Shouldn't we reconsider procedural techniques to prevent neonatal pain?

Many procedural interventions during neonatal stay remain a burden as they cause pain or discomfort (Simons et al., 2003). We therefore appreciate the review on non-pharmacological interventions for procedural pain relief (Cignacco et al., 2007). The authors concluded that future research should focus on the effectiveness of non-pharmacological interventions. The American Academy of Pediatrics recently reemphasized the need for concerted efforts of all caregivers involved to reduced the number of invasive procedures (American Academy of Pediatrics, 2006). In addition to the conclusions of both papers, we would like to point to the potential relevance to evaluate techniques on the associated stress- and pain response. Such an approach might equally be effective in addition to non-pharmacological interventions as has been documented for blood sampling, venipuncture being less painful compared to heel lancing. We would like to illustrate the potential impact of adaptations of procedural techniques on the associated stress and pain response based on a nursing (endotracheal suctioning), a medical screening (retinopathy of prematurity, ROP) and a surgical (retinal surgery) intervention. The stress response associated with closed endotracheal suctioning was documented in 10 ventilated neonates to evaluate the correlation between cathecholamine increase and increase in pain score to validate a neonatal pain scale (Allegaert et al., 2003). Findings in this cohort were compared with an earlier reported cohort of the same unit in whom open suctioning was applied (Bernert et al., 1997). Based on vital signs and pain assessment, a blunted stress response was observed following closed endotracheal suctioning while catecholamine release was less prominent compared to other reported observations (Greisen et al., 1985; Saarenmaa et al., 1999) (Table 1). In a bench test evaluation of a closed tracheal suction system, it was concluded that continuity of ventilation volume or pressure delivery during suction are not preserved and therefore can not explain the reported reduction in suction-related hypoxia (Cordero et al., 2000). It is not unlikely that the blunted stress response in part explains this reduction. In line with international guidelines on screening for ROP, infants with a gestational age below 32 weeks need to be screened, initiated at the postnatal age of 4–5 weeks. We recently reported on the prospective assessment of systemic side effects of topical ophthalmic drug administration for ROP screening (Willems et al., 2006). In the same cohort, the clinical pain response during indirect ophthalmoscopy was documented using the same outcome variables as described by Belda et al. (2004). However, instead of the classic scleral indentation technique, the eyelid was kept open with a 20 diopter lens (Fabrilens). A blunted clinical stress response was observed with a faster return to baseline in neonates in whom the Fabrilens was used: CRIES score returned to pre-intervention values within 5min while changes in cardiovascular indicators were less prominent (Table 2). Retinal surgery, either cryotherapy or laser photocoagulation has proven to be effective to prevent retinal detachment when threshold ROP is observed. Laser photocoagulation was introduced in the unit in 2001 and subsequently became the preferred treatment modality. We therefore were able to compare characteristics and peroperative management of two consecutively treated cohorts [cryotherapy (2000–2001), laser photocoagulation (2002–2004)]. Laser photocoagulation resulted in a faster clinical recovery (Table 3) (Allegaert et al., 2006). We hereby do not claim to have documented the superiority of a given procedural technique. However, these observations serve as indicators of a potential relevant approach. Similar to the conclusions of Cignacco et al., prospective studies should be performed to evaluate the impact of adaptations of techniques on the neonatal stress and pain response. In addition, methods for effective transfer of the available evidence on the relevance of pain prevention and management in neonates from the clinical research towards routine clinical care should be evaluated since one can not simply assume that ‘what has been proven will be done’ (Sharek et al., 2006).