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Original article
Procedural pain in neonatal units in Kenya
  1. O'Brien Munyao Kyololo1,2,3,
  2. Bonnie Stevens2,3,
  3. Denise Gastaldo2,
  4. Peter Gisore4
  1. 1School of Nursing, Moi University, Eldoret, Kenya
  2. 2Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
  3. 3The Hospital for Sick Children, Toronto, Ontario, Canada
  4. 4Department of Paediatrics and Child Health, Moi University, Eldoret, Kenya
  1. Correspondence to O'Brien Kyololo, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 300, Toronto, Ontario, Canada M5T 1P8; o.kyololo{at}mail.utoronto.ca; obrien.kyololo{at}sickkids.ca

Abstract

Objectives To determine the nature and frequency of painful procedures and procedural pain management practices in neonatal units in Kenya.

Design Cross-sectional survey.

Setting Level I and level II neonatal units in Kenya.

Patients Ninety-five term and preterm neonates from seven neonatal units.

Methods Medical records of neonates admitted for at least 24 h were reviewed to determine the nature and frequency of painful procedures performed in the 24 h period preceding data collection (6:00 to 6:00) as well as the pain management interventions (eg, morphine, breastfeeding, skin-to-skin contact, containment, non-nutritive sucking) that accompanied each procedure.

Results Neonates experienced a total of 404 painful procedures over a 24 h period (mean=4.3, SD 2.0; range 1–12); 270 tissue-damaging (mean=2.85, SD 1.1; range 1–6) and 134 non-tissue-damaging procedures (mean=1.41, SD 1.2; range 0–6). Peripheral cannula insertion (27%) and intramuscular injections (22%) were the most common painful procedures. Ventilated neonates and neonates admitted in level II neonatal units had a higher number of painful procedures than those admitted in level I units (mean 4.76 vs 2.96). Only one procedure had a pain intensity score documented; and none had been performed with any form of analgesia.

Conclusions Neonates in Kenya were exposed to numerous tissue-damaging and non-tissue-damaging procedures without any form of analgesia. Our findings suggest that education is needed on how to assess and manage procedural pain in neonatal units in Kenya.

  • Procedural Pain
  • Analgesia
  • Neonatal units
  • Procedures

https://doi.org/10.1136/archdischild-2014-306003

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    What is already known on this topic

    • Neonatal units in high-income countries strive to reduce the number of painful procedures performed on neonates and provide some form of analgesia during painful procedures.

    What this study adds

    • In sub-Saharan Africa, neonates undergo many painful procedures, often without any form of pain relief.

    Background

    Advancements in neonatal care over the last three decades have resulted in extremely premature neonates and those with life-threatening medical conditions, being admitted in neonatal intensive care units (NICUs).1 ,2 Their NICU hospitalisation is often accompanied by many painful procedures, such as heel lancing, endotracheal intubation, venepuncture and suctioning.3–5 Although these procedures are necessary for physiological stabilisation and treatment of underlying illnesses, frequent and untreated painful procedures in premature and critically ill neonates can lead to serious immediate and long-term consequences including physiological compromise, altered pain sensitivity, behavioural alterations and adverse neurodevelopmental outcomes.2 ,6–9

    In recognition of the significance of optimal pain management in neonates, the last decade has witnessed development of many national and international practice guidelines10–12 on pain assessment and management, particularly in high-income countries, with an overarching emphasis on consistent and regular assessment and effective treatment of procedural pain. Despite the existence of these guidelines, neonatal pain management remains suboptimal in many high-income countries4 ,13 ,14 and severely undertreated in low-income and middle-income countries (LMICs) in Asia3 and South America.15 Little is, however, known about the nature and frequency and management practices of neonatal pain in sub-Saharan countries such as Kenya where the world's highest rate of neonatal morbidity and mortality occur.16

    The purpose of this study was to (a) determine the nature and frequency of painful procedures in neonatal units in Kenya, (b) describe pain assessment and management practices and (c) explore neonatal characteristics and unit factors that influence procedural pain practices in neonatal units in Kenya.

    Participants and methods

    Sample

    A survey was conducted between July and August 2012. The two level II and six of the seven level I neonatal units17 (one level I neonatal unit was excluded due to security concerns) in Kenya were invited to participate in the study. All except one level II unit agreed to participate. In Kenya, level I neonatal units admit neonates more than 32 weeks’ gestation age at birth and only have the capacity to provide oxygen therapy via nasal cannula. Level II neonatal units admit less gestationally mature and sicker neonates, and provide oxygen via continuous positive airway pressure (CPAP). Neonates hospitalised in the units for at least 24 h and those less than 28 days postnatal age were eligible for inclusion in the study.

    Methods

    The study protocol was approved by Research Ethics Boards (REBs) in Canada and at the study hospitals. A validated checklist18 was modified to reflect the local context and used by the first author (OMK) to review medical records of eligible neonates with data collection period covering the previous 24 h (6:00 of the previous day to 6:00 of the day of data collection). Data on demographic characteristics and the nature and frequency of painful procedures were extracted. Procedures were categorised as tissue damaging if they involved a break to the skin (eg, heelsticks, injections, venepuncture) and non-tissue damaging if they did not break the skin surface (eg, nasal cannulation, nasopharyngeal suctioning).4 Pain intensity score (or narrative description of pain intensity) associated with each procedure and any pharmacological, behavioural or physical interventions accompanying each procedure were recorded.

    Analysis

    Data were analysed using SPSS V.17.0 (SPSS Inc, Chicago, Illinois, USA). Descriptive statistics were computed for demographic characteristics of the sample and the nature and frequency of painful procedures. Means, SDs, medians and IQR were computed for continuous data and frequency counts for categorical data. Demographic characteristics and number of painful procedures were compared using analysis of variance and unpaired t tests for normally distributed data and Mann–Whitney U test for non-normally distributed data. Categorical data were analysed using χ2 tests. A linear model was used to explore the influence of neonatal characteristics and unit factors on the number of painful procedures with population average models (generalised estimating equations (GEE)) being used to adjust for the lack of independence across observations (ie, clustering of neonates within study sites and units across sites).19 p Value <0.05 was specified as statistically significant.

    Results

    Medical records of 95 neonates, representing 83% of neonates admitted across the seven sites, were reviewed. Medical records of 20 neonates were not reviewed because the neonates had either been in the units for less than 24 h (n=12) or had exceeded 28 days postnatal age (n=8). Most of the neonates were admitted in level I neonatal units (80/95). Table 1 summarises the demographic characteristics of the sample.

    View this table:
    Table 1

    Demographic characteristics of sample

    Nature and frequency of painful procedures

    The 95 neonates experienced a total of 404 painful procedures over a 24 h period (mean 4.25, SD=2.01). Neonates underwent an average of 2.85 (SD 1.11) tissue-damaging and 1.41 (SD 1.24) non-tissue-damaging painful procedures. Most of the procedures performed on the neonates are associated with moderate-to-severe pain intensity5 (table 2).

    View this table:
    Table 2

    Nature and frequency of painful procedures by pain severity

    Factors associated with number of painful procedures performed

    Although gestational age, birth weight and place of birth had no association with the number of painful procedures, neonates on CPAP had twice the number of painful procedures per day compared with non-ventilated neonates (χ2=21.871, 95% CI −2.737 to 1.12; p<0.0001). Similarly, neonates in level II neonatal units experiencing 1.5 times the number of painful procedures compared with those in level I units (χ2=4.908, 95% CI 0.175 to 2.858; p=0.027) (table 3). Neither birth weight nor being inborn significantly influenced the number of painful procedures. However, the interaction between birth weight and born at study hospital was statistically significant (F=4.018, p=0.021). More specifically, very low birthweight neonates (<1500 g) who were outborn underwent more painful procedures (mean=6.75, 95% CI 4.779 to 8.721; p=0.01).

    View this table:
    Table 3

    Factors associated with number of painful procedures experienced in 24 h

    Pain assessment and management practices

    Of the 404 painful procedures recorded, only one (an intramuscular (IM) injection) had pain intensity documented in narrative form (neonate in a lot of pain). There was not any form of analgesia documented for any painful procedure; and none of the procedures was documented as having been performed in the presence of parents.

    Discussion

    To the best of our knowledge, this is the first study to report on procedural pain in hospitalised neonates in Kenya. Neonates in Kenya undergo multiple procedures, the majority being tissue-damaging and associated with moderate-to-severe pain intensity.5 Pain intensity was rarely assessed, and procedures were performed without any form of analgesia. Considering that unmanaged pain in neonates has immediate and long-term complications,2 ,6 ,8 ,9 there is a need to position neonatal pain as a fundamental component of care in neonatal units in Kenya and other LMICs.

    Neonates in Kenya underwent an average of four painful procedures per day. This frequency indicates remarkably fewer painful procedures compared with similar surveys in the Netherlands (14/day)14 and France (12/day)18 but are consistent with results of a recent Canadian survey (4/day).4 The higher frequency of painful procedures in the Dutch and French studies could be explained by the prospective observational design adapted while, in our study, data were extracted from medical records that is dependent on the documentation practices of healthcare providers (HCPs). Compared with other settings,4 ,18 neonates in Kenya were undergoing more invasive than non-invasive procedures. Unlike in Canadian NICUs4 where neonates were undergoing one tissue-damaging procedure for every three non-tissue-damaging procedures per day, in our study, neonates, on average, underwent two tissue-damaging procedures (2.85) for every one non-tissue-damaging procedure (1.4).

    Peripheral venous cannulation and IM injections contributed half (27% and 22%, respectively) of the total number of painful procedures performed in our study. Although the nature of these procedures is consistent with studies in other LMICs,3 it differs markedly with findings in high-income countries.14 ,18 In Chinese NICUs,3 intravenous cannulation contributed 21% of the total painful procedures while in Dutch14 and French NICUs,18 tracheal suctioning and nasal cannulation were the most commonly performed procedures (31% and 29%, respectively) with venous cannulation and IM injections being sparingly performed. The high number of IM injections in our study could be explained by delays in insertion of central and peripheral venous catheters owing to few physicians working in the neonatal units. With nurses’ scope of practice that does not allow for venous cannulation, nurses faced with such delays may opt for IM injections as alternative routes of administering life-saving medications (eg, antibiotics).

    Unlike in other studies,3 ,4 we found no relationship between gestational age at birth and number of painful procedures performed. However, consistent with previous surveys,5 more procedures were performed on outborn low birthweight neonates and those who were ventilated or receiving higher levels of care (level II). Although it is unclear why outborn low birthweight neonates had more painful procedures, it is highly likely that these neonates, usually referred from small community hospitals, were sicker, thus requiring more diagnostic and interventional procedures. Additionally, although we did not collect data on illness severity, it is probable that neonates in higher levels of care, and those requiring ventilation support, are critically ill, thus predisposing them to more diagnostic and treatment-related procedures.4 ,18

    Our study highlights a major evidence–practice gap on assessment and management of procedural pain12 in neonatal units in Kenya. Although 60% of the procedures were associated with moderate-to-severe pain intensity,5 only one procedure had pain intensity documented, and none had been performed with any form of analgesia. Although this finding is consistent with reports from other LMICs,3 ,20 it differs significantly from the neonatal pain assessment and management practices in high-income countries.4 ,18 Notably, unlike in high-income countries,4 ,11 ,18 none of the study units had a clinical practice guideline for pain management. The better pain management practices in high-income countries provide an impetus for efforts to improve procedural pain management in LMICs.

    Parents can be involved in the pain care of their neonates in a variety of ways,21–23 and their presence at the bedside has been associated with better pain management practices.4 ,18 We found no documented evidence of parental involvement in neonatal pain care. Whether this finding is a documentation issue or a reflection of parents’ reluctance to be involved in pain care24 is not clear. Nevertheless, given the documented effectiveness of pain management strategies involving parents (eg, kangaroo mother care, breast feeding),25 the feasibility of involving parents in neonatal pain management in LMICs should be explored.

    Some methodological issues limit the results of this study. First, we reviewed medical records whose completeness depends on documentation practices of HCPs. Although we had little insight into the documentation practices of the HCPs, it is possible that HCPs only document what they perceive as important information to share with colleagues for purposes of continued care. Additionally, variability in documentation practices among HCPs may have affected our findings, particularly on the number of painful procedures, interventions used and whether parents were present during painful procedures. Moreover, we had no opportunity to observe HCPs at any of the neonatal units to document their pain assessment and management practices in real time.

    Conclusion

    Neonates in Kenya experience many painful procedures per day, the majority of which are invasive in nature, often associated with moderate-to-severe pain intensity. Little documented evidence was found on assessment of pain intensity and administration of any form of analgesia during painful procedures. Future research should focus on determining the barriers to assessment and management of procedural pain and exploring the feasibility of involving parents in the management of procedural pain in neonatal units in Kenya.

    Acknowledgments

    We gratefully acknowledge the support of the administration and staff of the study hospitals. We also thank Charles Victor for assistance with statistical analysis.

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    Footnotes

    • Contributors OMK conceptualised the research idea, developed the study protocol, collected and analysed the data, drafted the initial manuscript, made revisions and approved the final manuscript as submitted. BS conceptualised the idea and provided mentorship to OMK during writing of the study protocol, revised the protocol and provided guidance during data collection and analysis. She critically reviewed and revised the manuscript and approved the final version of the manuscript as submitted. DG participated in conceptualisation of the research idea, provided mentorship to OMK on data collection, analysis and writing of the manuscript. She also reviewed and revised the manuscript, and approved the final version of the manuscript as submitted. PG reviewed the study protocol, mentored and provided direct guidance to OMK on data collection in Kenya, reviewed and revised the manuscript, and approved the final manuscript as submitted.

    • Funding This study was supported by a trainee award from the Pain In Child Health (PICH), Strategic Training In Health Research, Canadian Institutes of Health Research (CIHR); and the Signy Hildur Eaton Chair in Paediatric Nursing Research, The Hospital for Sick Children, Toronto, Canada.

    • Competing interests None.

    • Ethics approval The Hospital for Sick Children (Canada); University of Toronto (Canada); Moi University (Kenya).

    • Provenance and peer review Not commissioned; externally peer reviewed.