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Monday, April 23, 2012
Kim Francis PhD, RN, PHCNS-BC, Neonatal Clinical Nurse Specialist for the Massachusetts General Hospital Obstetric Service, Clinical Instructor for the MGH Institute of Health Professions, Haley Nurse Fellow for Boston College and Brigham & Women’s Hospital
Neonatal Clinical Nurse Specialist for the Massachusetts General Hospital Obstetric Service, Clinical Instructor for the MGH Institute of Health Professions, Haley Nurse Fellow for Boston College and Brigham & Women’s Hospital.
In addition to her responsibilities as the Neonatal Clinical Nurse Specialist for the well newborn and level II nurseries at MGH, Kim recently received her PhD from Boston College where she studied pain assessment for premature infants born prior to 34 weeks gestation.
Prior to the 1980s, it was believed that infants lacked the capacity to experience pain. It is now known that fetuses at 20 weeks’ gestational age have the appropriate pain receptors to sense pain. Even as recently as 2004, it was thought that the preterm infant responded only reflexively to stimuli. However, current evidence suggests that preterm infants are consciously processing painful stimuli in the higher centers of the brain. Pain in extremely low gestational age (ELGA) infants (24-29 weeks gestation) continues to be under-assessed and poorly managed. Infants experience pain that is of immediate concern and suffering that may have lifelong physiologic and psychological consequences. Improving pain assessment measures and in turn, the clinical management of pain in this patient population is a high priority in neonatology.
An ELGA infant’s pain response is difficult to assess due to factors associated with extreme prematurity. Few instruments exist to assess pain in the ELGA infant, as most pain assessment instruments have been developed for older infants (e.g. very low gestational age (VLGA) infants). Additionally, these pain assessment instruments are limited by inadequate reliability measures, and specifically, the exclusion of 24-26 week infants from the sample resulting in an underestimation of pain in the ELGA population. Furthermore, recent research on the premature infant’s physiologic variability suggests that combining physiologic and behavioral data may cloud assessment of the true pain score. Thus, the purpose of my dissertation research was to identify behavioral cues that are specific to the ELGA infant’s pain response along with understanding the similarities and differences between the ELGA and VLGA infant’s pain response.
Pain response recognition in ELGA infants
A newly developed pain assessment instrument, Pain Assessment and Care of the Extremely Low Gestational Age Infant Focused Instrument (PACEFI), was constructed to be gestational age appropriate for ELGA infants. The PACEFI demonstrated sound validity and reliability.
In addition to developing and testing a new pain instrument, similarities and difference were examined between ELGA and VLGA infant’s behavioral pain response at baseline, during, and recovery for any invasive and non-invasive procedure (diaper change). The behavioral pain response between ELGA and VLGA infants differed in the robustness of the response but not in the response itself. In addition, ELGA infants tended to have higher pain scores at baseline and recovery for the invasive procedure possibly signifying a sensitization from prior invasive or even non-invasive procedures. Infants in a sensitized state may demonstrate more behavioral cues as their developmental immaturity inhibits regulation of their pain response. Although, ELGA infants demonstrated a less robust pain response during the invasive procedure, it was clear that infants as young as 25 weeks gestational age can exhibit an apparent response to pain. VLGA infants showed less behavioral cues at baseline and recovery supporting the explanation that developmental maturity comes with advancing gestational age. Additionally, ELGA infants demonstrated a more vigorous response during the non-invasive procedure (diaper change). The fact that a diaper change produced the same response as an invasive procedure has significant implications in the delivery of routine care for these infants.
References: Francis, K. (2012). Development of a New Pain Assessment Instrument: Pain Assessment and Care of the Extremely Low Gestational Age Infant Focused Instrument (PACEFI). Doctoral Dissertation. Boston: Boston College.
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