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Letter to the Editor

What About Parental Involvement in Infants' Pain Management? A Commentary on Erkut, Mutlu, and Çakıcı (2021)

Candido, Ligyana K. PhD(c), MScN, RN; Forgeron, Paula PhD, RN; Harrison, Denise PhD, RN

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The Journal of Perinatal & Neonatal Nursing: April/June 2022 - Volume 36 - Issue 2 - p 96-98
doi: 10.1097/JPN.0000000000000654
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To Dr Katherine Gregory, neonatal editor-in-chief of The Journal of Perinatal & Neonatal Nursing.

Dear editors,

This commentary is in response to the article by Erkut et al,1 which reports on a randomized clinical trial investigating the analgesic effects of 3 forms of positioning for preterm infants during heel lance procedures. The study included 90 preterm infants randomly assigned to 2 experimental groups (upright or supine positions on the lap of a nurse) or a control group (supine on the crib). Results demonstrated that crying duration (P = .003), pain scores (P = .001), and procedure duration (P = .001) were statistically significantly higher in the control group compared with upright and supine positions on the lap. Although the 3 groups of infants experienced mean scores of 3 and greater (±2) on the Neonatal Infant Pain Scale (scores range from 0 to 7 and scores >3 are indicative of moderate pain),2 the authors concluded that upright holding by nurses should be recommended as an analgesic strategy during heel lance procedures performed in preterm infants.

A key point of this study is the lack of equipoise and justification of pain mechanisms. It is concerning that none of the infants included in this clinical trial received evidence-based analgesic strategies while undergoing the painful procedure of heel lance.3 Erkut et al1 also used an insufficient body of evidence to justify the effectiveness of upright and supine holding in the preterm infant population as an analgesic strategy. Moreover, this study disregards the essential role parents can play in their infants' pain management.

According to the principle of equipoise in research, the only ethical justification for enrolling a participant into an arm of the study is if there is true uncertainty on the effect of a therapeutic, prophylactic, or diagnostic set of interventions and if no consensus exists that an alternative intervention would better serve the participants enrolled in the study.4 In the case of Erkut et al,1 an extensive, robust body of research exists about the effectiveness of breastfeeding,5 skin-to-skin care,6 and small amounts of sweet solutions,7 such as glucose and sucrose, in reducing procedural pain in preterm and term neonates. Consensus also exists as these analgesic strategies are recommended in clinical practice guidelines worldwide.8 Given the state of knowledge in the field, allocating infants to the control group (supine position on the crib), or either of the treatment groups, where nurses hold the babies fully clothed, is therefore deemed unethical. Furthermore, references cited in this article to justify the need for this clinical trial do not support the potential analgesic mechanism of upright or supine holding alone.9,10 The authors did not mention an extensively cited Cochrane systematic review conducted by Riddell et al11 on the effectiveness of rocking/holding and other nonpharmacological analgesic strategies, which found low-quality evidence to suggest that holding alone is effective in reducing pain (ie, reactivity or regulation) in neonates. As highlighted by McNair et al,12 holding should be considered only as an adjuvant intervention to other effective analgesic strategies such as offering small amounts of sweet solutions. In addition, a recent systematic review of 20 studies investigating different positions for procedural pain relief (mostly during heel lances) concluded that different positioning in the incubator or the crib (prone, lateral, or supine positions) has minimal analgesic effects and, therefore, should not be used as analgesic strategies in neonatal intensive care units, considering the evidence of more effective nonpharmacological interventions.13

In terms of analgesic mechanisms of action, Erkut et al state that “holding relaxes the infant by providing tactile stimulation”1; this is insufficient as an analgesic mechanism to support the hypotheses that loosely swaddled infants held in upright or supine positions in the lap of a nurse could have their pain effectively decreased during heel lance procedures. Research suggests that analgesic strategies such as breastfeeding and skin-to-skin care are effective due to multisensory stimulation of tasting, tactile, olfactory, and auditory mechanisms.14,15 In the case of sweet-tasting solutions, their analgesic effect is due to an orally mediated increase in endogenous opioids.16

Finally, Erkut et al1 report that legal guardians were informed about the study and consented to their child's participation. However, were parents informed about the role they could play in their child's pain care by providing evidence-based analgesic strategies? The authors' only mention of parents' participation in pain management suggests that nurses should be preferred over parents to hold infants during painful procedures. Parents' advocacy for adequate neonatal pain management, closely related to the family-centered care philosophy, has significantly contributed to advancing research and clinical care practice in the past decades. As reported by systematic and scoping reviews,12,17,18 parent-nurse collaboration can optimize the use of effective and safe analgesic strategies in neonatal intensive care units.

In conclusion, lack of uncertainty (equipoise) in nonpharmacological neonatal pain management strategies no longer exists and there is abundant evidence supporting the use of parent-driven analgesic strategies, such as breastfeeding and skin-to-skin care, as well as sweet-tasting solutions when those options are not available. Therefore, it is unethical to continue conducting studies that do not provide evidence-based pain relief to newborns as standard care during painful procedures as they subject infants to unnecessary suffering. Moreover, there is a need to improve parents' involvement in pain management by informing and supporting their participation in decision making, advocacy, and actual use of analgesic strategies. In other words, there is a pressing need to translate existing evidence on neonatal pain management into clinical practice.

—Ligyana K. Candido, PhD(c), MScN, RN
School of Nursing, Faculty of Health Sciences
University of Ottawa
Ottawa, Ontario, Canada
—Paula Forgeron, PhD, RN
School of Nursing, Faculty of Health Sciences
University of Ottawa
Ottawa, Ontario, Canada
—Denise Harrison, PhD, RN
Department of Nursing, School of Health Sciences
Faculty of Medicine, Dentistry and Health Sciences
The University of Melbourne
Victoria, Australia
School of Nursing, Faculty of Health Sciences
University of Ottawa
Ottawa, Ontario, Canada


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