ORIGINAL RESEARCH

Discomfort and pain in the newborn: reflections of neonatal nursing

Roberta Costa^I; Raquel Alves Cordeiro^II

^I PhD in Nursing. Adjunct Professor of the Federal University of Santa Catarina. Researcher at the Research Group on Women and Newborn Health. Florianopolis, Santa Catarina, Brazil. E-mail: roberta.costa@ufsc.br
^II Professional Master in Management of Care in Nursing. Nurse at the neonatal unit of the University Hospital Polydoro Ernani de São Thiago. Florianopolis, Santa Catarina, Brazil. E-mail: raquelufsc75@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.11298

ABSTRACT

Objective: to engage nursing staff in thinking about management of discomfort and pain in newborn babies. Method: this convergentcare study was conducted in a neonatal unit in southern Brazil. The participants were 16 members of a nursing team. Data was collected during October and November 2012, through focus groups underpinned by the theory of Liberation Pedagogy. Results: from that practical educational activity three categories emerged: environmental stimuli cause pain and discomfort in the newborn; invasive procedures are the main causes of pain in the neonatal unit; and nurses recognize the signals of babies' pain. Conclusion: the results demonstrate health professionals' concern with identifying pain, the need to minimize environmental stimuli and the importance of using pharmacological and non-pharmacological measures, mainly during invasive procedures, to avoid effects on the psychomotor development of the newborn.

Keywords: Pain; infant, newborn; neonatology; nursing.

Improving the quality of life of the newborn (NB) admitted to neonatal intensive care unit (NICU) is a goal of the nursing team. Long-term studies have shown an increase of disabling sequelae, chronic and neurological diseases, learning difficulties and cognitive disorders of language, vision, hearing and behavioral, among others. Some studies have suggested that part of this morbidity may represent injuries in brain development, resulting from the stressful stimulation in the intensive care environment ^1-3.

The NICU hospitalization puts newborns in a restricted environment, where they are exposed to unpleasant stimuli such as bright light, noise, clinical and invasive procedures that cause discomfort and pain² . Therefore, it is essential that the neonatal health professional knows how to identify, assess and treat pain in NB, trying to reduce and / or avoid adverse effects on their development and contribute not only to a faster recovery but also to a quality care⁴.

As nurses working in NICUs, we realize the importance of promoting moments of reflection together with the nursing staff, aiming the construction of a conscious think-make through dialogue. This strategy allows that neonatal team members talk about their daily lives, about their actions in pain management and prevention of discomfort in newborns, promoting moments of exchange of experiences and knowledge, encouraging the search for new knowledge and favoring a new reality of care.

In this sense, it is understood that a quality and individualized care, adapted to the needs of each newborn, depends largely on awareness by the nursing team, who must adopt strategies for the comprehensive care of the neonate, potentially subject to suffer pain and discomfort⁴.

In the NICU, where researchers act as clinical nurses, pain assessment has been carried out since 2009, routinely, as one of the vital signs. However, we can see in the accounts of team members that there are difficulties regarding the implementation of pain assessment scale (Neonatal Infant Pain Score - NIPS), related to the required frequency and proper timing of such an evaluation, as well as to the difficulty of this perception in some moments. Commonly, the experience of NICU professionals makes them note that comfort measures such as containment, non-nutritive sucking and supply of glucose solution are applied, but often in conditional and non-systematic manner, and sometimes inadequate in face of the presented pain, when conducting a more succinct assessment ⁵. These factors reinforce the importance and need of this research.

These concerns motivated the development of this research, aiming to promote a process of reflection with the nursing staff on the management of discomfort and pain in newborns.

THEORETICAL FRAMEWORK

For theoretical support of this study, we have used the assumptions of Paulo Freire, which instigate subjects to discuss the reality^6,7 experienced by the newborn exposed to pain in NICU and allow the survey participants to reflect on their actions and to build, through dialogue, a conscious think-make. This process occurs through the action-reflection-action and thus builds the practice-theory-practice during the daily life of care in the hospital.

The investigative approach enables the progressive construction of individual knowledge through action-reflection-action and association between practice and theory⁶. Freire announces the transformation of reality of people through the problematic dialogic education, through the awareness process⁷.

METHODOLOGY

This is a convergent care research (CCR), which is characterized by the junction between care practice and the educational process that the nurse develops as a facilitator in their work environment in the nursing team. The CCR is a method aimed at resolutions or minimization of everyday problems that the nurse experiences and at possible changes that the reflection process might promote in the health practices⁸.

The study location was the NICU of a university hospital in southern Brazil. Study participants were four nurses, nine nursing technicians, a nursing assistant and two nursing students. All professionals from the nursing staff were invited to participate in the investigation, except those who were on vacation, sick leave or away from work activities for any other reason. Four reflection groups were conducted from October to November 2011 through the educational process guided by Paulo Freire's assumptions and through the arch of problematization^6,7.

At the firts meeting, we identified the perceptions of the group about the discomfort and pain experienced by newborns or the factors that trigger them. The second meeting proposed to verify the non-pharmacological methods known, in addition to reviewing in the literature other non-pharmacological methods mentioned as effective. In the third meeting, we discussed which and how the non-pharmacological methods for pain relief are used. In the last meeting, we assessed what works properly in our reality and what we can improve in relation to the management of discomfort and pain in newborns.

The collection of the data CCR was conducted based on the statements of nursing team members during the course of the meetings. A recorder was use to register the reflection groups, as agreed with the participating professionals. A record was also done in a field diary.

To analyze the data, we seek the most significant statements in relation to the proposed objective. This step involved the processes of seizure, synthesis and theorization proposed by the CCR⁸. Initially, there was reading of the lines obtained in the course of the reflection groups, from which keywords emerged, considering the purpose of the research. The synthesis stage referred the arduous reading of relevant articles to the subject, aiming the search for expressions issued by participants in view of raising the possible categories. Finally, the theorizing stage sought to narrow the list of categories with the theoretical framework⁸. From this process, three categories emerged: environmental stimuli cause pain and discomfort in NB; invasive procedures as the main causes of pain in newborns; and the nursing recognizes the newborn's nociceptive signals and discomfort.

Ensuring ethical precepts, survey participants agreed to participate voluntarily and were identified with alphabet letters regarding their professional category - nursing technician (T), nurse (N) and nursing assistant (A) - followed by a sequential number (e.g., T1, N2, A1). The meetings were held after the professionals signed the Informed Consent Form. The project was approved by the Ethics Committee on Human Research of the Federal University of Santa Catarina, under opinion number 2241 462 628 FR.

RESULTS AND DISCUSSION

The analysis was performed from the three categories that emerged from data collected during the process of reflection.

Environmental stimuli cause pain and discomfort in NB

Technological advances have resulted in an increase in handling of newborns, especially preterm and low birth weight infants, causing them to remain under strong light and noise all the time^2,9. There are multiple causes of discomfort for the newborn in a NICU, including: prolonged ventilation, inadequate nutrition, episodes of oxygen saturation falls, intense lighting, constant noise, multiple procedures, among others. In addition, the neonate is subjected to various noises that are produced by ventilators, incubators, monitors, alarms, secretion cleaners, oxygen exits and compressed air, telephones and dialogues established between professionals and family members, which may hamper their well-being baby and harm their development¹⁰.

Another aspect that has concerned researchers is the consequences of the use of continuous fluorescent lights on the baby, due to physiological and biochemical effects of this type of lighting. The continuous lighting also affects the standard of day and night, important in the future development of children and can cause retinopathy in premature infants, leading to blindness¹¹.

The nursing professionals' statements show the concern with excessive environmental stimuli, such as noise and light.

[...] we have to explain to a newborn what a day is, what night is; we open the curtains, show the light, because the newborn should be in the belly, so he does not need to have external stimuli of light, heat, noise, so he does not need any of these stimuli, they need tranquility (T2).

[…] sometimes [...], even when I am going to open the incubator, I feel pity [...] because they are asleep and just because of that little noise their hands and feet go up there, in fright (T7).

There are several behavioral (non-pharmacological) measures that can be performed in order to prevent discomfort and pain during hospitalization and also to make the environment more humanized and less stressful for babies and their families: controlling the incidence of bright lights on the NB; reducing noise around them (alarms and conversation); avoiding the handling of the NB (preserving free periods for sleep and avoiding multiple blood samples, which must be grouped) using minimal handling protocols; encouraging the use of central venous catheters; decreasing the amount of adhesive tapes and other tapes on the skin; positioning properly the tracheal tube, avoiding its traction or dislocation¹².

A speech that draws attention is the concern that professionals have to respect the baby's time, as the following line shows:

We must wait, warm them, talk to the doctor to see if it could be later, or how long the baby can go without certain medication. Let the baby rest and know that we will not be more competent by handling a baby all the time (T2).

Take a break in handling is an approach that should be used by all staff in the NICU and also by the parents after guidance. Before performing technical procedures, the professional who takes care of the baby may ask the colleague or the parents to assist in neonatal care, offering warmth and comfort, trying that the therapeutic stimuli remain within the baby's tolerance¹³. Regardless of the strategy adopted by the health professional to minimize the pain of the newborn, humanization and respect should be the main focus of care practices, seeking to reduce the trauma caused by the hospitalization⁴.

Invasive procedures as the main causes of pain in newborns

The fact that newborns do not verbalize their pain caused that, until the mid-1970s, clinicians and researchers believe that the infant was unable to feel pain, because of neurological immaturity. Now, however, researches have documented that the newborn has all the functional and neurochemical components required for reception and transmission of painful stimuli ^4,12,14.

In parallel to the sophistication of therapeutic resources, more invasive procedures are necessary to ensure the survival of these children. This technological advancement and new practices have brought a cost to the neonate, including greater exposure to painful phenomena. Therefore, the neurological immaturity does not make the NB incapable of sensitivity and painful memories. Rather, incomplete myelination is offset by the lower interneuronal distance, which increases the average velocity of nerve conduction ^4,14.

In daily practice, numerous routine procedures are conducted in neonatal units such as heel and arteriovenous punctures, considered painful for the newborn. Due to their inability to verbalize concepts, they are dependent on the observation and interpretation of their behavior by caregivers ^12,15.

It is known that proper treatment of neonatal pain is associated with lower implications and reduced mortality. In this context, it is important to add techniques to prevent and control pain in the NICU. In the meetings, we observed that professionals have already identified the procedures that cause pain in newborns and they care about using strategies to minimize the deleterious effects of pain.

Of all the procedures we do, aspiration, I think, is the most painful. Actually, CPAP intubation ... lumbar puncture, blood gas, which are among the tests (E1).

The chest tube is very painful (T3).

[…] the Abocath® already hurts like hell. Imagine! When we get nudging the artery! Who uses CPAP is always irritated [...] (N1).

[…] six days after she got medicated, I thought it was pain, I saw and stretched [her limb], she cried [...] (A1).

It is of prime importance the use of a precautionary approach when the pain can be predicted. In the case of procedures such as venipuncture, intubation, among others, it is better to do prophylaxis than waiting for the painful stimuli happen to treat or remediate^12,15.

Several studies have shown that the painful and prolonged repetitive stimulation in early life can lead to changes in the central nervous system with consequences during childhood and possibly later in life ^15,16.

Participants' statements revealed that some professionals still have difficulty in treating pain, as we can see:

[...] resistance because they [doctors] always say that a few years ago [it was thought] that newborns felt no pain because a part of the nervous system was not formed. That's what they always said (T5).

It is not for any crying that we can give medication. Here we speak of pharmacological and non-pharmacological measures (T4).

Here they do not receive routine medication, only ours [referring to nursing], we have to realize that part (T2).

The difficulties for the proper treatment of pain in newborns are not only linked to the lack of diagnostic and therapeutic options, but also in how health professionals use the scientific knowledge about the presence, diagnosis and pain treatment in their practice daily^12,17.

The indication of analgesia should be individualized and always considered in every newborn with potentially painful disorders and / or undergoing invasive procedures, surgical or not ¹⁸.

A humanization strategy seen in this group is to make the procedures always with two people, a practice also recommended on the Humanized Care Guideline for low-weight newborns, of the Brazilian Ministry of Health ¹³.

I have never punctured alone, I do not even know if I am able to puncture alone (T2).

[...]I came here and I have already learned to punch in pairs because of the pain […] (T4).

Professionals should work together during the proceedings, taking the precaution of leaving a person giving continuous support to the NB (which can be the father or the mother), being cautious during the care and keeping all interactions within the tolerance of the neonate ^12,13.

We must enhance professionals' awareness, especially nursing professionals, to the language of the NB, in order to improve the care of these patients undergoing numerous painful procedures along the admissions to the NICU's, as these professionals are primarily involved in management and neonatal care^12,16.

The nursing recognizes the newborn's nociceptive signals and discomfort

Prevention and treatment of pain is a constant challenge. It involves the evaluation of the presence, type, intensity, location and possible causes of pain. The parameters of this assessment may vary from customer to customer and, in the case of newborns, this assessment becomes even more difficult, since they do not communicate verbally, demanding from the nursing professional an effective critical thinking, proper training and constant updating ^16,17.

Currently, a widely accepted notion is that both full-term and preterm newborns have all essential anatomical, functional and neurochemical components for nociception, that is, for the reception, transmission and integration of painful stimuli. Among the behaviors that may indicate pain in infants are crying, facial expression and agitation. In the list of physiological reactions, there is highlight for increased heart rate, respiratory rate and blood pressure, decreased oxygen saturation, apnea, cyanosis, tremors and sweating^12,16,18.

In the testimonies, we find lines that illustrate the ability of nurses to identify the pain.

In fact, the perception of pain is quite notorious for everyone here (N1).

If we work here in nursing, we have to look for the well-being, the humanization of the other, because we are doing for the other, not for us (T1).

[...] when I'm inserting a probe, it hurts a lot. It hurts me and it hurts them (A1).

[...] all babies here feel pain [...] let them feel the pain? Just because they will not remember later? (N1).

The latter speaks well portrays the concern for the future of the newborn in the NICU, because the neurological immaturity does not make the infant incapable of sensitivity and painful memories ¹⁶. The difficulty of evaluation and measurement of discomfort and pain in the newborn is the greatest obstacle to the proper treatment of pain in neonatal units ¹⁵.

In the reflection meetings, professionals also highlighted the importance of observing, to recognize the baby's signs.

I think we can enlarge a little more the observation of the pain, not only the crying, but the facial expression, as we have in the scale [...] (N1).

In the unit where the research was conducted, the NIPS scale is used to standardize and facilitate the evaluation of pain in newborns. The multi-dimensional scales, such as NIPS, were developed from the need to decode the behavioral and physiological signs of the newborn. The NIPS is composed of six indicators of pain, five behavioral and one physiological, including facial expression, crying, moving arms and legs, the state of sleep / alert and breathing pattern¹⁵. Knowing that the NB manifests their pain in different ways is not enough, it is necessary to use tools that allow professionals to decode the language of these expressions and establish appropriate strategies to minimize pain and discomfort.

CONCLUSION

In seeking to understand the expectations of the professionals participating in the debate about the management of discomfort and pain in newborns, it was found that the members of this group, through dialogue and reflection-action-reflection, envisioned new perspectives and reflected the practices already carried out, guided by scientific knowledge, contextualizing them as managements seized in daily life in NICU, thereby achieving the objective of this investigation.

During the meetings, we realized the concern of professionals with the influence of environmental factors that lead to possible discomfort / pain to infants, with implications on their psychomotor development, and these have already adopted practical measures to reduce noise and light. Moreover, they stressed the need for non-pharmacological and pharmacological measures in pain management, especially related to invasive procedures.

We also highlight, in this research, the importance of nursing professionals to recognize the signs of discomfort and pain emitted by the baby and the use of NIPS scale as a facilitator of this process. Newborns, through signs such as facial expression, body movement, crying and the state of consciousness, among others, expresses and attempts to communicate the pain. Thus, the signals emitted by the NB before the painful stimulus area code, or a language. It is necessary, then, that the professional recognizes or decodes these signals. Pain assessment scales have helped health professionals in this process.

As limitation of this study, there was a need to discuss this subject with all professionals working in the neonatal unit and not only with nursing professionals. In this environment, the integrated work in multidisciplinary team is essential to ensure the safety and quality of care.

The development of this research promoted a collective thinking through dialogue and reflections on the articles published on the theme, and explored the nursing team experiences in daily life in NICU, resulting in a re-think that may favor the construction of new concepts and renovation of practices.

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