Nonpharmacological Pain Management for Premature Neonates in Neonatal Intensive Care Units: A Meta-Analysis

Preterm neonates are at higher risk of cumulative procedural pain at a crucial point in brain development. Several procedures performed in neonatal intensive care units (NICUs) have ineffective or absent pain management protocols. Nonpharmacological interventions are simple to implement and cost-efficient. Still, these interventions are underused, and knowledge surrounding the variety of different interventions is lacking. The primary objective of this meta-analysis is to compare and describe nonpharmacological pain management in different clinical procedures in NICUs using Premature Infant Pain Profile (PIPP) as the primary outcome measure.

A literature search was conducted using the databases PubMed (MEDLINE), ScienceDirect, and EBSCO. Selection criteria limited the inclusion of studies describing a nonpharmacological pain-management technique applied to preterm neonates during a painful procedure in a NICU, and which reported pain scores using the PIPP scale. Studies published during the last 10 years were included. A total of 22 types of nonpharmacological pain management strategies were analyzed, as well as combination therapies.

A total of 391 articles were retrieved. Following screening, 45 articles were selected for analysis. Our analysis of nonpharmacological pain management strategies for invasive procedures in NICU patients found that the highest mean effect size was observed for multimodal therapies (mean Hedges' g = 2.4), followed by gustatory stimulation (1.68), olfactory stimulation (0.87), tactile stimulation (0.85), and auditory stimulation (0.79). Only one study addressed visual stimulation, which showed a high effect size (0.91).

Nonpharmacological pain management is most effective on procedures that cause mild to moderate pain according to PIPP classification. Multimodal therapies were most effective. The therapies showed positive results on pain reduction and on neurobehavioral patterns and reduced cumulative stress.