REGISTRO DOI: 10.69849/revistaft/cl10202412181135
Adriana Silva de Moraes1; Marcela de Souza Vieira2; Laudicéia Monteiro Alves Rett3; Rodrigo Barbosa de Oliveira Brito4; Lucimar Conceição Carvalheiro Bernardes5; Silvia Alves da Silva Carvalho6; Cristiano Oliveira Nascimento Costa7; Dulcineia Almeida Silva8; Soraia Previato9; Tamiris Moreira da Silva de Araújo10
Abstract
Introduction: Neonatal pain management is a critical component of neonatal intensive care. Non-pharmacological methods, such as skin-to-skin contact, non-nutritive sucking, and facilitated tucking, have shown promise as effective and low-risk alternatives to pharmacological interventions. However, their successful application depends on the coordination and expertise of multidisciplinary healthcare teams. Objective: This study evaluates the role of multidisciplinary teams in implementing non-pharmacological strategies for neonatal pain relief in NICUs, identifying the most utilized practices and existing barriers to their effective use. Methods: A systematic review was conducted, analyzing literature from 2019 to 2023, sourced from databases including LILACS, BDENF, and SciELO. Ten studies focusing on non-pharmacological interventions in neonatal pain management were included. Results: Key findings highlight the frequent use of methods such as non-nutritive sucking, skin-to-skin contact, and the kangaroo method. While healthcare professionals demonstrated a strong understanding of these techniques, challenges such as inadequate standardization of protocols and gaps in training were identified. Conclusions: Non-pharmacological interventions are effective in managing neonatal pain. However, the establishment of clear protocols and continuous professional education are essential to optimize care quality and outcomes.
Keywords: Neonatal pain, non-pharmacological methods, multidisciplinary team, neonatal intensive care, pain management.
Introduction
Neonatal pain is a complex phenomenon that, when left untreated, can lead to long-term consequences such as chronic pain sensitization, behavioral changes, and even neurological development issues (Ortiz et al., 2024). Recent studies highlight that newborns, even in their earliest days of life, experience intense responses to painful stimuli (Ferro et al., 2024; Padula et al., 2024). However, managing neonatal pain presents unique challenges since infants cannot verbalize their discomfort, complicating both the identification and effective treatment of pain (Thompson et al., 2023). Moreover, invasive procedures performed in neonatal intensive care units (NICUs), such as heel pricks or intubation, often involve painful techniques, increasing the risk of physical and emotional complications for neonates (Giacomozzi et al., 2023).
In recent years, non-pharmacological approaches to neonatal pain relief have gained prominence due to the limited efficacy and potential adverse effects of medications, such as opioids and analgesics, on early development (Dias et al., 2024). Techniques such as skin-to-skin contact, non-nutritive sucking, and facilitated tucking have proven effective in providing immediate pain relief while also fostering a sense of comfort and security for the infant (Lorrane et al., 2024). These methods not only alleviate physical suffering but also strengthen the emotional bond between the mother and the newborn, offering additional benefits to the infant’s recovery process (Mendes et al., 2024). Furthermore, these strategies are cost-effective, easy to implement, and carry minimal risks, making them attractive options in NICU settings (Fernandes et al., 2024).
Implementing these practices, however, requires coordinated efforts among healthcare professionals, emphasizing the need for a well-trained and integrated multidisciplinary team (Bispo Júnior & Almeida, 2023). Nurses, physicians, physical therapists, dietitians, and psychologists all play crucial roles in neonatal care, particularly in pain management (Da Costa et al., 2024). Collaboration among these diverse professionals allows for tailored care strategies that address each infant’s unique needs, ensuring pain is managed effectively and holistically (Dias et al., 2024). For instance, adopting non-pharmacological practices demands not only technical knowledge but also effective communication among team members and ongoing professional development to align with best practices in care delivery (Abrão et al., 2024).
This study aims to explore the role of multidisciplinary teams in managing neonatal pain, focusing on non-pharmacological strategies, identifying the most commonly used practices, the challenges faced by healthcare professionals, and the implications for newborn well-being.
Method
This study employed an integrative literature review to investigate the role of multidisciplinary teams in managing neonatal pain, focusing on non-pharmacological interventions. The review analyzed articles published between 2019 and 2024 that addressed the contributions of various healthcare professionals in alleviating neonatal pain in Neonatal Intensive Care Units (NICUs). The inclusion criteria encompassed quantitative, qualitative, and randomized clinical trials, providing a comprehensive perspective on practices implemented by nurses, physicians, physiotherapists, psychologists, and other professionals.
The literature search utilized databases such as LILACS, SCIELO, BDENF, and PUBMED. Keywords included “non-pharmacological methods,” “neonatal pain management,” “multidisciplinary team,” “NICU,” “non-nutritive sucking,” “skin-to-skin contact,” and “non-invasive interventions.” Selected studies met criteria such as a focus on neonatal pain management, non-pharmacological approaches, and multidisciplinary involvement. Only full-text articles published within the last five years in Portuguese, English, or Spanish were included.
The analysis involved thematic synthesis, identifying emerging categories related to non-pharmacological practices for neonatal pain relief, the involvement of multidisciplinary teams, and challenges encountered in NICUs. The review mapped commonly utilized strategies and explored implications for improving care quality and neonatal well-being. All included studies were evaluated based on methodology, sample size, and relevance to the research objectives to ensure the validity and reliability of the findings.
Results
Table 1 – Summary of Selected Articles
| Year | Author(s) | Objective | Conclusion |
|---|---|---|---|
| 2024 | Bonato, L. C., Matte, C., & Cruz | Investigate non-pharmacological methods used for neonatal pain relief in Neonatal Intensive Care Units (NICUs) and nurseries, identifying the most effective practices adopted by nursing professionals. | Non-pharmacological methods such as touch, massage, proper positioning, and non-nutritive sucking are widely used for neonatal pain relief and are effective in reducing stress and discomfort in babies. |
| 2024 | Larissa, Lúcia, A., Rosa, S., Ramos, G. C., Rayanne, G et al. | Identify in the literature current discussions on neonatal pain and highlight non-pharmacological management by nurses to relieve neonatal pain. | Health institutions need to promote health education to enhance professional knowledge and skills for effectively alleviating neonatal pain and ensuring proper recovery. |
| 2024 | Dumont, F. E., Aires, Y. R. de F., Nascimento, T. R., Santos, M. P et al. | Analyze the effectiveness of comfortable transport and swaddling in reducing pain in premature infants. | The study demonstrated the effectiveness of non-pharmacological interventions, such as swaddling and containment, in managing pain during distressing procedures in neonates |
| 2023 | Ribeiro, G. L., Costa, C. C. da, Damasceno, A. K. de C., Vasconcelos, C. T. M et al. | Assess the experiences of postpartum women regarding childbirth and postpartum care, focusing on practices that influence newborns’ well-being, such as skin-to-skin contact and early breastfeeding. | The study suggests that skin-to-skin contact and early breastfeeding have indirect analgesic effects, promoting comfort and emotional relief for the baby, while also strengthening the mother-child bond. |
| 2023 | Medina, E. T., Mouta, R. J. O., Carmo, C. N. do, Filha, M. M. T et al. | Compare obstetric care in birthing centers and public hospitals within Brazil’s Unified Health System (SUS) in the Southeast region, considering best practices, interventions, and maternal and perinatal outcomes. | Birthing centers offer greater adherence to best practices and fewer interventions in childbirth care, ensuring safety and care without affecting outcomes. |
| 2022 | Silva, A., Querido, D. L., & Magesti, B. N. | Develop and validate an educational technology in the form of a folded leaflet to guide mothers of hospitalized newborns in rooming-in settings on neonatal pain relief. | The educational technology was validated in terms of appearance and content to guide and encourage maternal participation in managing newborn pain during painful procedures in rooming-in settings. |
| 2022 | Moraes, M. G. | Evaluate the effectiveness of non-nutritive sucking (NNS) in alleviating term neonates’ pain during heel pricks. | NNS proved effective in reducing neonatal pain during heel pricks, with NIPS scores for the intervention group being <4. |
| 2021 | Moura, D. M., & Souza, T. P. B. | Describe the knowledge of nursing staff on assessing and managing pain in term and preterm newborns in NICUs, as well as daily challenges. | Nursing staff demonstrated awareness of hemodynamic changes, consequences of prolonged pain exposure, and mastery of non-pharmacological strategies for managing neonatal pain. |
| 2021 | Silva, S. F. da, Rolim, K. M. C., Albuquerque, F. H. S., Santos, M. S. N et al. | Investigate nursing staff’s knowledge about non-pharmacological pain management and describe the main methods used for neonatal pain relief in preterm newborns under intensive care. | Some participants lacked knowledge of non-pharmacological methods for managing neonatal pain in preterm newborns, highlighting the need for further research on the topic. |
| 2020 | Oliveira, C. R. de, Santos, J. M. de J., Guarda, L. E. D. A., Barbieratto, B. J et al. | Identify neonatal pain management practices from the perspective of health team leaders in a low-risk maternity hospital. | Leaders of health teams demonstrated superficial knowledge of neonatal pain assessment and non-pharmacological management, with no formal protocols or training in place. |
Discussion
The Role of the Multidisciplinary Team in Neonatal Pain Management
Neonatal pain management is a complex clinical challenge that requires a collaborative and coordinated approach from a multidisciplinary team. Pain, often underestimated or underreported in neonates, can have significant consequences on neurological and physiological development, underscoring the need for effective management strategies (Moura & Souza, 2021). In Neonatal Intensive Care Units (NICUs), the healthcare team must be integrated, sharing knowledge and experiences to alleviate pain effectively. Nurses, for instance, play a central role in implementing non-pharmacological interventions, such as non-nutritive sucking (NNS) and skin-to-skin contact, which have shown excellent results in reducing neonatal discomfort. Silva et al. (2022) emphasize that communication among healthcare professionals is critical, as the success of these techniques depends not only on technical knowledge but also on team coordination. Additionally, creating an environment where all team members are well-informed about pain management protocols facilitates the effective use of strategies like breastfeeding and the Kangaroo Care method, which also contribute significantly to pain relief (Moura & Souza, 2021).
Non-Pharmacological Interventions as Effective Practices for Neonatal Pain Relief
Among the non-pharmacological interventions, non-nutritive sucking (NNS) is one of the most studied and recommended practices for alleviating neonatal pain, particularly during invasive procedures. Moraes (2022) reported that NNS, when properly administered, results in a reduction of clinical pain signs such as excessive crying and facial expressions of discomfort. Recent studies, such as Silva et al. (2021), support this view, indicating that NNS has a positive effect on reducing pain and stress, particularly in premature or low birth weight neonates. This is because active sucking stimulates the release of endorphins, which act as natural painkillers. Moreover, this practice offers psychological comfort to the neonate, establishing an initial bond between mother and child, which also contributes to the baby’s emotional regulation.
Another frequently used method is skin-to-skin contact, or Kangaroo Care, which has been widely studied as an effective intervention for neonatal pain relief. Oliveira et al. (2020) assert that skin-to-skin contact not only alleviates pain but also contributes to the neuropsychomotor and physical development of the newborn. The calming effect of touch, in addition to stimulating the production of hormones like oxytocin, creates a sense of security for the baby, reducing stress and pain levels. Studies also show that direct skin-to-skin contact helps regulate physiological parameters, such as body temperature, heart rate, and blood pressure, factors that may be influenced by pain (Moura & Souza, 2021).
In addition to skin-to-skin contact and NNS, breastfeeding has also been shown to be effective in reducing neonatal pain. Bonato et al. (2024) indicate that breastfeeding, even in short episodes, can significantly impact the comfort and well-being of the baby. This is because the act of sucking releases substances like prolactin and endorphins, which are associated with pain relief and pleasure. In NICUs, where direct breastfeeding may not always be possible, offering breast milk through tubes can also provide similar analgesic effects, making it an important tool in pain management (Bonato et al., 2024).
Challenges in Implementation and Ongoing Education of the Team
Despite strong evidence supporting non-pharmacological practices, the implementation of these approaches faces significant challenges, particularly regarding healthcare team training and the standardization of pain management protocols. Oliveira et al. (2020) highlight that although practices such as NNS and skin-to-skin contact are recognized as effective, their application remains uneven across NICUs. This can be attributed to a lack of continuous training and the absence of specific protocols. Moura & Souza (2021) note that the implementation of these strategies depends not only on technical knowledge but also on a cultural shift within healthcare institutions, which must be supported by clinical leadership that encourages adherence to recommended practices. Furthermore, the underreporting of pain, often linked to the difficulty of accurately assessing pain in neonates, remains a persistent issue. Silva et al. (2022) emphasize that many professionals still face challenges in measuring pain in newborns, which may lead to underestimation of pain and, consequently, the failure to implement appropriate interventions.
The lack of continuous training that integrates non-pharmacological practices into daily NICU routines can be seen as one of the biggest obstacles to improving neonatal care. Silva et al. (2021) stress that ongoing education and the creation of clear, accessible protocols are crucial for the effective and consistent application of pain management practices. Building a continuous learning environment and fostering the exchange of experiences among team members can help overcome these barriers. Additionally, creating an institutional culture that values patient-centered, family-oriented care is essential to ensure that pain management is approached holistically and integratively.
Integration of Non-Pharmacological Practices with Humanized Care
The integration of non-pharmacological practices with a humanized care approach is essential for effective neonatal pain management. As suggested by Bonato et al. (2024), humanization in neonatal care should not be viewed merely as a trend but as an intrinsic necessity for newborn health care, involving everything from creating a welcoming environment to implementing practices that reduce stress and pain. Combining interventions such as skin-to-skin contact and NNS creates a care environment that prioritizes physical and emotional proximity between the neonate and the parents, providing not only pain relief but also security and comfort.
Additionally, practices such as neonatal massage, recommended by Moraes (2022), have shown significant benefits in pain relief and promoting relaxation in the baby. Massage stimulates blood circulation and reduces cortisol levels, the stress hormone, and is especially effective in premature neonates, who are more vulnerable to physiological changes associated with pain. Medina et al. (2023) also highlight the role of therapeutic touch, noting that massage not only alleviates pain but also strengthens the parent-child bond, an essential component of humanized care.
In this context, the combined efforts of nursing, physiotherapy, and psychology professionals ensure that the neonate receives not only technical care but also emotional and psychological support. Silva et al. (2022) suggest that a multidisciplinary approach is essential to ensure that pain management practices are carried out integrally and continuously, promoting the newborn’s well-being and facilitating a quicker and less traumatic recovery.
Research Biases
One major bias in this research could relate to the limitation of included studies, selected only from publications in the last five years. This temporal restriction may have excluded relevant earlier research on neonatal pain management and non-pharmacological practices, which could provide a broader context on the topic. Additionally, the choice to include studies only in English and Portuguese may have limited the diversity of approaches and neonatal pain management practices used in other cultures and healthcare systems.
Another potential bias stems from the heterogeneity of the methods used in the selected studies, which may have influenced the results and the generalizability of the conclusions. Variations in interventions, pain assessment criteria, and studied populations may have resulted in efficacy data that are not always directly comparable. This could affect the external validity of the findings and limit the universal applicability of the discussed practices.
Conclusion
In conclusion, neonatal pain management is a shared responsibility among all members of the multidisciplinary team. It is essential that care includes not only pharmacological interventions but also non-pharmacological approaches, which have proven to be highly effective in clinical practice. Non-nutritive sucking, skin-to-skin contact, breastfeeding, and other humanized care techniques have shown positive effects on both pain relief and the overall well-being of newborns. However, challenges such as pain underreporting and the lack of ongoing team training must be overcome. The integration of continuous education and the creation of clear protocols for neonatal pain management are essential for the effective implementation of these practices. With greater awareness and improved coordination among healthcare professionals, it will be possible to ensure that neonatal pain management is carried out more effectively and humanely, promoting the comfort and healthy development of newborns.
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1Adriana Silva de Moraes, PhD student at the Catholic University of Santos (UNISANTOS); Nursing Coordinator at the University of Western São Paulo (UNOESTE), Guarujá campus.
2Marcela de Souza Vieira, Nurse; Postgraduate in Health Management, Gynecology/Obstetrics, and Urgency/Emergency from São Camilo University Center.
3Laudicéia Monteiro Alves Rett, Nurse with postgraduate studies in Neonatal and Pediatric Intensive Care from Nove de Julho University (UNINOVE).
4Rodrigo Barbosa de Oliveira Brito, PhD in Medicine from the 9th of July University (UNINOVE); Medical student at the University of Ribeirão Preto (UNAERP), Guarujá campus.
5Lucimar Conceição Carvalheiro Bernardes, Nurse; Postgraduate in Occupational Nursing from COREN.
6Silvia Alves da Silva Carvalho, Medical student at the University of Ribeirão Preto (UNAERP), Guarujá campus.
7Cristiano Oliveira Nascimento Costa, Bachelor’s degree in Accounting from the Faculty of the Americas (FAM); Nursing student at the University of Ribeirão Preto (UNAERP).
8Dulcineia Almeida Silva, Medical student at the University of Ribeirão Preto (UNAERP), Guarujá campus.
9Soraia Previato, Medical student at the University of Ribeirão Preto (UNAERP), Guarujá campus.
10Tamiris Moreira da Silva de Araújo, Nurse; Postgraduate in Women’s Health and Higher Education Teaching at Holistic Faculty (FAHOL).
Corresponding Author: Adriana Silva de Moraes; Guarujá, São Paulo, Brazil. E-mail: enfmoraes280@gmail.com