The perception of pain in newborns has been recognized since the 1980s. However, up to 80% of them do not receive any management before painful procedures. The problem is greater if one considers that, on average, there are 15 such procedures per day during hospitalization (1). Multiple clinical practice guidelines, such as those published by the American Academy of Pediatrics (2) and the Canadian Pain Management Society (3), recognize its importance and propose guidelines for its management, but adherence to these recommendations is low. The reasons for this include that health care personnel underestimate pain sensation, do not know the mechanisms for its evaluation or limit management to maximum pain procedures (4).

The lack of knowledge regarding the evaluation and management of pain in neonates is a widespread problem, as evidenced in studies carried out in Korea (4), China (5), Brazil (6), India (7), the United States (8) and Japan (9). These studies highlight the importance of designing a strategy that comprehensively addresses the diagnosis and management of pain in this population.

There are findings of the consequences of inadequate pain management, such as physiological or hemodynamic instability, alteration in brain development and neurodevelopment, abnormalities in stress response, and somatosensory systems, which may persist throughout childhood (8).

The objectives of the research were, on the one hand, to evaluate the impact of designing and implementing an educational strategy on the perceptions and knowledge of health personnel working in three newborn units in the city of Bogotá (Colombia), both public and private; on the other hand, to evaluate whether there is a change in clinical practice regarding the evaluation and management of pain, comparing a period before and after the implementation of this educational strategy.

The present work corresponds to a before and after study. It was carried out at the Hospital Universitario San Ignacio (private fourth level of care institution), at the Fundación Hospital de La Misericordia (private fourth level of care institution), and at the Instituto Materno Infantil de Bogotá (public third level of care institution) between June and December 2018. It was submitted to the Ethics Committee of the three hospitals where it was performed (Minute 10-2018, Minute 251 of September 24, 2018, and Minute 68-2018, respectively). Survey participants signed informed consent. The work was conducted in three phases.

In this work, pioneer in Colombia, it was found that after developing and implementing an educational intervention strategy for health personnel working with hospitalized newborns, a significant increase in the use of pain management scales is achieved, adherence to the recording of pain in clinical histories is increased, and pharmacological measures to prevent and treat pain are used more frequently when painful procedures are performed.

In our study we found that the change was moderate in the perception of health personnel regarding the recording of pain (78.4 % vs. 85.2 % % %), in contrast to other authors (28), who reported larger changes (54.1 % vs. 78.1 %); however, the actual clinical impact when recording pain in the medical record was greater (1.3% vs. 54.4%), suggesting that the actual changes in practice may be even greater than the perception of health personnel. It was striking that the change in perceptions was greater in the non-medical staff group, possibly associated with the lower level of baseline training in nursing and therapy programs. In contrast, the physicians, since the previous period, manifested a greater knowledge and willingness to manage pain.

Regarding the use of methods (pharmacological and non-pharmacological) to relieve pain, we found a lower increase than that reported by Aymar et al. (28). Both with a higher proportion of pharmacological than non-pharmacological measures. This may be because in the three institutions where the present study was conducted, the use of oral sucrose is not established, and its availability in Colombia is limited. An alternative is to perform a daily preparation with sugar and distilled water, as is done in many neonatal units in the country, but there is a fear that this manipulation may favor infections, such as necrotizing enterocolitis of the newborn if it is not performed with the pertinent biosafety and pharmacovigilance measures.

There are also studies showing that it is also possible to use 20% or 30% glucose with doses similar to those recommended for sucrose. A systematic review of 38 studies, including 3,785 neonates, demonstrated a reduction in the score on pain scales, without side effects (29). Kangaroo position, restraint, and breastfeeding are also very important non-pharmacological measures; however, we may not have detected changes in their use since they are not recorded in the histories as measures to reduce pain.

The performance of kangaroo procedures such as venipunctures, aspirations, heel punctures, probe insertion, transfontanelar ultrasounds, ophthalmology evaluations, and echocardiograms (with inverted kangaroo), require some time for their implementation, but their benefits and safety merit their routine use. Pharmacological measures may be reserved for more invasive procedures, such as surgery, catheter insertion, lumbar puncture, insertion, or removal of thoracostomy tubes (30-32).

The data recorded in the literature are consistent with those found in this study. In our case, a higher proportion of participants consider that they record more pain, apply collectively and individually more pain scales, know more about non-pharmacological measures, use more pharmacological measures for major therapeutic pain procedures and consider that after the intervention pain is well managed in their unit; but the same does not occur with non-pharmacological measures.

In the records analyzed in the clinical histories, statistically significant differences were found, except in non-pharmacological management. The frequency of recording pain in diagnostic painful procedures before and after the intervention was higher, with an increase of more than 30% in therapeutic procedures, such as surgeries and catheter insertion, and a much smaller increase in minor procedures, such as heel punctures or venipunctures, which are the most frequent.

In pilot testing the implementation of the strategy, we found that using a pain scale that was difficult to understand or apply, with multiple items, would not achieve the necessary adherence (23-28); therefore, we preferred the PIPP scale. In the future, we could add the Comfort-Neo scale, which would evaluate very well ventilated and sedated patients at term, with acute and prolonged pain, but which requires much more experience and time, given the number of items it evaluates.

The main limitation of this study is the absence of a control group of units in which an educational strategy was not implemented; however, during the execution of this work, no measures were implemented to which the observed changes could be attributed. Additionally, a limitation is that the health personnel evaluated before and after the intervention were not exactly the same, which reflects the reality of intensive care units in Colombia, where there is a high turnover of personnel. Nevertheless, these data suggest that the benefit of interventions can be significant, even under these conditions, as long as training strategies that include new staff entering each institution are maintained, as was done in our strategy.

This study demonstrated that implementing an educational strategy improves sensitivity to pain management, reflected in the diagnosis and therapy applied promptly. These findings suggest that it is necessary to insist on the development of standardized protocols for pain management in each health institution, including scales that allow an objective evaluation of pain and the establishment of the appropriate therapy.

None of the authors declare any conflict of interest.