Nonpharmacological Interventions for Preventing Pain During Endotracheal Suctioning in Neonates Receiving Mechanical Ventilation

What are the benefits and harms of nonpharmacological interventions for preventing pain during endotracheal suctioning in neonates receiving mechanical ventilation?The understanding of neonatal pain continues to advance, and it is now well established that newborns are capable of detecting, processing, and responding to pain. In fact, neonates have an immature nervous system that creates a hypersensitivity to pain, resulting in a greater risk for experiencing pain.1 Repeated painful experiences in neonates can cause harmful systemic physiological effects, leading to long-term complications and potentially life-threatening risks. However, pain-relief interventions in neonates remain insufficient and inconsistently applied, with some studies showing that only half of the painful procedures in neonates are accompanied by appropriate pain relief.2 These inconsistencies, combined with gaps in knowledge, evidence, and practice, present significant challenges in the effective assessment and management of neonatal pain.1A considerable proportion of premature neonates require mechanical ventilation at some point during their hospitalization, which often involves repeated endotracheal tube (ETT) suctioning. Endotracheal tube suctioning, performed using either the closed in-line method or the open method requiring disconnection from the ventilator, consists of applying negative pressure as the catheter is being withdrawn. This type of suctioning is recognized as one of the most common and painful interventions used for preterm infants.3 Even with efforts to limit the frequency of ETT suctioning in neonates, certain conditions require repeated suctioning. Because of the associated pain and discomfort, evaluating nonpharmacological options to minimize and manage pain is necessary. The main categories for nonpharmacological pain management in neonates are environmental and behavioral strategies. The environmental strategies include decreasing noise and lighting, clustering procedures to minimize activities, and aromatherapy. Behavioral strategies include repositioning, holding or human touch, and nonnutritive sucking, such as with a pacifier.4Although previous systematic reviews have been conducted on nonpharmacological pain management strategies in neonates, none focused on pain related to ETT suctioning in neonates undergoing mechanical ventilation.As new evidence on a topic becomes available, updates are necessary to account for the results that the new evidence presents. This summary is based on an updated version of a systematic review that was originally published in 2019. This update, conducted in 2024 by Pirlotte et al,5 included 8 randomized controlled trials involving 386 preterm neonates receiving ventilation. The review investigated 3 primary outcomes: premature infant pain profile (PIPP), measured using a composite of various validated pain tool scores; physiological changes (eg, heart rate), measured in the standard way; and behavioral indicators, including stress and defensive or self-regulatory behaviors (eg, facial changes, body movements), measured via observation. For this systematic review, 3 different categories of interventions were explored. The first category encompassed several positioning or touch interventions. One of these interventions was facilitated tucking, which involved gently holding the neonate in a flexed posture under the head and buttocks (eg, turning the neonate to the side, back curled gently, legs flexed >90° and brought to midline, and shoulders brought to midline with elbows flexed >90° and hands near the mouth or on the neonate’s face). The next intervention was the 4-handed approach, which involved 2 clinicians, with 1 providing gentle touch while the other performed the procedure (eg, 1 team member warms their hands and provides supportive care such as allowing a finger grasp to promote self-regulation while the other performs the procedure). The last intervention in this group was gentle human touch, which involved skin-to-skin contact, such as cupping 1 hand around the neonate’s head while cupping the other hand around the neonate’s bottom. The second category of interventions included using a familiar odor, such as breast milk, and the third category of interventions was the use of white noise (using a combination of all audible sound frequencies to minimize distractions).5Pirlotte et al5 independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. Any disagreements were resolved by reviewing the data together and through discussion. Mean differences (MDs) with 95% CIs were used as measures of treatment effect between various comparisons and outcomes. The internationally approved Grading of Recommendations Assessment, Development and Evaluation (GRADE)6 approach was used to determine the certainty of evidence—high, moderate, low, or very low—for each outcome.This review showed that the non-pharmacological approaches of facilitated tucking, a 4-handed approach, and gentle human touch probably reduce pain and stress behaviors during neonate ETT suctioning compared with standard pain management practices. Only 1 study explored using a familiar odor or white noise, and the results showed no significant effect on the outcomes.The results from this review align with other studies that explored pain management in critically ill neonates. Hartley et al7 found that using facilitated tucking reduced pain in neonates. The technique is described as holding an infant in a flexed position with minimal repositioning, which is ideal for those receiving mechanical ventilation. The positioning used mimics the position in utero, enhancing comfort and physiological stability and reducing pain responses.7One benefit of the interventions included in this review is that they all can be relatively easily applied in practice, although the use of facilitated tucking, the 4-handed approach, or gentle human touch requires a second team member. Adequate training of health care team members is important to ensure effectiveness and sustainability. Parents can also provide such comfort and would require adequate training to do so successfully.5 Notably, the studies included only preterm neonates; therefore, how effective these methods would be for term neonates is unknown. The low-quality scores for some of the findings were due to the fact that several of the included studies had small sample sizes and used a variety of measurement methods.This systematic review was based on the best available evidence and highlights the ongoing need for further investigation related to the interventions used. Nevertheless, the evidence from this review may affect the decisions of clinical care teams in creating pain management plans for neonates, especially those undergoing ETT suctioning. As nurses caring for critically ill patients, we must regard advocating for the best evidence-based treatment as an important part of our role. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is most appropriate to implement in our individual context.