Background.Accurate assessment and treatment of pain and stress in preterm infants in neonatal intensive care units (NICU) is vital because pain and stress responses have been linked to long-term alterations in development in this population. Purpose.To review the evidence of specific extremity movements in preterm infants as observed during stressful procedures. Methods.Five on-line databases were searched for relevant studies. For each study, levels of evidence were determined and effect size estimates were calculated. Each study was also evaluated for specific factors that presented potential threats to its validity. Results.Eighteen studies were identified and seven comprised the review. The combined sample included 359 preterm infants. Six specific movements were associated with painful and intrusive procedures. Clinical Implications.A set of specific extremity movements, when combined with other reliable biobehavioural measures of pain and stress, can form the basis for future research and development of a clinical stress scale for preterm infants.
AlsH. (1982). Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Mental Health Journal, 3, 229–243.
2.
AlsH. (1984). Manual for the naturalistic observation of newborn behavior (preterm and fullterm). Boston: The Children's Hospital.
3.
AlsH. (1986). A synactive model of neonatal behavioral organization: Framework for the assessment of neurodevelopmental development in the premature infant and for support of infants and parents in the neonatal intensive care unit. In SweeneyJ. K. (Ed.), The high-risk neonate: Developmental therapy perspectives (6th ed., pp. 3–55). Binghamton, NY: Haworth Press.
4.
AnandK.J.S. (2000). Pain, plasticity, and premature birth: A prescription for permanent suffering. Nature Medicine, 6 (9), 971–973.
5.
AnandK.J.S.CoskunV.ThrivikramanK.V.NemeroffC.B. & PlotskyP.M. (1999). Long-term behavioral effects of repetitive pain in neonatal rat pups. Physiology and Behavior, 66 (4), 627–637.
6.
AndrewsK. & FitzgeraldM. (1994). The cutaneous withdrawal reflex in human neonates: Sensitization, receptive fields, and the effects of contralateral stimulation. Pain, 56, 95–101.
7.
AndrewsK. & FitzgeraldM. (1999). Cutaneous flexion reflex in human neonates: A quantitative study of threshold and stimulus-response characteristics after single and repeated stimuli. Developmental Medicine and Child Neurology, 41, 696–703.
8.
AnismanH.ZahariaM.D.MeaneyM.J. & MeraliZ. (1998). Do early-life events permanently alter behavioral and hormonal responses to stress?International Journal of Developmental Neuroscience, 16, 149–164.
9.
AnseloniV.C.Z.HeF.NovikovaI.RobbinsM. TurnbackLidowI.A.EnnisM., et al. (2005). Alterations in stress-associated behaviors and neurochemical markers in adult rats after neonatal short-lasting local inflammatory insult. Neuroscience, 131, 635–645.
10.
BarrR.G. (1998). Reflections on measuring pain in infants: The problem of dissociation in response systems and “honest signaling”. Archives of Disease in Childhood, 79, F152–F156.
11.
BhuttaA.T. & AnandK.J.S. (2002). Vulnerability of the developing brain: Neuronal mechanisms. Clinics in Perinatology, 29 (3), 357–372.
12.
BlumbergM.S. & LucasD.E. (1996). A developmental and component analysis of active sleep. Developmental Psychobiology, 29 (1), 1–22.
13.
BozzetteM. (1993). Observation of pain behavior in the NICU: An exploratory study. Journal of Perinatal and Neonatal Nursing, 7 (1), 76–87.
14.
ChengC.M. & ChapmanJ.S. (1997). Assessment of reliability and validity for the behavioral observation record for developmental care. Nursing Research, 46 (1), 40–45.
15.
CraigK.D.WhitfieldM.F.GrunauR.V.E.LintonJ. & HadjistavropoulosH.D. (1993). Pain in the preterm neonate: Behavioral and physiological indices. Pain, 52, 287–300.
16.
de LimaJ.AlvaresD.HatchD. & FitzgeraldM. (1999). Sensory hyperinnervation following skin wounding: The effect of bupiviacaine sciatic nerve blockade. British Journal of Anaesthesia, 83, 662–664.
EvansJ.C.VogelpohlD.G.BourguignonC.M. & MorcottC.S. (1997). Pain behaviors in LBW infants accompany some “non-painful” caregiving procedures. Neonatal Network, 16 (3), 33–40.
19.
FitzgeraldM. (2000). Development of the peripheral and spinal pain system. In AnandK.J.S., StevensB.J., & McGrathP.J. (Eds.), Pain in neonates, 2nd revised and enlarged edition: Pain research and clinical management (pp. 9–21). Amsterdam: Elsevier Science.
FitzgeraldM.MillardC. & McIntoshN. (1989). Cutaneous hyper-sensitivity following peripheral tissue damage in newborn infants and its reversal with topical anaesthesia. Pain, 39, 31–36.
22.
FitzgeraldM.ShawA. & McIntoshN. (1988). Postnatal development of the cutaneous flexor reflex: Comparative study of preterm infants and newborn rat pups. Developmental Medicine and Child Neurology, 30, 520–526.
23.
FranckL.S. (1986). A new method to quantitatively describe pain behaviors in infants. Nursing Research, 35, 28–31.
24.
FranckL.S.GreenbergC.S. & StevensB. (2000). Pain assessment in infants and children. Acute Pain in Children: Pediatric Clinics of North America, 47 (3), 487–512.
25.
FranckL.S. & MiaskowskiC. (1997). Measurement of neonatal responses to painful stimuli: A research review. Journal of Pain and Symptom Management, 14 (6), 343–378.
26.
GoubetN.CliftonR. & ShahB. (2001). Learning about pain in preterm newborns. Journal of Developmental & Behavioral Pediatrics, 22 (6), 418–424.
27.
GrenierI.R.BigsbyR.VergaraE.R. & LesterB.M. (2003). Comparison of motor self-regulatory and stress behaviors of preterm infants across body positions. American Journal of Occupational Therapy, 57, 289–297.
28.
GrunauR. (2002). Early pain in preterm infants: A model of long-term effects. Clinics in Perinatology, 29 (3), 373–394.
29.
GrunauR.E. (2003). Self-regulation and behavior in preterm children: Effects of early pain. In McGrathP.J. & FinleyG.A. (Eds.), Pediatric pain: Biological and social context, progress in pain research and management (pp. 23–55). Seattle, WA: IASP Press.
30.
GrunauR.E.HolstiL.HaleyD.OberlanderT.F.WeinbergJ.SolimanoA., et al. (2005). Neonatal procedural pain exposure predicts lower cortisol and behavioral reactivity in preterm infants in the NICU. Pain, 113, 293–300.
31.
GrunauR.E.HolstiL., WhitfieldM.F. & LingE. (2000). Are twitches, startles and body movements pain indicators in extremely low birth weight infants?Clinical Journal of Pain, 16 (1), 37–45.
32.
GrunauR.E.OberlanderT.HolstiL. & WhitfieldM.F. (1998). Bedside application of the Neonatal Facial Coding System in pain assessment of premature neonates. Pain, 76, 277–286.
33.
GrunauR.E.OberlanderT.F.WhitfieldM.F.FitzgeraldC. & LeeS.K. (2001a). Demographic and therapeutic determinants of pain reactivity in very low birth weight neonates at 32 weeks postconceptional age. Pediatrics, 107 (1), 105–112.
34.
GrunauR.E.OberlanderT.F.WhitfieldM.F.FitzgeraldC.MorisonS. & SaulJ.P. (2001b). Pain reactivity in former extremely low birth weight infants at corrected age 8 months compared with term born controls. Infant Behavior and Development, 24 (1), 31–55.
GrunauR.V.WhitfieldM.F. & PetrieJ. (1998). Children's judgments about pain at age 8–10 years: Do extremely low birthweight (<1000g) children differ from full birthweight peers?Journal of Child Psychology and Psychiatry, 39, 587–594.
37.
GrunauR.V.WhitfieldM.F.PetrieJ.A. & FryerE.L. (1994). Early pain experience, child and family factors, as precursors of somatization: A prospective study of extremely premature and fullterm children. Pain, 56, 353–359.
38.
GrunauR.V.E. (2000). Long-term consequences of pain in human neonates. In AnandK.J.S., StevensB.J., & McGrathP.J. (Eds.), Pain in neonates: Pain research and clinical mangement (pp. 5576). Amsterdam: Elsevier.
39.
GrunauR.V.E. & CraigK.D. (1987). Pain expression in neonates: Facial action and cry. Pain, 28, 395–410.
40.
GrunauR.V.E.WhitfieldM.F. & PetrieJ.A. (1994). Pain sensitivity and temperament in extremely-low-birth weight premature toddlers and preterm and full-term controls. Pain, 58, 341–346.
41.
HellerudB.C. & StormH. (2002). Skin conductance and behaviour during sensory stimulation of preterm and term infants. Early Human Development, 20, 35–46.
42.
HolstiL.GrunauR.E.OberlanderT. & WhitfieldM.F. (2004). Specific NIDCAP® movements are associated with acute pain in preterm infants in the NICU. Pediatrics, 114, 65–72.
43.
HolstiL.GrunauR.E.OberlanderT.F. & WhitfieldM.F. (2005a). Prior pain induces heightened responses during clustered care in preterm infants in the NICU. Early Human Development, 81 (3), 293–302.
44.
HolstiL.GrunauR.E.WhitfieldM.F.OberlanderT. & WeinbergJ. (2005b). Body movements, an important additional factor discriminating pain from stress in preterm infants. Clinical Journal of Pain, 21 (6), 491–498.
45.
HowardV.A. & ThurberF.W. (1998). The interpretation of infant pain: Physiological and behavioral indicators used by NICU nurses. Journal of Pediatric Nursing, 13 (3), 164–174.
46.
InderT.E.WarfieldS.K.WangH.HüppiP.S. & VolpeJ.J. (2005). Abnormal cerebral structure is present at term in preterm infants. Pediatrics, 115 (2), 286–294.
47.
IsaacsE.B.LucasA.ChongW.K.WoodS.J.JohnsonC.L.MarashallC., et al., (2000). Hippocampal volume and everyday memory in children of very low birth weight. Pediatric Research, 47 (6), 713–720.
48.
JohnstonC.C. & StevensB.J. (1996). Experience in a neonatal intensive care unit affects pain response. Pediatrics, 98 (5), 925–930.
49.
JohnstonC.C.StevensB.J.FranckL.S.JackA.StremlerR. & PlattR. (1999). Factors explaining lack of response to heel stick in preterm newborns. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 8 (6), 587–94.
50.
LaddC.O.HuotR.L.ThrivikramanK.V.NemeroffC.B.MeaneyM.J. & PlotskyP.M. (2000). Long-term behavioral and neuroendocrine adaptations to adverse early experience. Progress in Brain Research, 122, 81–103.
51.
LawM.CooperB.StrongS.StewartD.RigbyP. & LettsL. (1996). The Person-Environment-Occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9–23.
52.
LawrenceJ.AlcockD.McGrathP.KayJ.MacMurrayS.B. & DulbergC. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12, 59–66.
53.
MorisonS.J.GrunauR.E.OberlanderT.F. & WhitfieldM.F. (2001). Relations between behavioral and cardiac autonomic reactivity to acute pain in preterm neonates. Clinical Journal of Pain, 7 (4), 350–358.
54.
MorisonS.J.HolstiL.GrunauR.E.WhitfieldM.F.OberlanderT.F.ChanH.W.P., et al. (2003). Are there developmentally distinct motor indicators of pain in preterm infants?Early Human Development, 72 (2), 131–146.
55.
NosartiC.Al-AsadyM.H.S.FrangouS.StewartA.L.RifkinL. & MurrayR.M. (2002). Adolescents who were born very preterm have decreased brain volumes. Brain, 125, 1616–1623.
56.
OberlanderT.F.GrunauR.E.FitzgeraldC. & WhitfieldM. F. (2002). Does parenchymal brain injury affect biobehavioral pain responses in very low birth weight infants at 32 weeks postconceptual age?Pediatrics, 110 (3), 570–576.
57.
OberlanderT.F.GrunauR.V.E.WhitfieldM.F.FitzgeraldCPitfieldS. & SaulJ.P. (2000). Biobehavioral pain responses in formerly extremely low birth weight infants at four months corrected age. Pediatrics, 105 (1), e6.
58.
PetersK.L. (1998). Bathing premature infants: Physiological and behavioral consequences. American Journal of Critical Care, 7 (2), 90–100.
59.
PetersK.L. (2001). Association between autonomic and motor systems in the preterm infant. Clinical Nursing Research, 10 (1), 82–91.
60.
PetersonB.S.AndersonA.W.EhrencranzR.StaibL.H.TageldinM.ColsonE., et al. (2003). Regional brain volume abnormalities and their later neurodevelopmental correlates in term and preterm infants. Pediatrics, 111 (5), 939–948.
61.
PetryshenP.StevensB.HawkinsJ. & StewartM. (1997). Comparing nursing costs for preterm infants receiving conventional vs. developmental care. Nursing Economics, 15 (3), 138–150.
62.
PorterF.L.WolfC. & MillerJ. P. (1998). The effect of handling and immobilization on the response to acute pain in newborn infants. Pediatrics, 102 (6), 1383–1389.
63.
PresslerJ.L.HelmJ.M.HepworthJ.T. & WellsN.L. (2001). Behaviors of very preterm neonates as documented using NIDCAP observations. Neonatal Network, 20 (8), 15–24.
64.
RenK.AnseloniV.ZouS.-P.WadeE.B.NovikovaS.I.EnnisM., et al. (2004). Characterization of basal and re-inflammation-associated long-term alteration in pain responsivity following short-lasting neonatal local inflammatory insult. Pain, 110, 588–596.
65.
RosenthalR.RosnowR.L. & RubinD.B. (2000). Contrasts and effect sizes in behavioral research: A correlational approach. Cambridge, United Kingdom: UK University Press.
SlevinM.DalyL. & MurphyJ.E.A. (1998). Preterm infants stress responses to an invasive NICU event: Endotracheal suctioning. Journal of Reproductive and Infant Psychology, 16 (4), 285–292.
68.
SommerfeltK.TrolandK.EllerstenB. & MarkestadT. (1996). Behavioral problems in low-birthweight preschoolers. Developmental Medicine and Child Neurology, 38 (10), 927–940.
69.
SparshottM.M. (1996). The development of a clinical distress scale for ventilated newborn infants: Identification of pain and distress based on validated behavioural scores. Journal of Neonatal Nursing, April, 5–10.
70.
StephensS.E. & GlazerG. (1992). Evaluating and monitoring the effects of the admission process on the premature infant. Journal of Perinatal and Neonatal Nursing, 5 (4), 46–57.
71.
SternbergW.F.ScorrL.SmithL.D.RidgwayC.G. & StoutM. (2005). Long-term effects of neonatal surgery on adulthood pain behavior. Pain, 113, 347–353.
72.
StevensB. & GibbinsS. (2002). Clinical utility and clinical significance in the assessment and management of pain in vulnerable infants. Clinics in Perinatology, 29 (3), 459–468.
73.
StevensB.JohnstonC. & GrunauR.V.E. (1995). Issues of assessment of pain and discomfort in neonates. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24 (9), 849–855.
74.
StevensB.J.JohnstonC.C. & HortonL. (1994). Factors that influence the behavioral pain responses of premature infants. Pain, 59 (1), 101–109.
75.
StevensB.JohnstonC.C.PetryshenP. & TaddioA. (1996). Premature infant pain profile: Development and initial validation. Clinical Journal of Pain, 12, 13–22.
76.
TeicherM.H.AndersenS.L.PolcariA.AndersonC.M.NavaltaC.P. & DimD. (2003). The neurobiological consequences of early stress and childhood maltreatment. Neuroscience and Biobehavioral Reviews, 27, 33–44.
77.
TorsneyC. & FitzgeraldM. (2003). Spinal dorsal horn cell receptive field size is increased in adult rats following neonatal hind-paw skin injury. Journal of Physiology, 550 (Pt 1), 255–61.
78.
TribottiS.J. & SteinM. (1992). From research to clinical practice: Implementing the NIDCAP®. Neonatal Network, 11 (2), 35–40.
79.
TromblyC.A. & MaH. (2002). A synthesis of the effects of occupational therapy for persons with stroke, part I: Restoration of roles, tasks, and activities. American Journal of Occupational Therapy, 56, 250–259.
80.
Van CleveL.JohnsonL.AndrewsS.HawkinsS. & NewboldJ. (1995). Pain responses of hospitalized neonates to venipuncture. Neonatal Network, 14 (6), 31–36.
81.
VisserG.H.A. (1992). The second trimester. In NijiusJ.G. (Ed.), Fetal behaviour: Developmental and perinatal aspects (pp. 1725). Oxford: UK: University Press.
82.
WaldenM.PenticuffJ.H.StevensB.LotasM.J.KozinetzC.A.ClargA., et al. (2001). Maturational changes in physiologic and behavioral responses of preterm neonates to pain. Advances in Neonatal Care, 1 (2), 94–106.
83.
WhitfieldM.F.GrunauR.V. & HolstiL. (1997). Extreme premature (≤ 800 g) schoolchildren: Multiple areas of hidden disability. Archives of Disease in Childhood, 77, F85–F90.
