The neonatal intensive care unit at BC Women’s is the first home for premature babies born at the hospital.
Some of these “preemies” are born up to four months before their normal due date, and all of them need specialized care until they become strong enough to go home with their parents. Such care often includes painful procedures like blood tests, intubation and ventilation.
Dr. Anne Synnes, a neonatologist and researcher at the BC Children's Hospital, was recently part of a national study that aimed to reduce the pain experienced by neonates in hospital.
“Pain reduction is an important goal in itself,” says Dr. Synnes. “But the study was also driven by increasing evidence that painful procedures are a predictive factor for adverse effects in early development.”
The study has led to the adoption of new pain management practices for all premature neonates born at BC Women’s Hospital.
Locally, Synnes was responsible for tailoring the study to address a specific set of pain management goals for neonates at BC Women’s Hospital. To start, the research team reviewed the charts of 120 infants in the hospital’s neonatal intensive care unit (NICU), to establish a baseline against which to measure their progress. They found, on average, each baby had nine potentially painful procedures every day.
Babies can have different pain thresholds, and not all babies cry when they’re in pain.
Dr. Liisa Holsti, an occupational therapist and a clinical researcher at BC Children's Hospital, says:
There is new research showing that repeated pain in the nursery changes how the brain develops . . . and we have seen associations between early pain and how (children) do from a developmental perspective.
To accurately assess infant pain, the research team needed a validated tool. The one they chose – the Behavioural Indicators of Infant Pain (BIIP) – had been previously developed by team member Dr. Liisa Holsti.
“The BIIP tool involves observing specific movements in the baby’s face and hands,” says Holsti. Using the set list of behavioural and physiological cues included on the BIIP, a trained observer can assess the extent of an infant’s pain, whether the baby is asleep or awake.
After training NICU nursing staff in using the BIIP, the research team was ready for the next phase of their study, starting with a decision about which pain management strategies to implement. Synnes says the team found good evidence for using non-pharmacologic “comfort measures,” including non-nutritive sucking (using a soother), facilitated tucking (swaddling the baby and cradling its head and buttocks) and skin-to-skin comforting. NICU staff were trained in these techniques and encouraged to follow the new pain management protocol – including regular BIIP assessments and the use of comfort measures.
“When we started this study, nobody was doing pain assessment, but as the cycles of our study went along staff became more and more aware,” says Synnes. “The BIIP is now part of our culture, it’s on all the nursing flow sheets that are filled out for every baby, every hour… it’s part of normal clinical care in the NICU.”
“The purpose of the study for us was to change pain management practice in the assessment and treatment realms, and to get consistent practice in both areas,” says Holsti. “Thanks to the efforts of our team and the NICU staff, we seem to have succeeded.”
Dr. Anne Synnes is a neonatologist and a clinical researcher at BC Children's Hospital.
Dr. Liisa Holsti is an occupational therapist and a clinical researcher at BC Children's Hospital. She holds a Canada Research Chair in Neonatal Health and Development.