Cochrane Review: Non‐pharmacological management of infant and young child procedural pain
Authors: Pillai Riddell Rebecca R , Racine Nicole M , Turcotte Kara , Uman Lindsay S , Horton Rachel E , Din Osmun Laila , Ahola Kohut Sara , Hillgrove Stuart Jessica , Stevens Bonnie , Gerwitz‐Stern Alanna 
Published: November 2012

AbstractBackgroundInfant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.ObjectivesTo assess the efficacy of non‐pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain‐related regulation).Search methodsWe searched CENTRAL inThe Cochrane Library(2011, Issue 1), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), PsycINFO (1967 to April 2011), Cumulative Index to Nursing and Allied Health Literature (1982 to 2011), Dissertation Abstracts International (1980 to 2011) andwww.clinicaltrials.gov. We also searched reference lists and contacted researchers via electronic list‐serves.Selection criteriaParticipants included infants from birth to three years. Only randomized controlled trials (RCTs) or RCT cross‐overs that had a no‐treatment control comparison were eligible for inclusion in the analyses. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results.Data collection and analysisWe refined search strategies with three Cochrane‐affiliated librarians. At least two review authors extracted and rated 51 articles. Study quality ratings were based on a scale by Yates and colleagues. We analyzed the standardized mean difference (SMD) using the generic inverse variance method. We also provided qualitative descriptions of 20 relevant but excluded studies.Main resultsFifty‐one studies, with 3396 participants, were analyzed. The most commonly studied acute procedures were heel‐sticks (29 studies) and needles (n = 10 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non‐nutritive sucking‐related interventions (preterm: SMD ‐0.42; 95% CI ‐0.68 to ‐0.15; neonate: SMD ‐1.45, 95% CI ‐2.34 to ‐0.57), kangaroo care (preterm: SMD ‐1.12, 95% CI ‐2.04 to ‐0.21), and swaddling/facilitated tucking (preterm: SMD ‐0.97; 95% CI ‐1.63 to ‐0.31). For immediate pain‐related regulation, the largest SMDs were: non‐nutritive sucking‐related interventions (preterm: SMD ‐0.38; 95% CI ‐0.59 to ‐0.17; neonate: SMD ‐0.90, 95% CI ‐1.54 to ‐0.25), kangaroo care (SMD ‐0.77, 95% CI ‐1.50 to ‐0.03), swaddling/facilitated tucking (preterm: SMD ‐0.75; 95% CI ‐1.14 to ‐0.36), and rocking/holding (neonate: SMD ‐0.75; 95% CI ‐1.20 to ‐0.30).The presence of significant heterogeneity limited our confidence in the lack of findings for certain analyses.Authors' conclusionsThere is evidence that different non‐pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.Plain Language SummaryNon‐pharmacological interventions for acute pain in infantsWe examined 13 different types of commonly investigated non‐pharmacological treatments (excluding breastmilk, sucrose, and music) to determine their efficacy for pain reactions after an acutely painful procedure (right after the needle ('pain reactivity') and less immediate pain reactions ('immediate pain‐related regulation').Fifty‐one randomized controlled trials were included involving 3396 participants. For preterm infants, there was sufficient evidence to recommend kangaroo care, sucking‐related interventions, and swaddling/facilitated tucking interventions for both pain reactivity and immediate pain‐related regulation. For neonates, there was sufficient evidence to recommend sucking‐related interventions as an effective treatment for pain reactivity and immediate pain‐related regulation.Rocking/holding was also found to be efficacious for neonatal immediate pain‐related regulation.For older infants, there were no treatments reviewed that demonstrated sufficient evidence. Due to significant differences in the magnitude of treatment effects among studies (heterogeneity), some analyses that found a lack of treatment effect need to be interpreted with caution.