Effects of non-pharmacological methods on post-operative procedural pain management in neonates admitted in the neonatal intensive care unit: A systematic review

  • Abhishek Sharma Department of Physiotherapy, Arogyam Institute of Paramedical and Allied Sciences (Affiliated to H.N.B. Uttarakhand Medical Education University) Roorkee
  • Nidhi Sharma Department of Health Science, Uttaranchal College of Health Sciences, Uttaranchal University, Dehradun
  • Aksh Chahal Department of Physiotherapy, School of Allied Health Sciences, Galgotias University, Greater Noida, Uttar Pradesh
Keywords: infant; neonates; newborns; NICU; procedural pain; pain management


Background In the post-operative period during the NICU stay, neonates must undergo various painful procedures. Non-pharmacological methods may be beneficial in managing the harmful effects of procedural pain on the development of neonates in their early life.

Objectives To investigate the effect of non-pharmacological methods on post-operative procedural pain in neonates admitted to neonatal intensive care units.

Methods A search in electronic databases was done to identify randomized clinical trials published from 2010 to 2020 that encompassed neonates undergoing painful procedures in the NICU and followed PRISMA guidelines. Studies with non-human subjects, neonates with unstable vital signs, non-clinical studies, and incomplete methodology were excluded. PubMed, Cochrane, and Physiotherapy Evidence Database (PEDro) were evaluated respectively using Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS).

Results Two reviewers examined articles independently and found 11 articles that met the study's inclusion criteria, with a total of 955 neonates with non-pharmacological methods of pain management in neonates. Non-pharmacological methods, such as massage therapy, oral sucrose, kangaroo mother care, and facilitated tucking showed significant reduction in pain scores among neonates who underwent painful procedures in NICU. Outcomes showed variability in effectiveness, emphasizing the need for tailored approaches.

Conclusions The findings indicated that non-pharmacological methods can effectively manage pain in neonates admitted to the NICU. Pain management improves the clinical condition of neonates and promotes parents-neonate bonding, with consequent reduction in length of stay in the hospital. 


1. Obu HA, Chinawa JM. Neonatal analgesia: A neglected issue in the tropics. Niger Med J. 2014;55:183-7. DOI: https://doi.org/10.4103/0300-1652.132034
2. Zamzmi G, Kasturi R, Goldgof D, Zhi R, Ashmeade T, Sun Y. A Review of Automated Pain Assessment in Infants: Features, Classification Tasks, and Databases. IEEE Rev Biomed Eng. 2018;11:77-96. DOI: https://doi.org/10.1109/RBME.2017.2777907
3. Tortora D, Severino M, Di Biase C, Malova M, Parodi A, Minghetti D, et al. Early Pain Exposure Influences Functional Brain Connectivity in Very Preterm Neonates. Front Neurosci. 2019 ;13:899. DOI: https://doi.org/10.3389/fnins.2019.00899
4. Zargham-Boroujeni A, Elsagh A, Mohammadizadeh M. The effects of massage and breastfeeding on response to venipuncture pain among hospitalized neonates. Iran J Nurs Midwifery Res. 2017;22:308-12. DOI: https://doi.org/10.4103/ijnmr.IJNMR_119_13
5. Brummelte S, Chau CM, Cepeda IL, Degenhardt A, Weinberg J, Synnes AR, et al. Cortisol levels in former preterm children at school age are predicted by neonatal procedural pain-related stress. Psychoneuroendocrinology. 2015;51:151-63. DOI: https://doi.org/10.1016/j.psyneuen.2014.09.018
6. Vinall J, Grunau RE. Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res. 2014;75:584-7. DOI: https://doi.org/10.1038/pr.2014.16
7. Panfoli I, Candiano G, Malova M, De Angelis L, Cardiello V, Buonocore G, et al. Oxidative stress as a primary risk factor for brain damage in preterm newborns. Front Pediatr. 2018;6:369. DOI: https://doi.org/10.3389/fped.2018.00369
8. Parsa P, Karimi S, Basiri B, Roshanaei G. The effect of KMC on physiological parameters of premature infants in Hamadan City, Iran. Pan Afr Med J. 2018;30:89. DOI: https://doi.org/10.11604/pamj.2018.30.89.14428
9. Peyrovi H, Alinejad-Naeini M, Mohagheghi P, Mehran A. The effect of facilitated tucking position during endotracheal suctioning on physiological responses and coping with stress in premature infants: a randomized controlled crossover study. J Matern Fetal Neonatal Med. 2014;27:1555-9. DOI: https://doi.org/10.3109/14767058.2013.868429
10. Abuelkheir M, Alsourani D, Al-Eyadhy A, Temsah MH, Meo SA, Alzamil F. EMLA(R) cream: a pain-relieving strategy for childhood vaccination. J Int Med Res. 2014;42:329-36. DOI: https://doi.org/10.1177/0300060513509473
11. Uman LS, Chambers CT, McGrath PJ, Kisely S, Matthews D, Hayton K. Assessing the quality of randomized controlled trials examining psychological interventions for pediatric procedural pain: recommendations for quality improvement. J Pediatr Psychol. 2010;35:693-703. DOI: https://doi.org/10.1093/jpepsy/jsp104.
12. Moseley AM, Fernández Hernando D, Saragiotto BT, Sharma S, Maharjan E, Elkins MR. The Physiotherapy Evidence Database (PEDro) has better free full-text access than PubMed: An observational study. Braz J Phys Ther. 2022;26:100392. DOI: https://doi.org/10.1016/j.bjpt.2022.100392
13. Review Manager (RevMan) [Computer program]. Version 5.4.1. [May;2020 ];http://revman.cochrane.org 2020.
14. Bayomi OR, El-nagger NS. Effect of applying massage therapy on physical , physiological and behavioral states of premature neonates. J Nurs Educ Prac. 2015;5:105–14. DOI: https://doi.org/10.5430/jnep.v5n10p105.
15. Yin T, Yang L, Lee TY, Li CC, Hua YM, Liaw JJ. Development of atraumatic heel-stick procedures by combined treatment with non-nutritive sucking, oral sucrose, and facilitated tucking: a randomised, controlled trial. Int J Nurs Stud. 2015 Aug;52(8):1288-99. doi: 10.1016/j.ijnurstu.2015.04.012. Epub 2015 Apr 23. PMID: 25939641.
16. Chik YM, Ip WY, Choi KC. The effect of upper limb massage on infants' venipuncture pain. Pain Manag Nurs. 2017;18:50-7. DOI: https://doi.org/10.1016/j.pmn.2016.10.001
17. Banga S, Datta V, Rehan HS, Bhakhri BK. Effect of sucrose analgesia, for repeated painful procedures, on short-term neurobehavioral outcome of preterm neonates: A randomized controlled trial. J Trop Pediatr. 2016;62:101-6. DOI: https://doi.org/10.1093/tropej/fmv079
18. Liaw JJ, Yang L, Katherine Wang KW, Chen CM, Chang YC, Yin T. Non-nutritive sucking and facilitated tucking relieve preterm infant pain during heel-stick procedures: a prospective, randomised controlled crossover trial. Int J Nurs Stud. 2012;49:300-9. DOI: https://doi.org/10.1016/j.ijnurstu.2011.09.017
19. Stevens B, Yamada J, Beyene J, Gibbins S, Petryshen P, Stinson J, et al. Consistent management of repeated procedural pain with sucrose in preterm neonates: Is it effective and safe for repeated use over time? Clin J Pain. 2005;21:543-8. DOI: https://doi.org/10.1097/01.ajp.0000149802.46864.e2
20. Sundaram B, Shrivastava S, Pandian JS, Singh VP. Facilitated tucking on pain in pre-term newborns during neonatal intensive care: a single blinded randomized controlled cross-over pilot trial. J Pediatr Rehabil Med. 2013;6:19-27. DOI: https://doi.org/10.3233/PRM-130233
21. Cong X, Cusson RM, Walsh S, Hussain N, Ludington-Hoe SM, Zhang D. Effects of skin-to-skin contact on autonomic pain responses in preterm infants. J pain. 2012;13:636–45. DOI: https://doi.org/10.1016/j.jpain.2012.02.008
22. Alinejad-Naeini M, Mohagheghi P, Peyrovi H, Mehran A. The effect of facilitated tucking during endotracheal suctioning on procedural pain in preterm neonates: a randomized controlled crossover study. Glob J Health Sci. 2014 May 4;6(4):278-84. doi: 10.5539/gjhs.v6n4p278
23. Mitchell AJ, Yates CC, Williams DK, Chang JY, Hall RW. Does daily kangaroo care provide sustained pain and stress relief in preterm infants? J Neonatal Perinatal Med. 2013;6:45-52. DOI: https://doi.org/10.3233/NPM-1364212
24. Gao H, Xu G, Gao H, Dong R, Fu H, Wang D, et al. Effect of repeated KMC on repeated procedural pain in preterm infants: A randomized controlled trial. Int J Nurs Stud. 2015;52:1157-65. DOI: https://doi.org/10.1016/j.ijnurstu.2015.04.006
25. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. DOI: https://doi.org/10.1136/bmj.d5928
26. Massaro AN, Hammad TA, Jazzo B, Aly H. Massage with kinesthetic stimulation improves weight gain in preterm infants. J Perinatol. 2009;29:352-7. DOI: https://doi.org/10.1038/jp.2008.230
27. Boardman JP, Craven C, Valappil S, Counsell SJ, Dyet LE, Rueckert D, et al. A common neonatal image phenotype predicts adverse neurodevelopmental outcome in children born preterm. Neuroimage. 2010;52:409-14. DOI: https://doi.org/10.1016/j.neuroimage.2010.04.261
28. van den Anker JN. Developmental pharmacology. Dev Disabil Res Rev. 2010;16:233-8. DOI: https://doi.org/10.1002/ddrr.122
29. Cignacco E, Hamers J, van Lingen RA, Stoffel L, Büchi S, Müller R,et al. Neonatal procedural pain exposure and pain management in ventilated preterm infants during the first 14 days of life. Swiss Med Wkly. 2009;139:226-32. DOI: https://doi.org/10.4414/smw.2009.12545
30. Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317:1321-9. DOI: https://doi.org/10.1056/NEJM198711193172105
31. Levene M. Morphine sedation in ventilated newborns: who are we treating? Pediatrics. 2005;116:492-3. DOI: https://doi.org/10.1542/peds.2005-0441
32. Maciel HIA, Costa MF, Costa ACL, Marcatto JO, Manzo BF, Bueno M. Pharmacological and nonpharmacological measures of pain management and treatment among neonates. Rev Bras Ter Intensiva. 2019;31:21-6. DOI: https://doi.org/10.5935/0103-507X.20190007
33. Hall RW. Anesthesia and analgesia in the NICU. Clin Perinatol. 2012;39:239-54. DOI: https://doi.org/10.1016/j.clp.2011.12.013
34. Field TM, Schanberg SM, Scafidi F, Bauer CR, Vega-Lahr N, Garcia R, et al. Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics. 1986;77:654-8. PMID: 3754633.
35. Ang JY, Lua JL, Mathur A, Thomas R, Asmar BI, Savasan S, et al. A randomized placebo-controlled trial of massage therapy on the immune system of preterm infants. Pediatrics. 2012;130:e1549-58. DOI: https://doi.org/10.1542/peds.2012-0196
36. Field T, Diego M, Hernandez-Reif M. Preterm infant massage therapy research: a review. Infant Behav Dev. 2010;33:115-24. DOI: https://doi.org/10.1016/j.infbeh.2009.12.004
37. Melzack R. Gate control theory: on evolution of main concept. Pain Forum 1996; 5: 128–38. DOI: https://doi.org/10.1016/S1082-3174(96)80050-X
38. Field HL, Basbaum AI. Central nervous system mechanism of pain modulation. In: Wall PD, Melzack R, editors. Textbook of Pain. New York: Churchill Livingstone; 1994. p.243–57.
39. Yin T, Yang L, Lee TY, Li CC, Hua YM, Liaw JJ. Development of atraumatic heel-stick procedures by combined treatment with non-nutritive sucking, oral sucrose, and facilitated tucking: a randomised, controlled trial. Int J Nurs Stud. 2015;52:1288-99. DOI: https://doi.org/10.1016/j.ijnurstu.2015.04.012
How to Cite
Sharma A, Sharma N, Chahal A. Effects of non-pharmacological methods on post-operative procedural pain management in neonates admitted in the neonatal intensive care unit: A systematic review. PI [Internet]. 27Feb.2024 [cited 18Apr.2024];64(1):65-6. Available from: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/3088
Received 2022-07-26
Accepted 2024-02-27
Published 2024-02-27