Effect of a Vibratory Stimulus on the Mitigation of Nociception-specific Behavioral and Electroencephalographic Responses to Skin Puncture in Neonates: a Randomized Control Trial
Phase: NA
Conditions: Infant, Newborn, Infant, Premature, Pain Perception, Pain Measurement, Pain Management, Electroencephalography
Sponsor: Lance M Relland, MD, PhD

 
 
Effect of a Vibratory Stimulus on Mitigating Nociception-specific Responses to 
Skin Puncture in Neonates 
 
 
NCT04050384 
 
 
December 19, 2018 

Summary – We aim to fill existing knowledge gaps in neonatal pain mitigation by conducting an 
interventional randomized control trial (RCT) using a novel non-pharmacological approach to 
decrease the nociceptive response to skin puncture.  In addition to validating the effectiveness 
of our intervention, time-locked electroencephalographic (EEG) methods will provide an 
objective measure to which behavioral responses will be compared.  This project will allow the 
development of a battery of quantitative and accurate tools for neonatal pain assessment, 
translate neuroscientific theory of gating into a bedside application in the intensive care unit, and 
facilitate future investigation by pediatric anesthesiologists into regional alternatives for neonatal 
pain management. Because of the established associations between nociceptive 
experiences in the neonatal period and worse developmental, neurological and 
behavioral consequences, our current line of rigorous research can be broadly 
developed, leading to more positive long-term outcomes for hospitalized infants. 
Overall Aim – Optimizing the developmental potential of neonates requires appropriate pain 
control that depends on accurate pain assessment.  For pediatric anesthesiologists, this 
remains challenging due to the lack of self-reporting of subjective experiences in nonverbal 
patients.  Many current uni- and multidimensional pain assessment tools for neonates fail to 
consider developmentally important cues and have incomplete psychometric testing1. In a 
research setting, neonatal pain responses can be accurately measured at the cortical level.  Our 
overall goal is to establish founding principles on which to build objective, clinically practical 
tools that will guide the development of effective pain management in infants.  As validation of 
behavioral components of the pain response is best performed in a non-pharmacological 
setting, we propose a non-invasive technique using a standardized vibratory stimulus (V) to 
mitigate the nociception-specific response to heel lance (HL).  Our brain-oriented measurement 
approach uses EEG-based analysis time-locked to painful or vibratory stimuli, and masked 
coding of facial expression and withdrawal reflex video segments (after reliability training). To 
prove the efficacy of using a Neonatal Intensive Care Unit (NICU)-safe vibration approach in 
decreasing pain during common skin punctures, we will leverage our expertise of EEG methods 
through an RCT in hospitalized infants (n= 134) with the following aims. 
Aim 1: Demonstrate that amplitude of cortical nociceptive response (EEG-based) during 
skin puncture decreases in infants treated with controlled vibration prior to puncture, 
compared to those who receive standard care. 
Aim 2: Establish the feasibility of a novel, evidence-based bedside assessment tool to 
quantify pain responses in infants with and without the intervention, by comparing 
scores on the bedside tool to cortical measures. 
Hypotheses – Our hypotheses will be tested using 
prospectively designed experiments with stimulus 
conditions sequentially administered (see Table).  
First, we hypothesize that during the 350-700ms 
post-stimulus window, there will be a decrease in 
mean amplitude of the EEG nociceptive response at 
the group level (treatment vs. control), as measured 
by the difference in response to HL (C vs. D). There  
should also be a decrease in video-coded behavioral scores.  We will then examine 
associations between nociceptive amplitude and behavioral responses across the entire cohort, 
with and without adjustment for post-menstrual age at testing time.  
Secondly, we hypothesize that EEG will allow measurement of the effect size of vibration on 
amplitude of the nociceptive response at the individual level (pairwise, B vs. D); behavioral 
scores may or may not allow this measurement if a partial reduction of the nociceptive response 
is below the threshold of bedside scales, but not below that of EEG.   
Finally, we hypothesize that there will be significant differences both in the EEG-based and 
the behavioral responses between baseline and HL (A vs. C). Conversely, responses to non-
nociceptive stimulus (A vs. B), will be detectable via EEG response amplitude and frequency, 
but not by video coding. 

Background, Significance, and Relevance –  
Among the 4 million infants hospitalized every year in the U.S., nearly one-third are infants 
with complicating diagnoses increasing their likelihood of exposures to iatrogenic pain.  During 
the first two weeks of life in the NICU, each newborn may undergo an average of 8 to 17 
invasive procedures daily2.  In preterm infants, this may result in 14 painful procedures per day, 
up to 80% of which are not preceded by specific analgesia3.  An exposure rate of up to 300 
painful events during a NICU stay, or even higher in the youngest preterm neonates4, can have 
serious adverse effects.  These range from micro- and macro-structural brain changes in the 
neonatal period, to neurophysiologic alterations of touch and pain processing at discharge, to 
sensory and behavioral problems in adolescence5,6.  In addition to pain hypersensitivity and 
dysesthesias, problems with chronic pain and early uncontrolled pain can alter the 
responsiveness of the neuroendocrine and immune systems to stress in adulthood7.  While the 
American Academy of Pediatrics regularly reaffirms its practice statement that mitigation of pain 
in neonates is of critical importance8, there are currently few effective non-pharmacological 
strategies9, none intended as a prophylactic intervention at the site of a painful stimulus. 
 
The mainstay of bedside management in the NICU consists of reducing the number of 
painful procedures and providing extra hands-on behavior-regulation support. The development 
of novel methodologies to reduce pain is complicated by the difficulties of accurate evaluation of 
pain in neonates.  A national survey of neonatal nurses revealed that only half of them feel 
adequately trained on the topic of pain10.  While over three quarters of these nurses reported 
using pain assessment tools and having confidence in providing interventions, fewer than half 
reported that pain was well managed and that their pain protocols were research or evidence-
based.  A perceived fear of side effects of medications and incorrect interpretation of pain 
signals, as well as lack of trust in pain assessment tools, is in line with other published findings: 
a considerable number of health professionals do not assess the level of pain based on scales 
developed for this purpose3.  Finding an accurate means of pain assessment and its appropriate 
treatment in neonates is of particular importance to pediatric anesthesiologists who are often 
called upon to assist in neonatal procedures involving skin breaks, or to mitigate pain 
experienced during necessary operations. Therefore, projects aiming to safely and 
effectively reduce neonatal pain from skin-puncturing procedures can have a broad 
impact on clinical practice, especially if they are based on rigorous mechanistic 
principles and accurate measurements of neonatal pain. 
 
An initial gap in knowledge we plan to address is the lack of feasible, standardized non-
pharmacological interventions to mitigate pain during routine skin-breaking procedures in the 
NICU. Mitigation of neonatal pain during skin-breaking has been achieved using 
pharmacological means, such as general anesthesia, for complex surgical operations or more 
recently, regional anesthesia through indwelling catheters. Minor neonatal procedures usually 
employ systemic analgesic and sedative administration, but needless administration of these 
agents (from opiates, to benzodiazepines, to sucrose) are associated with multiple concerns 
including prolonged need for mechanical ventilation, delayed feeding, impaired brain growth, 
poor socialization skills, and impaired performance in short-term memory tasks11,12.  Current 
effective non-pharmacological methods include skin-to-skin care and facilitated tucking, but they 
are difficult to implement without parental presence or additional personnel resources. A 
mechanistically-based alternative would be to leverage the “gate-control” properties of the 
peripheral nervous system by stimulating nerve fibers that conduct non-noxious stimuli13. Two 
proposed mechanisms for gate control of nociception are either the stimulation of inhibitory 
interneurons by activation of the large Aβ fibers by vibration, or the induction of low frequency 
(9-20 Hz) “interfering” oscillations by continuous vibration14,15. The concept of “vibration 
anesthesia” has been applied to reduce discomfort in adults undergoing injections16,17, but has 

not been used in the neonatal population. This approach does not simply mask the behavioral 
signs of pain or act as a sedative, it decreases the amplitude of a signal being transmitted to the 
somatosensory cortex. Therefore, delivering a controlled vibration prior to skin-breaking 
could decrease amplitude of the pain response.  
 
In order to ensure the feasibility of implementing novel pain mitigation approaches, a second 
critical gap in knowledge that must be addressed is the lack of quantitative bedside pain 
measures that have been rigorously validated against brain-based methodologies.  The first 
infant behavioral pain measure was developed 30 years ago and was later incorporated into 
several multidimensional scales18.  Many of these scales integrate facial and physiological 
components in addition to non-pain related measures like gestational age.  Most scales have 
incomplete psychometric testing, conflicting evidence with regards to their accuracy, and little 
evidence for their use in pain management1.  Validation using brain-oriented methods has been 
investigated with EEG providing direct evidence of pain-induced brain activity19.  While the 
clinical practicality of time-locked EEG is still limited, this methodology provides a 
means to validate more feasible bedside neonatal pain assessment tools within the 
context of an RCT of a pain-mitigating intervention. 
 
With advancements in technology and a progressively larger number of neonates 
undergoing invasive treatments in the critical care setting in lieu of having them done in 
operating room, the role of pediatric anesthesiologists in optimizing pain assessment and 
management in the youngest of patients has grown beyond the perioperative period.  
Suggestions that general anesthesia may induce toxic biochemical and morphological changes 
in the brain has become a widespread concern20.  This advocates for a trend toward more 
conservative therapies such as using regional or local anesthetic techniques or non-
pharmacological interventions when feasible.  As fewer patients may become subject to 
sedating protocols, it becomes increasingly important to establish clinically practical tools that 
allow for reliable pain assessment and effective treatments in neonates who are behaviorally 
intact.  Our proposed project will set the framework on which to develop such tools and 
therapies, which we will adapt accordingly to a variety of clinical situations, whether it be 
perioperatively, in the critical care setting, or during follow-up for chronic outpatient conditions. 
 
Therefore, the development of novel approaches to pain mitigation for skin breaking 
procedures in hospitalized infants must integrate mechanistic knowledge of nociceptive 
processing with brain-based measurement methodologies. This will allow the development 
of more practical, effective and accurate bedside tools.  Our current study leverages our 
anesthesiology team's extensive experience with pain management in the NICU, our 
laboratory’s expertise in EEG and behavioral video-coding and robust preliminary data to 
develop a bedside pain-mitigation approach, and independently, a validated measurement of its 
effectiveness. 

Preliminary Results –  
 
Our preliminary data as a whole demonstrate the feasibility of our proposed study as well 
confirm the functionality of our customized vibratory device.  The primary weakness noted in the 
review of our initial proposal pertained to the dependence of a study design on a prototype that 
was yet to be manufactured.  We addressed this concern by having completed construction of 
the device and with successful acquisition of adult-based data for proof of concept.   These pilot 
data are detailed in the latter part of this section, preceded by previous work that demonstrate 
our ability to carry out the current study in terms of the using a brain-oriented approach.  
 
We have shown that our team can conduct accurate and specific measurement of pain and 
touch using high-density time-locked EEG (Figure 1) in cohorts of hospitalized neonates21,22.  
Figure 2 demonstrates this in a 
recent cohort of term infants.  This 
published work is the basis for our 
power analysis in the current 
proposal.  Our team can rapidly 
and non-invasively acquire large 
high-quality datasets of brain-
based sensory measures, and 
analyze them with innovative 
spatiotemporal 
and 
spectro-
temporal 
computational 
tools.  
This approach allows us to obtain 
quantitative information with high 
temporal resolution on neural 
activation 
responses, 
without 
requiring active participation or directed attention in awake or resting infants.   
 
We have conducted a rigorous systematic review of all currently 
published pain scales, behavioral and physiological signs that were 
compared to measures based on near-infrared spectroscopy or 
EEG23.  The findings of this work served in the development of a 
panel of only the components most highly associated with pain 
presence and intensity.  The withdrawal reflex and changes in facial 
expression are most strongly associated with nociception-specific 
brain activity while physiological signs, such heart rate and oxygen 
saturation, have little to no association with this type of response.  
We have also developed a system for objective video-coding of 
behavioral responses in infants with reliability >90% using a highly 
manualized approach24. 
 
The device that will provide the intervention in our proposed study has been constructed and 
trialed successfully in a healthy adult male volunteer.  The device has been tested to provide a 
vibration frequency of 178 Hz, with a free-hanging 0.24 mm range of motion and a power output 
of less than 5 watts.  The internal electronic customizations of the device were tested and work 
well in terms of labelling the EEG data to allow for appropriate time-locking with the vibratory 
and/or skin puncturing stimulus. While lancet-based blood sampling in adults is conventionally 
done using one of the upper extremity digits, we emulated a heel lance more closely by 
performing skin puncture on the hypothenar eminence.  For the purposes of this pilot run, we 
analyzed data from a single male adult in fronto-central regions under the various conditions (A 
through D) listed in our study design and specific aims section. 
 
Figure 1 – Cortical Responses to Somatosensory Stimuli in 
33 term infants 

The results illustrate how four 
stimuli conditions can have different 
responses that are consistent with 
the neuroscience of nociceptive 
processing and the gate-control 
theory.  Because they represent 
findings in a single subject, the 
background oscillations smoothed 
out in the grand averaged figure 
above (Figure 1) can still be noted 
and measured. We found distinctive 
waveform patterns after stimulation 
that varied in terms of mean amp-
litude and mode frequency.  In 
Figure 3, the mean amplitude of  
these evoked responses over the fronto-central locations can be quantified in the time window 
of 350-700 ms. In Figure 4, the mode frequency for four distinct conditions are identified.  (A) 
Baseline (white bars), mean amplitude of three averaged segments and mode of background 
frequency is very low. (B) After 
vibration (gray bars), mean amplitude 
of three averaged segments increases 
and a regular 13 Hz frequency is 
detected. (C) After heel lance without 
prior vibration (black bars), mean 
amplitude is elevated and irregular 
high-frequency oscillations occur. (D) 
After heel lance with concurrent 
vibration (striped bars), mean 
amplitude of the response is visibly 
lower than compared to heel lance 
alone, and high frequency oscillations 
are no longer apparent. 
 
 

Experimental Plan, Methods and Statistical Plan – We will conduct an RCT in term and 
preterm infants that are to undergo heel-lancing as part of their routine clinical care.  We 
contracted a group of biomedical engineers (Actuated Medical LLC) to construct a prototype 
that can provide a non-noxious vibratory stimulus in addition to a standard heel-lance.  The 
function of this device has been time-locked with EEG signal acquisition and video of facial 
expression along with limb withdrawal.  Allocation concealment and blind-to-assignment 
conditions for EEG and video examiners will minimize bias. The process flow is depicted in 
Figure 5 with each component of the protocol described in more detail below. 
 
Process Flow 
 
 
Figure 5 

 
Study Population 
 
Inclusion criteria: The study population will be comprised of hospitalized infants in the 
NICU at Nationwide Children’s Hospital (NCH). Because the specific pain response is not 
mature until 36 weeks post-menstrual age (PMA)25, only infants 36-52 weeks will be 
included.  Included infants must be medically stable and due to have a heel lance as part of 
their routine medical care. 
 
Exclusion criteria:  
• 
Patient is over 3 months corrected age 
• 
Infants who receive sucrose (SweetEase) or other analgesic or sedative prior to their 
procedure 
• 
Infants with congenital brain abnormalities 
 
Withdrawal criteria: Infants can be withdrawn from the study at any time at parent’s 
request or if the medical team determines that study participation is not in the patient’s best 
interest. 
 
 
Recruitment and Informed Consent 
 
Recruitment: The research coordinator will identify prospective participants from the electronic 
census of infants admitted to the NCH NICU. Informed consent will be obtained from parents 
using Internal Review Board (IRB) approved documents. Parents will be consented in their 
native language with the use of translated forms and translators when required.  Parents will be 
given information about the study as well as explanations of risks and benefits. Parents will be 
given a signed copy of the informed consent; a second signed copy will be placed in a locked 
cabinet in the Principal Investigator’s locked office. No waivers of informed consent will be 
sought. 
 
 
Intervention 
 
After a resting baseline measurement, each subject 
will undergo three vibration sequences (V) to determine 
an averaged response.  The vibration sequence will be 
provided by a prototype device that connects directly to 
EEG equipment for synchronization purposes.  Output 
signals occur 1-2 milliseconds after manual button 
pushes, one that serves to start/stop the vibration, and 
the other that deploys the lancet (Figure 6).  The device’s 
power output is under 5 watts and provides a vibration of 
178 Hz over a free-hanging distance of 0.24 mm.  The Unistik 3™ Gentle lancets are single-use,  
disposable, 30 gauge needles that penetrate to a depth of 1.5 mm.  Respective control and 
experimental infants will be either treated or not treated with this vibration immediately 
preceding the heel lance (HL).  The V and HL will be time-locked to set video and EEG 
segments for analysis.  Similarly, synchronized video segments will be recorded and coded for 
facial and reflex components.  A schematic of this is outlined in Figure 7. 
Fidelity of intervention monitoring will be assessed by an independent reviewer not 
involved in analysis or intervention support using a checklist developed prior to study start. The 

reviewer will verify a random sample of 10% of unsegmented videos throughout the course of 
the study and note any deviations on the checklist. If any deviations from the intervention 
protocol are observed, the reviewer will notify the research coordinator to correct the deviation 
before the next procedure. 
 
 
Facial Expression Coding and Limb Withdrawal 
 
Facial expression will be scored following the Neonatal Facial Coding System (NFCS)26.  
Components of this scale include the following: brow bulge, eye squeeze, naso-labial furrow, 
open lips, horizontal mouth stretch, vertical mouth stretch, lip purse, taut tongue, chin-quiver, 
tongue protrusion.  Each is assigned one point for its presence then summed for a total score.  
Coding will be based on time-locked video segments that have been processed for the 
purposes of blinding examiners to the condition.  Each video segment will be evaluated by two 
independent researchers not participating in the intervention and masked to group and to 
session sequence. Video coders on the research team will undergo reliability training to achieve 
>90% inter-rater reliability in each domain of assessment on a subset of 20 random video 
segments.  For study scoring purposes, a third masked and reliability-trained coder will also 
review video segments that have more than a 15% score discrepancy between the first two 
reviewers over the entire assessment. The third reviewer’s score will then be averaged with the 
other two scores to minimize discrepancies.   
Limb withdrawal will be assessed in a similarly blinded, randomized fashion and using a 
third coder as needed to address any discrepancies.  Limb movement will be assessed based 
on the following: no movement, ipsilateral withdrawal, contralateral withdrawal or bilateral 
movement. 
 
 
Electroencephalography procedure 
 
Recording: A high-density array of 128 electrodes embedded in soft sponges (Electrical 
Geodesics, Inc. (EGI); Eugene, Oregon, USA) soaked in warm saline and applied to the infant’s 
head will be used to record event related potentials (ERPs) as previously described27,28, with a 
sampling rate of 1000 Hz, filters set to 0.1-400 Hz.  As per published protocols, the midline Cz 
electrode will be used as the reference27.  Infants will be tested in a quiet room in drowsy or 
quiet alert states.  No sucrose or other oral solutions will be used during the procedure and no 
infants will be tested in skin-to-skin hold, but all infants will receive containment support as per 
unit protocol.  Recording of brainwaves will be controlled by Net Station V.4.3. The vibratory 
device and heel lance have been electronically engineered to label the EEG stream for time-
locking purposes to analyze equivalent time windows for the vibratory stimuli and heel lance.   
 

Processing and analysis: ERP data will be filtered using a 0.3–40 
Hz bandpass filter and segmented29,30, using manually verified 
algorithms in the NetStation software to exclude segments 
contaminated by motor or ocular artifacts. Post processing of the data 
will include NetStation tools for bad channel replacement, montage 
referencing and baseline correction. Four scalp regions of interest 
(F3, F4, C3, C4) will be selected for analysis, defined using clusters 
of electrodes identified in published studies of somatosensory stimuli 
(Figure 8)31. Averaged mean amplitude data will be extracted in pre-
specified time windows corresponding to nociceptive specific activity 
(350-700 ms).   
 
 
Statistical Plan 
 
Sample size and power: Based on our previous data21, setting α at 0.05 and setting power 
at 0.80, it will take a sample size of 48 patients per group to demonstrate a medium effect size 
(Cohen's d = 0.57).  This translates into a reduction of mean amplitude of the pain response 
from 5.5 to 3.5 µvolts from our intervention. Factoring in previous rates of artifact-free cortical 
responses and data loss during heel lance, we plan to enroll a total of 134 subjects into the 
study to account for a possible attrition rate of 28 percent.  
 
Analysis: Results will be summarized by intervention group and by stimulus segment using 
means with standard deviations or medians with interquartile range for continuous variables and 
frequencies with percentages for categorical variables. Paired t-tests will be used to compare 
the within-patient change in EEG response and facial response scores, while McNemar tests 
will be used to compare change in extremity response and change in each individual 
subcomponent of the facial response score (A vs. B).  A similar analysis will compare baseline 
to heel lance responses among the control group subjects (A vs. C), as well as vibration to heel 
lance with vibration among the intervention group subjects (B vs. D).   
 
For conditions of skin puncture with or without a vibratory stimulus (between control and 
intervention groups), a two-sample t-test will be used to compare EEG and total facial response 
scores after heel lance by intervention arm, while chi-square or Fisher’s exact tests will be used 
to compare extremity response and individual subcomponents of the facial response tool.  For 
the secondary analysis of these conditions, EEG response will be treated as the dependent 
variable and PMA, intervention group, facial response score, and extremity response will be 
considered as independent variables. Interactions between PMA and intervention group, facial 
response score, and extremity response will also be tested for this secondary analysis, in order 
to determine whether the association between each variable and EEG response varies with 
post-menstrual age; if a significant interaction is found, results will be summarized within PMA 
strata to aid interpretation.   
 
As a final analysis spanning all four experiments, we will use linear and binomial mixed 
effects models to evaluate change in response across each stimulus segment among all 
patients, change in response within each intervention arm, and to compare response in each 
stimulus segment by intervention arm.  All analyses will be conducted using SAS 9.4 with two-
sided p-values<0.05 considered statistically significant. 
 
 
 

Dealing with potential problems:  
 
• 
Attrition and sample size: should the attrition due to motion artifact be higher than expected, 
we can easily increase our recruitment and still remain within the projected timeline. The 
NCH NICU has 140 beds with over 3,000 annual admissions, with infants having multiple 
skin breaking procedures during hospital stays ranging from several days to several months.  
• 
Fidelity of intervention and of behavioral coding will be monitored rigorously as described 
above.  
• 
Diffusion effects between patients are unlikely as only one vibration device exists, for 
research purposes.  
• 
Differential treatment effect considerations: We do not assume that our treatment will affect 
all participants equally. Our analysis plan includes secondary exploratory analyses 
determining the differences in effect as a function of selected variables measured prior to 
randomization. 
• 
Random assignment of infants to one of two groups, masking of all personnel analyzing 
data to study group and statistical control of key pre-randomization covariates will minimize 
selection bias.  
• 
Intent-to-treat analysis is not possible in this design as mechanistic inferences on brain 
responses can only be made based on time-locking to the actual stimulus. 

Approvals for Human Subjects, Potential Problems and Pitfalls, and Risk Mitigation – 
Our study has been approved by the NCH IRB.  The ERP protocols in our study have also 
been approved previously for other studies that are actively taking place at NCH.  Each section 
of our protocol is in alignment with the Office of Human Research Protections Category 1 (45 
CFR 46.404; 21 CFR 50.51) requirements, the custom device is exempt under 21 CFR 
812.2(c), and the FDA-approved heel lancets will be used in accordance with labelling. All heel 
sticks will be those required for routine clinical care and none of the blood will be used for 
research purposes. 
Informed consent will be obtained from parents using IRB approved documents. An 
experienced research coordinator will initiate the informed consent process according to the 
Good Clinical Practice guidelines. Parents will be given information about the study as well as 
explanations of risks and benefits.  The equipment and protocol pose minimal risk to 
participants, and are reasonable in relation to the anticipated benefits to research participants 
and others. 
ERP paradigm minimal risk rationale: The EGI system used to record the brain responses is 
electrically isolated from the participant, eliminating the risk of any current flowing to the 
participant under all conditions, including a ground fault. In the event of a worse-case equipment 
failure where the participant would be grounded, and current paths are reversed to move 
towards the participant, no current beyond 0.2 micro-amps would pass to the participant. This 
level is approximately 250 times lower than the current industrial standards. The electrodes 
used for this study do not require skin abrasion for proper contact and therefore minimize 
infection risk. Risk of infection is further reduced through specific electrode care procedures that 
include rinsing all electrodes with water immediately after testing and then soaking the electrode 
net in a cold sterilizing solution to eliminate any contaminants that otherwise might pass from 
participant to participant. Following soaking, the electrodes are again rinsed and then air dried.   
The vibratory device is made of construction materials that allow for sanitizing the equipment 
between patients, and the internal circuitry that will allow for time-locking the function of the 
device with the EEG data in the EGI system is also electrically isolated from the patients and 
carry minimal risk. 
Video of the subjects will be taken before, during, and after the procedure. The study 
coordinator and other NCH study personnel who are blinded to the infant’s identity will be the 
only people to view the videos, and all video material will be destroyed after six years from study 
completion. The video material will be kept in a folder within a secure, NCH-managed Dropbox 
account and the only people who will have access to this folder are the personnel involved in 
the study.  
Risk minimization includes adherence to the procedural guidelines to maintain standard of 
care, following unit protocols and infection control procedures, and utilization of RedCap 
database for data storage. Study data will be stored using REDCap, which is a secure, web-
based application designed to support data capture for research studies by building and 
managing online surveys and databases. Study video material will be stored using an NCH-
managed Dropbox account, and the only people who will have access to the study folder will be 
the personnel involved in the study. Infants will be continuously monitored, not only by study 
personnel, but also by the infant's bedside nurse during all steps of the protocol, to mitigate any 
possible risk. Study personnel will be the only people to view the videos, and all video material 
will be destroyed after six years from study completion. 
We do not anticipate withdrawal due to safety or toxicity concerns. Should the participant 
become medically unstable and participation not be in the patient's best interest, he or she will 
be withdrawn from the study.

References – 
1. Holsti, L., R.E. Grunau, and E. Shany, Assessing pain in preterm infants in the neonatal intensive care unit: moving to 
a 'brain-oriented' approach. Pain Manag, 2011. 1(2): p. 171-179. 
2. Cruz, M.D., A.M. Fernandes, and C.R. Oliveira, Epidemiology of painful procedures performed in neonates: A 
systematic review of observational studies. Eur J Pain, 2016. 20(4): p. 489-98. 
3. Carbajal, R., et al., Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA, 
2008. 300(1): p. 60-70. 
4. Porter, F.L., C.M. Wolf, and J.P. Miller, Procedural pain in newborn infants: the influence of intensity and 
development. Pediatrics, 1999. 104(1): p. e13. 
5. Anand, K.J. and F.M. Scalzo, Can adverse neonatal experiences alter brain development and subsequent behavior? 
Biol Neonate, 2000. 77(2): p. 69-82. 
6. Grunau, R.E., Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. 
Rambam Maimonides Med J, 2013. 4(4): p. e0025. 
7. Page, G.G., Are there long-term consequences of pain in newborn or very young infants? J Perinat Educ, 2004. 13(3): 
p. 10-7. 
8. American Academy of Pediatrics Committee on, F., et al., Prevention and management of pain in the neonate: an 
update. Pediatrics, 2006. 118(5): p. 2231-41. 
9. Sposito, N.P.B., et al., Assessment and management of pain in newborns hospitalized in a Neonatal Intensive Care 
Unit: a cross-sectional study. Rev Lat Am Enfermagem, 2017. 25: p. e2931. 
10. Cong, X., C. Delaney, and V. Vazquez, Neonatal nurses' perceptions of pain assessment and management in NICUs: 
a national survey. Adv Neonatal Care, 2013. 13(5): p. 353-60. 
11. de Graaf, J., et al., Long-term effects of routine morphine infusion in mechanically ventilated neonates on children's 
functioning: five-year follow-up of a randomized controlled trial. Pain, 2011. 152(6): p. 1391-7. 
12. Ferguson, S.A., et al., A pilot study of preemptive morphine analgesia in preterm neonates: effects on head 
circumference, social behavior, and response latencies in early childhood. Neurotoxicol Teratol, 2012. 34(1): p. 47-55. 
13. Moayedi, M. and K.D. Davis, Theories of pain: from specificity to gate control. J Neurophysiol, 2013. 109(1): p. 5-12. 
14. Melzack, R. and P.D. Wall, Pain mechanisms: a new theory. Science, 1965. 150(3699): p. 971-9. 
15. Dinse, H.R., et al., Low-frequency oscillations of visual, auditory and somatosensory cortical neurons evoked by 
sensory stimulation. Int J Psychophysiol, 1997. 26(1-3): p. 205-27. 
16. Smith, K.C., et al., Vibration anesthesia: a noninvasive method of reducing discomfort prior to dermatologic 
procedures. Dermatol Online J, 2004. 10(2): p. 1. 
17. Park, K.W., et al., The efficacy of 95-Hz topical vibration in pain reduction for trigger finger injection: a placebo-
controlled, prospective, randomized trial. J Hand Surg Am, 2014. 39(11): p. 2203-7. 
18. de Melo, G.M., et al., [Pain assessment scales in newborns: integrative review]. Rev Paul Pediatr, 2014. 32(4): p. 
395-402. 
19. Hartley, C., et al., The relationship between nociceptive brain activity, spinal reflex withdrawal and behaviour in 
newborn infants. Scientific Reports, 2015. 5: p. 12519. 
20. Jevtovic-Todorovic, V., General Anesthetics and Neurotoxicity: How Much Do We Know? Anesthesiol Clin, 2016. 
34(3): p. 439-51. 
21. Maitre, N.L., et al., Cry presence and amplitude do not reflect cortical processing of painful stimuli in newborns with 
distinct responses to touch or cold. Archives of Disease in Childhood: Fetal and Neonatal Edition, 2017. 102(5): p. 
F428-F433. 
22. Maitre, N.L., et al., The Dual Nature of Early-Life Experience on Somatosensory Processing in the Human Infant 
Brain. Curr Biol, 2017. 27(7): p. 1048-1054. 
23. Relland, L.M., A. Gehred, and N.L. Maitre, Behavioral and Physiological Signs for Pain Assessment in Preterm and 
Term Neonates during a Nociception-Specific Response: A Systematic Review. Pediatric Neurology, 2018. In Press. 
24. Emery, L., et al., Protocolized music therapy supports developmental progression in hospitalized infants: a 
comparative effectiveness study. Acta Paediatrica, 2018. Accepted. 
25. Fabrizi, L., et al., A shift in sensory processing that enables the developing human brain to discriminate touch from 
pain. Curr Biol, 2011. 21(18): p. 1552-8. 
26. Grunau, R.E., et al., Bedside application of the Neonatal Facial Coding System in pain assessment of premature 
neonates. Pain, 1998. 76(3): p. 277-86. 
27. Maitre, N.L., Z.P. Barnett, and A.P. Key, Novel assessment of cortical response to somatosensory stimuli in children 
with hemiparetic cerebral palsy. J Child Neurol, 2012. 27(10): p. 1276-83. 
28. Maitre, N.L. and A.P. Key, Quantitative assessment of cortical auditory-tactile processing in children with disabilities. J 
Vis Exp, 2014(83): p. e51054. 
29. Michail, G., et al., Neuronal Oscillations in Various Frequency Bands Differ between Pain and Touch. Front Hum 
Neurosci, 2016. 10: p. 182. 
30. Schulz, E., et al., Neurophysiological coding of traits and states in the perception of pain. Cereb Cortex, 2011. 21(10): 
p. 2408-14. 
31. Worley, A., et al., Multi-modal pain measurements in infants. J Neurosci Methods, 2012. 205(2): p. 252-7.