is based on assessment of limb movement, cry and autonomic reaction. Reliability was assessed by inter-rater agreement and internal consistency (Cronbach's alpha). Validity was evaluated by agreement between scales (intraclass correlation coefficient (ICC)). The Wilcoxon test evaluated the FANS score differences between conditions. Results are expressed as medians (25th and 75th percentiles). Ranges are presented for outcome parameters., Results: From April 2006 to September 2007, 53 preterms of 32 (30-35) gestational weeks and 1500 (1000-2200) g were observed. Cronbach's alpha was 0.72. The ICC was 0.92 (0.9-0.98) for inter-rater agreement and 0.88 (0.76-0.93) for agreement between scales., Conclusion: FANS, which is reliable and valid, is the first scale to score pain in preterm newborns when facial expression is not accessible.

Background: The analgesic effect of oral sucrose in newborn infants undergoing painful procedures is generally accepted. For blood sampling, some studies have shown that venepuncture (VP) is less painful than heel lance (HL)., Objective: To determine the least painful and most effective method among blood sampling by VP or HL with or without sucrose., Design: Randomised, double blind, placebo controlled trial., Subjects: A total of 100 healthy, full term newborn infants being screened for inborn errors of metabolism were randomly allocated to one of four experimental groups (25 infants in each). Intervention and, Outcome Measure: Seven specially trained nurses took turns to carry out blood sampling two minutes after administration of oral sucrose or water. Neonatal pain was assessed by the neonatal facial coding system (NFCS), as well as by crying., Results: Without sucrose, the NFCS score was higher in the HL group than the VP group during blood sampling (median 58 v 23, p<0.001). Oral sucrose significantly reduced the score of the HL group (58 v 47, p<0.01) and also tended to reduce the score of the VP group (23 v 2, p<0.1). However, the HL with sucrose group still had a higher score than the VP without sucrose group (47 v 23, p<0.01). Crying and the total procedure time showed the same trends as the NFCS score., Conclusions: VP is less painful and more effective than HL for blood sampling in newborn infants. Although oral sucrose may have an additive analgesic effect, it is not necessarily required if VP is used for blood sampling.

Objectives: To evaluate in a randomised blind study the effect on puncture site lesions of two different incision devices used to obtain blood samples from preterm infants by repeated heel sticks., Setting: The neonatal intensive care unit at the Hospital for Children and Adolescents and Laboratory, Helsinki University Central Hospital., Patients: A total of 100 preterm infants (birth weight below 2500 g) not previously subjected to heel stick sampling., Interventions: The infants were randomly allocated to blood sampling from the heel with either a conventional manual lancet or an automatic incision device. The same type of lancet was used for any given baby throughout the study (2-21 days)., Main Outcome Measures: The damage caused by sampling was evaluated using four criteria: bruising of the heel, inflammation of the heel, bruising of either the ankle or the leg, and skin healing at the puncture site. The evaluation was based on photographs presenting typical categories of each outcome., Results: To obtain a sufficient volume of blood, on average 2.6 times more punctures were needed when the conventional manual lancet was used than when the automatic incision device was used. Heels punctured with the lancet had more bruising (100% v 84%) and more signs of inflammation (79% v 53%), and there was more bruising of the ankle or leg (92% v 53%) than when the automatic incision device was used. Skin healed equally rapidly in the two groups., Conclusion: The use of an automatic incision device for collecting repeated skin puncture samples from preterm infants is less traumatic than the use of a conventional manual lancet.

Aim: To determine whether venepuncture accords with the accepted (BPA) criteria of not causing more than minimal physical or psychological distress during non-therapeutic research., Methods: Ninety two venepunctures were carried out in 69 neonates between days 6 and 10 of life, and in some cases, on day 28. Parents were fully informed of the need for the procedure and allowed to attend while it was performed. Ninety parents and 87 doctors completed questionnaires to assess the levels of perceived parental and child distress and anxiety before and after the procedure., Results: Only three parents were very upset, and 47% reported the test as being better than they expected, compared with 10% who thought it worse than expected. Seven babies were recorded as being very upset. Doctors tended to underestimate the degree of anxiety before the procedure and the level of distress afterwards., Conclusions: Venepuncture in neonates seems to be acceptable to most parents and is associated with a favourable risk: benefit ratio using semiquantitative assessment of risk and benefit.

Neonatal pain response and adverse effects and maternal anxiety were assessed in 27 infants who were randomly allocated to venepuncture or heel stick. Pain was assessed by nurses using the Neonatal Infant Pain Scale (NIPS) and a three point scale for the mothers. NIPS scores were higher in the heel stick group compared with the venepuncture group. Maternal anxiety was higher before the procedure while perception of an infant's pain was lower in the venepuncture group compared with the heel stick group. Venepuncture is less painful than heel stick in newborn infants undergoing routine blood sampling.

Objective: To evaluate the effects of different sucrose concentrations on measures of neonatal pain., Design: Randomised, double blind, placebo controlled trial of sterile water (control) or one of three solutions of sucrose--namely, 12.5%, 25%, and 50% wt/vol., Setting: Postnatal ward., Patients: 60 healthy infants of gestational age 37-42 weeks and postnatal age 1-6 days randomised to receive 2 ml of one of the four solutions on to the tongue two minutes before heel prick sampling for serum bilirubin concentrations., Main Outcome Measure: Duration of crying over the first three minutes after heel prick., Results: There was a significant reduction in overall crying time and heart rate after three minutes in the babies given 50% sucrose as compared with controls. This was maximal one minute after heel prick in the 50% sucrose group and became statistically significant in the 25% sucrose group at two minutes. There was a significant trend for a reduction in crying time with increasing concentrations of sucrose over the first three minutes., Conclusion: Concentrated sucrose solution seems to reduce crying and the autonomic effects of a painful procedure in healthy normal babies. Sucrose may be a useful and safe analgesic for minor procedures in neonates.

The hypothesis that the variability of physiological parameters may indicate pain or stress in the neonate was examined. Four parameters (heart rate, respiratory rate, transcutaneous oxygen tension, and carbon dioxide tension) were examined over a 2 minute epoch in response to a heel prick in an attempt to measure stress/pain in 35 preterm newborn infants (26-34 weeks' gestation) half of whom were receiving intensive care. The change in absolute values of these parameters did not discriminate a dummy procedure without prick from the actual procedure containing the prick (paired t test), but the variability of the parameters during an epoch showed significant discrimination. Three procedures were evaluated to reduce this distress using unpaired t test. The use of local anaesthetic cream was not successful. The components of the mixture cause vasoconstriction that would reduce blood flow to the heel and lead to more squeezing which is likely to be painful in the presence of tissue damage. A nurse comforting the infant with tactile and vocal stimulation was slightly helpful but the use of a spring loaded lance was most successful in reducing the distress. The use of spring loaded lances may be more humane for heel pricks.

Massive subaponeurotic haematoma occurred in a baby after suture of bleeding scalp blood sampling stabs made before delivery. Eighteen hours after delivery blood samples showed marked prolongation of the prothrombin time. The condition was successfully treated with vitamin K(1) and blood transfusion.

In a neonatal postmortem histological study of scalp stabs made with a fetal blood sampling blade the aponeurosis was punctured in up to 38% of cases even when it was more than 2 mm deep. This and other indirect and direct evidence discussed suggest that five of the seven reported cases of major bleeding after fetal blood sampling in labour were due to blood clotting defects and that these should be considered urgently in the management of future cases.