Child Health

Your research into the prevention and higher risk of poor learning, higher risk of management of and stress in poor physical strength and coordination, healthy and sick newborn babies and and higher risk of behavioural problems young children has clear benefits for (Ranger & Grunau, 2014). If we consistently parents worldwide. What drives you use effective ways to reduce pain, during to do this important work and educate all necessary needles and other painful others? procedures, we may be able to reduce the As a neonatal intensive care nurse and a risk of these poor outcomes. midwife with over 25 years of experience, I have seen, helped with and done You describe and skin- thousands of painful but necessary to-skin care as some of the best ways procedures on sick and healthy babies to reduce pain. Why are these simple and young children. We used to be taught measures so frequently ignored by that young babies did not feel pain, or that doctors, nurses and midwives who they did not remember pain, yet it was care for newborn babies and young obvious that this was not the truth, and children? that babies, no matter how preterm and The good news is that, if feasible sick, suffered immensely during painful and possible, supporting mothers to procedures. breastfeed, or supporting mothers, fathers or their family or friends to hold I was driven to research how to improve premature babies skin-to-skin, during pain treatment for sick babies after painful procedures, is so simple to do and helping a physician place a drip in a very so effective. It not only helps the babies, sick baby boy with chronic it is a very powerful way for parents to due to his prematurity. The little guy help and support their role as protectors became so distressed and after a few of their babies. If this cannot occur, very weak cries, he turned blue, then grey, and small amounts, just a drop, of sugar water Three ways to we needed to give him extra and given to babies to suck, is also profoundly help him breathe, then still had to put calming for small sick babies and babies the drip in. It was at that point I became up to a year old. very sad for this little baby, who I can still reduce pain in picture clearly, and angry that we were Why are these simple measures not being doing such painful procedures with no consistently used? There may be many pain relief. So I set out to discover how to answers to this question. Again, the good reduce pain during these painful needles news is these treatments are being used early-life medical in sick babies. more often than they were. The World Health Organization has now publicly What are the risks of poor pain recommended that babies breastfeed management during procedures? during early childhood vaccination, which procedures More and more, researchers are is a huge step in reducing vaccination discovering that poorly-treated pain needle pain. There is more and more Dr Denise Harrison is a nursing professor who, over the during the many painful procedures awareness of the poor outcomes of very sick babies need as part of their care, sick babies, and ways we can give far more past 15 years, has published many studies about pain is harmful to the growing . The gentle care, reduce the number of painful relief for undergoing painful procedures in their first scenario described above tells of the procedures and support parents in their few months of life. Her research aims to narrow the gap short-term effects of harm, with the baby role in caring for their sick babies. between research evidence and practice. This includes being unable to catch his breath and encouraging the implementation of three simple, cost- then needing us to resuscitate him. We However, we certainly know that many now know that the number of painful babies, both sick and healthy, still have effective and well-studied strategies to reduce pain in procedures is the strongest predictor of painful procedures with no pain treatment. babies during needles and other procedures. poor brain development – which means In some cases, this is due to unfounded

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myths about using breastfeeding or skin-to- skin care, including that the baby will choke Social media [is] an (this has not been reported in any trials), the baby will associate the mother with painful effective way of procedures (this makes no sense, as a baby communicating and will breastfeed about 8 times/day, every day, and during only a couple of these feeds will disseminating information a procedure be performed), or that mothers do not want to be there for their baby’s about neonatal pain needles. When mothers are asked this question, they tell the opposite, that they reduction strategies do want to do everything they can to help their babies. Other reasons may be due to lack of knowledge of the effectiveness of breastfeeding, skin-to-skin or sucrose for painful procedures, or workload issues. For SKIN-TO-SKIN CARE example, standard practice in a unit may be If breastfeeding during painful that babies are taken away from mothers procedures is not possible, research for blood work, or that parents are asked to shows that skin-to-skin care leave the room when procedures are done. (SSC) also reduces babies’ pain. Holding newborns to a parent or Could you explain the importance of caregiver’s chest, on their skin, collaboration in disseminating the Breastfeeding is a very effective helps to keep the baby relaxed evidence behind your work and suggest way to keep an infant calm during painful and calm during blood tests or procedures such as a heel lance or venepuncture what more international organisations injections. This is especially useful could do to improve painful procedures for premature babies, and babies for infants? who cannot breastfeed, and means Although there are 100s of published that fathers or other carers can also scientific trials and large systematic reviews provide this care. SSC is most effective (the most recent Cochrane systematic review any newborn infants recommended if started around 15 minutes before a of sucrose for analgesia in newborn babies must undergo painful for babies procedure. Nurses, doctors and lab techs is 360 pages long), and extensive clinical procedures such as a heel who are not able to can help parents do SSC during painful practice guidelines, these documents are aim of unifying neonatal nurses globally, in this article, do you have a key lance or venepuncture breastfeed. This involves the baby being procedures by doing non-urgent blood not easy to read, especially for parents shares the BSweet2Babies video series from message for parents who must put for blood extraction, or held against the skin of a caregiver before tests when parents are able to be present. of babies. We need to show health care their site for worldwide dissemination to their babies and young children immunisations. Premature or sick infants and during painful procedures. Finally, providers and parents how they can help, nurses caring for newborns. We can, and through painful procedures? Mneed more invasive and painful procedures, the baby can be given small amounts of a SWEET SOLUTIONS and clearly show both groups the profound need to, do more, but most knowledge My key message would be: ‘ask your because they are more likely to need sweet-tasting solution, either sucrose or Sweet-tasting solutions are the most calming benefits to the babies of using translation begins at our own doorstep: nurse or doctor, about ways you can help screening and testing to help them recover glucose, before and during a procedure. commonly studied pain treatment in breastfeeding, skin-to-skin or sucrose during working with our local units, hospitals and your baby and young child during painful and become healthy children. After All three methods are easily administered babies. Very small amounts (just a few painful needles. Widely disseminating health care centres to use such simple procedures’. Request to breastfeed, working for many years in neonatal and and can be applied in diverse settings, such drops) of sucrose or glucose, reduce pain clear visual messages in the form of ‘usable strategies consistently is key to changing based on the recommendations of the paediatric intensive care units Dr Denise as neonatal intensive care units, healthy during procedures for newborns and babies evidence’ to health care providers and practices; ensuring that routine practices, World Health Organization. If you are Harrison began her research career with the newborn baby units and immunisation up to one year of age. The pain reducing parents around the world will help spread such as newborn screening, are performed not breastfeeding, request to hold your question, ‘how can we reduce pain during clinics worldwide. effects are due to distraction, because of the messages. Providing videos which when mothers are able to breastfeed, or little baby skin-to-skin, or your toddler painful procedures in sick babies?’ the sweet taste, and more importantly, an are free, easily accessible, and in many someone is able to hold the babies skin-to- upright and front to front. If your baby BREASTFEEDING orally mediated sweet-taste-induced languages helps to ensure the evidence is skin; ensuring that non-urgent blood work is is in the NICU, and able to be held, Pain early on in life can have a negative Although on its own breast milk in small response. For best effects, small amounts able to be shared and used internationally. done when parents are able to be present, request that non-urgent bloods are effect on cognitive development and quantities is not a very effective , of sucrose or glucose are given to babies on rather than at 4am in the morning – a very done only when you, or your partner / have long-term adverse effects on brain the entire process of breastfeeding during their tongue, with or without a soother, just What could international organisations do difficult time for parents to be with their family member / friend is there and able development that means infants have procedures is highly valuable. The benefits before and then during painful procedures. to improve pain treatment? baby in a NICU, yet this is routine practice to hold your baby skin-to-skin. You are altered responses to pain. For instance, are multifactorial: it combines maternal The concentration needs to be sufficiently Some organisations are already working in many organisations; truly partnering with the ones who will comfort your little painful immunisations and injections early holding, sucking, a slightly sweet taste sweet, therefore at least 20% glucose or on this. ChildKind International focuses on parents in our pain care and facilitating their toddler when they stumble and graze in life can cause a fear of needles, with and . More than anything, sucrose is needed. reducing pain and suffering in organisations presence and their support; working with their knees, when they fall off their bikes negative consequences later on. it is comforting to babies because it is that care for children. The Pain in Child our organisations to ensure easy availability and need stitches and whenever they associated with maternal care. This provides MEASURING PAIN Health (PICH) consortium has supported of sweet solutions – sucrose or glucose. have a ‘hurtie’ or an ‘owie’. Start now, REDUCING PAIN IS SIMPLE effective pain reduction while a nurse takes Due to extensive research by nurses, training of a large community of health These are small steps yet they are essential when your baby is just born. You can Harrison and her team highlight three blood samples or delivers immunisations. If doctors, psychologists and scientists over care researchers aimed at improving for babies who do not have a voice or a say partner with us – your doctors, nurses, simple, cost-effective ways to reduce pain a mother and baby are able to breastfeed, the last 20 years, Harrison’s team have knowledge about pain and reducing pain in the matter. midwives and lab techs – to help us all in infants. Firstly, breastfeeding before and this method costs nothing because it good ways to measure pain. For babies, in children around the world. The Council with your baby’s care during painful during painful procedures can minimise requires no additional resources. It is they use the Premature Infant Pain Profile- of International Neonatal Nurses, with their In addition to the guidelines outlined procedures. distress to babies. Secondly, skin-to- suitable for non-urgent procedures and can Revised (PIPP-R) and for older babies and skin care, also called ‘’, is be used in almost any context. young children, they have the FLACC index

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(Face, Legs, Activity, Cry, Consolability). first step to breaking down the barriers The most commonly used indicator in to their implementation. After many Detail pain measurement is facial expressions of years of research, educating healthcare pain. It is clear that for studies measuring practitioners (nurses, doctors, lab techs) RESEARCH OBJECTIVES pain in babies during procedures, babies and encouraging adoption of pain Dr Harrison’s program of research, given no treatment have higher pain scores management strategies in clinical settings, called ‘Be Sweet to Babies’, focuses compared to babies breastfed, held with there has been little actual uptake. This led on in neonates, SSC or given sucrose or glucose. Harrison to try a different approach. She infants and children. Her studies now also partners with parents of babies, include efficacy, effectiveness, safety BARRIERS TO IMPLEMENTATION and targets the communication of her and utilisation of sucrose in diverse Harrison emphasises the importance of findings at parents, advising how to assist neonatal, infant and child populations; working at translating knowledge into during procedures, and how to advocate on systematic reviews of sucrose for action, and tries to identify facilitators and behalf of their babies. pain management; pain prevalence barriers to the implementation of pain in diverse clinical settings; pain reduction strategies. It seems counter- As part of her campaign ‘Be Sweet to management in NICUs and community intuitive that these methods are not widely Babies’, Harrison and her team have settings during immunisation; used, because they are easily administered produced Youtube videos to promote knowledge translation; and ethics of and incur few financial or time costs. In pain management strategies to parents, conducting clinical trials in vulnerable one study, where they examined YouTube and to demonstrate how to deliver them. patient populations. videos of infant immunisations, Harrison’s She sees social media as an effective way team concluded that there were very few of communicating and disseminating COLLABORATORS cases where any pain relief was used, information about neonatal pain reduction • Sandy Dunn from BORN with consequent impacts on the babies’ strategies. They have also produced simple • Baby Friendly Initiative discernible level of distress. posters outlining the three techniques • Bonnie Stevens at SickKids and that can be used, which aim to encourage University of Toronto In a later study exploring the barriers to parents and healthcare practitioners • Paula Forgeron and The Pain Hub at the implementation of pain reduction to adopt them. These methods of University of Toronto strategies, Harrison’s team found that communication can also be extended to • And all parents of babies and the main reasons that measures were not other settings, such as the developing young children taken were related to the knowledge and world, or clinics with poor resources or education of healthcare practitioners, and training. BIO practical factors related to the medical Dr Denise Harrison is the Chair in procedure and organisational structure. Harrison also identifies the need for Nursing Care of Children, Youth and Further constraints, such as the attitudes of a coordinated and uniform approach their Families at the Children’s Hospital healthcare practitioners and the preference to reducing neonatal pain, involving of Eastern Ontario (CHEO) and CHEO to complete procedures without parents participation from healthcare professionals, Research Institute and an Associate present were also identified. parents, frontline carers and the leaders of Professor at the University of Ottawa. organisations and professional associations. Her research program “BSweet2Babies” OVERCOMING BARRIERS Clear guidelines for clinicians on focuses on improving pain Understanding the reasons why pain pain management techniques are management for sick and reduction strategies are not widely necessary, but advice for parents healthy babies and young adopted in neonatal contexts is the is also needed. The evidence is children. Her research includes clear that parents can help reduce using innovative ways to move babies’ pain with simple strategies pain treatment knowledge into – Harrison wants to help healthcare action. professionals work together with parents to put this evidence into practice. CONTACT Faculty of Health Sciences 538-540 KE, Ottawa, ON, K1N 6N5 Canada

E: [email protected] T: +1 613 562-5800 W: www.cheori.org

@dharrisonCHEO BeSweetToBabies

To see Denise’s work for yourself check out her videos on YouTube