Pain relief in ventilated preterm infants during endotracheal suctioning: the need for an integrated approach.

Dear editor, Many procedural interventions during a neonatal stay remain a burden as they cause pain or discomfort. We therefore appreciate the randomised controlled trial reported in this journal on the impact of a pharmacological (intermittent morphine) and a non-pharmacological intervention (multisensorial stimulation) on pain relief during endotracheal suctioning in preterm neonates [1]. In brief, neither morphine, nor multisensorial stimulation resulted in pain relief based on the assessment tools used. This led the authors to conclude that further research should focus on other non-pharmacological interventions to relieve pain during endotracheal suctioning. In addition to their conclusions, we would like to re-emphasise the potential relevance of evaluating and comparing techniques on the associated pain response as has been documented for blood sampling, venipuncture being less painful compared to heel lancing [2]. Similarly, we and others suggested that procedural adaptations in the endotracheal suctioning technique (i.e. closed suction) also result in a blunted pain response [3, 4]. The stress response associated with closed endotracheal suctioning was documented in 10 ventilated neonates to evaluate the correlation between cathecholamine increase and increase in pain score to validate a neonatal pain scale. Findings in this cohort were compared with an earlier reported cohort from the same unit where open suctioning was applied. Based on vital signs and pain assessment, a blunted stress response was observed following closed endotracheal suctioning [3]. Similar observations have been described by Tan et al. using a paired approach in 15 ventilated preterm neonates [4]. Adequate management of pain necessitates an integrated approach. Such an approach is not only limited to systematic evaluation of pain and subsequent use of validated pharmacological and non-pharmacological interventions, but should also include the use of the most effective methods to perform a given procedure [2]. In addition to the prospective validation of various pharmacological and non-pharmacological interventions for procedural pain relief as suggested by the authors, there is another extensive field of prospective evaluation of various procedural techniques waiting for neonatal caregivers, nurses and doctors, to provide us with the data we urgently need to further reduce the pain and stress related to the medical and nursing care in preterm neonates. The clinical research of Karel Allegaert is supported by the Fund for Scientific Research, Flanders (Belgium) (F.W.O. Vlaanderen) by a Fundamental Clinical Investigatorship (1800209 N). Correspondence: K. Allegaert Neonatal Intensive Care Unit Division of Woman and Child University Hospital Herestraat 49 3000 Leuven Belgium E-Mail: karel.allegaert@uz.kuleuven.ac.be