title: Contextual factors influencing pain response to heelstick procedures in preterm infants: what do we know? A systematic review.
abstract: Major efforts to develop objective measurement tools for neonatal pain assessment have been made. However, the challenge of measuring pain in neonates remains suggesting that contextual factors (cFs) might alter their responses to pain. Although the role of cFs is increasingly discussed as crucial for pain assessment, they are not well described in the literature and are rarely considered in the clinical setting despite their importance.
  
  
  OBJECTIVE
  To systematically examine studies investigating the impact of cFs on pain response in preterm infants.
  
  
  METHODS
  A literature search was undertaken for the period from 1990 to 2009. Studies reporting the relation between one or more cFs and pain response in preterm infants during a heelstick procedure were considered for inclusion.
  
  
  RESULTS
  Twenty-three studies satisfied inclusion criteria. The studies varied relative to their design, sample, analysis procedures, and variables examined. Six categories of cFs emerged: age, pain exposure, health status, therapeutic interventions, behavioral status, and demographic factors. The examined cFs varied in the strength of their association with pain response, although none were invariably related, as evidenced by contradictory findings. In some cases the inconsistencies appeared attributable to methodological limitations in studies. Behavioral and physiological pain responses were not always in agreement as would be expected.
  
  
  CONCLUSIONS
  This review supports the influence of some cFs on pain response. However, the results remain inconclusive which may be, in part, related to the heterogeneity of the studies. Contextual factors need further investigation for a better understanding of the magnitude of their effect on pain response.
authors.affiliation: Institute of Nursing Science, University of Basel, Switzerland.
authors.forename: Gila
authors.initials: G
authors.lastname: Sellam
authors.forename: Eva L
authors.initials: EL
authors.lastname: Cignacco
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Craig
authors.forename: Sandra
authors.initials: S
authors.lastname: Engberg
mesh_terms: D001800:Blood Specimen Collection / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D018730:Infant Behavior / Q000502:physiology; D007231:Infant, Newborn; D007234:Infant, Premature / Q000502:physiology*; D010146:Pain / Q000209:etiology* / Q000503:physiopathology; D010147:Pain Measurement / Q000379:methods*; D058748:Pain Perception / Q000502:physiology*