Key messages
— Gently holding the infant in a flexed posture (facilitated tucking, which is the gentle positioning of an infant's arms and legs in a bent, midline position close to the infant's body while the infant is lying on their side, lying on their back with their face upwards (supine), or lying on their tummy with their head to one side (prone)) is probably effective in reducing pain during endotracheal suctioning in ventilated newborn infants
What is endotracheal suctioning?
An endotracheal tube is a flexible plastic tube placed in the windpipe (trachea), through either the nose or mouth, to maintain an open airway in mechanically ventilated newborn infants (a mechanical ventilator is a machine to help the baby breathe).
The tip of the endotracheal tube is suctioned to keep it clean, open and free of secretions, enabling the infant to breathe oxygen. Endotracheal suctioning is a standard nursing procedure. It is painful and uncomfortable for the infant.
What did we want to find out?
We wanted to find out how to reduce infants' pain during endotracheal suctioning without using medicines.
What did we do?
We searched medical databases for clinical studies looking at ways to reduce infants' pain during endotracheal suctioning.
What did we find?
We found eight studies of 386 infants.
We assessed six different ways of reducing infants' pain during endotracheal suctioning without using medicines, such as:
– gently holding the infant in a facilitated tucking position;
– familiar odour (breast milk smell);
– use of a sugar solution (sucrose);
– use of expressed breast milk;
– white noise;
– swaddling.
Main results
In ventilated newborn infants
Facilitated tucking probably reduces pain during endotracheal suctioning.
Familiar odour and white noise have little or no effect during endotracheal suctioning. The use of expressed breast milk or oral sucrose suggests that there is no real advantage of one method over the other for reducing pain during endotracheal suctioning.
What are the limitations of the evidence?
There were not enough studies to be certain about the results in the review, and the staff were aware of which method was used to reduce pain. More studies are needed to support these results.
How up to date is this evidence?
The evidence is up to date to 21 June 2023.
Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning.
Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.
Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations.
Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain.
To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention.
We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion.
We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals.
Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators.
We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE.
We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates.
Facilitated tucking versus standard care (four studies)
Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD −2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence).
Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD −3.06 beats per minute (bpm), 95% CI −9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI −1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD −1.20, 95% CI −3.47 to 1.07; 1 study, 20 infants; low-certainty evidence).
Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence).
No studies reported intraventricular haemorrhage (IVH).
Familiar odour versus standard care (one study)
Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD −0.30, 95% CI −2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD −6.30 bpm, 95% CI −16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD −0.80, 95% CI −4.82 to 3.22; 1 study, 40 infants; low-certainty evidence).
No studies reported SRB, SDB or IVH.
White noise (one study)
White noise during endotracheal suctioning probably has little or no effect on PIPP (MD −0.65, 95% CI −2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD −1.85 bpm, 95% CI −11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI −2.03 to 6.53; 1 study, 40 infants; low-certainty evidence).
No studies reported SRB, SDB or IVH.