At the IASP 2021 Virtual World Congress on Pain, to take place June 9-11 and June 16-18, the International Association for the Study of Pain (IASP) will present awards to honor the achievements of up-and-coming as well as more established investigators (these awards were originally to be presented at the 2020 World Congress on Pain in Amsterdam, which was canceled due to the COVID-19 pandemic). In advance of the meeting, PRF spoke with each of the winners. In this interview, we chat with Ana Vieira, RN, MScN, PhD, one of the two winners of the IASP Award for Excellence in Pain Research and Management in Developing Countries (see interview with Ashok Kumar Saxena, MD, DA, the other winner of this award, here). This award honors an individual or team that has achieved an outstanding level of excellence in programs of basic science research in pain or pain management, clinical research or practice, and/or policy changes in pain management in the developing world.
Vieira is an associate professor of pediatric nursing at Universidade Federal de Pelotas, Rio Grande do Sul, Brazil. She champions the role of parents in helping to alleviate pain in the youngest and one of the most vulnerable groups of hospital patients: newborns in the neonatal intensive care unit (NICU) and young children in the pediatric intensive care unit (PICU). As part of that work, she developed a unique social media program to help educate clinicians across Brazil about the use of breastfeeding to help better manage pain in neonates and small children. Here, Vieira spoke with freelance writer Kayt Sukel to discuss the use of breastfeeding to help ease pain, the power of social media to disseminate knowledge about pain management, and her dream of opening a center of excellence dedicated to the study of pain at the Universidade Federal de Pelotas. The following is an edited transcript of the conversation.
How did you first become interested in pain research?
I have been a nurse since 1986. Initially, I worked at the Hospital da Criança Santo Antônio in Porto Alegre, Brazil, as a pediatric intensive care nurse. Since then, I’ve worked in diverse clinical settings, including oncology and surgical areas, and I have seen the reality of what children and families have gone through with regard to pain during treatment. It showed the cruelty of a society with enormous social and economic inequality.
It was important to me to understand the pain that many of these children endured, and to help find ways to reduce it. I felt it was my responsibility to do this for all my little patients.
In 1990, I started working in the NICU at Hospital Mãe de Deus, also in Porto Alegre. It is a very big challenge to work with very premature babies. I was very concerned about the necessity of many procedures these babies went through; they often have very complex diseases and often undergo many different types of procedures. I hoped to find opportunities to promote life and decrease the number of painful procedures that these children had to go through, or at least find ways to perform them with less pain. As a clinical nurse, I was always thinking about how to better manage pain – how to help these little, helpless patients avoid pain.
What is your main research focus today?
In my current position as a professor of pediatric nursing, my research focus is on pain management in these young patients. I work on projects about breastfeeding to help relieve pain in neonates and small children, as well as to support mothers who may be experiencing difficulties like breast engorgement, nipple trauma, or other issues during the lactation process.
My primary research aim is to help parents, health professionals, policymakers, and all other stakeholders who are involved with neonates and young children understand that it is possible to reduce procedural pain in this population. I want to show them how to search for evidence about pain relief, to understand it, and to put that evidence into clinical practice so we can minimize pain. There is a lot of good information out there about how to better manage pain, but it’s been difficult to put it into practice here in Brazil.
Why do you think breastfeeding helps?
Breastfeeding seemed like a natural way to help soothe babies. I used to ask mothers to breastfeed during venous punctures, for example, to provide that important skin-to-skin contact. These strategies have been used by mothers since the beginning of time to help babies. Now we know there is quite a bit of evidence to support breastfeeding as a method of pain relief. But in the 1990s, we didn’t have access to sources of evidence about this. We could only work with our observation and instinct.
Today, there are many good studies and guidelines that recommend breastfeeding during medical procedures. And we see it used in many countries like Canada, Australia, the United States, and England; they have been very receptive to its use. But it is not as common in Brazil.
In the past, health professionals like nurses and doctors were very resistant to the use of breastfeeding. They were not aware of the evidence. So I wanted to improve the practice within our culture of medicine because I had personally observed how calm the babies could be when they were so close to their mom, and how the procedures went much more easily. But for many hospitals, and their respective NICUs and PICUs, it was hard to convince doctors and nurses because they just didn’t know how breastfeeding might help with pain management.
How does it work?
When a mother holds her baby closely, it increases the production of endorphins, which helps the baby stay very calm. The combination of skin-to-skin contact and breastfeeding, including the flavor of milk and the process of sucking, increases levels of those molecules and helps to modulate the pain, minimizing it during uncomfortable procedures.
What are some of the challenges involved with getting clinicians on board with using breastfeeding to help with pain management?
As we know, neonates, infants, and young children are unable to communicate their pain, especially when they need intensive medical care. Additionally, many health professionals don’t receive pain management education during their undergraduate courses, especially in Brazil, where health professionals have little or no time available for this.
The language barrier is also an issue. Most nursing professionals in Brazil, for example, don’t speak English. Most of the recommended guidelines are published in English, and it can be difficult to get Portuguese translations.
There are also some cultural barriers. Sometimes nurses worry about involving the parents in painful procedures. They are afraid the parents will be upset, and they want to protect them. My mentor, Dr. Denise Harrison from the University of Ottawa, developed a very good educational program, including a video called “Be Sweet to Babies” that shows a mom using breastfeeding or a sweet solution, like a sucrose or glucose solution, to help reduce pain during procedures. It also shows the importance of skin-to-skin contact. It’s important to find ways to educate doctors and nurses about how breastfeeding can help with the management of pain during procedures like blood collection or other ones.
The research has shown that parents can play an important role in managing pain. But, as I mentioned, it is a challenge to implement programs like the breastfeeding program because doctors and nurses can be wary of engaging parents. But parents know better about their babies. So it is very important to allow parents to talk about this, to teach them how to prevent and alleviate pain, and help them work with health professionals to help their children. Parents, really, are the key to this process.
Tell me about your use of social media to help educate Brazilian clinicians about breastfeeding and pain modulation.
I was following the lead of my mentor, Dr. Harrison. She showed me the power of social media to spread information. I never imagined how powerful a tool it could be. While I was working with her as a visiting researcher, I used platforms like Facebook to spread pain management strategies to help babies and infants up to 12 months of age.
When I returned to Brazil in 2017, I wanted to use social media to help with knowledge translation and to help change perspectives about breastfeeding and pain. So I developed a project to reduce children’s pain during immunizations. On social media, we developed parent-oriented activities carried out as “scientific cafés” to engage doctors, nurses, parents, and policymakers. We put up a video and then asked everyone to respond to a survey, asking them if they knew about breastfeeding, sweet solutions, and about the importance of skin-to-skin contact to alleviate pain. After three months, the page had over 28,000 views across 45 municipalities in Brazil. I could not believe it.
Social media has been vital to our efforts to educate nurses and doctors in Brazil because we have so many different states and regions. Using a platform like Facebook, I can share interesting data, and people can access it using a smartphone and then share the content very easily with other people. It’s been so interesting to me because we have all the traditional ways to publish a scientific paper to share new findings. But the results, so often, are in English. And it’s more difficult for people in Brazil, who speak Portuguese, to access this information. With social media, I can quickly share it with many people in the region.
How would you describe the state of pain care in Brazil, compared to other countries?
In some ways, we have evolved quite a bit over the past 20 years. Certainly, today, there is a lot of interest in minimizing the pain of babies and children. But health professionals do not know how to do it. We need to use more evidence in clinical practice and help engage more parents to participate in pain management in all settings.
What are your future plans?
I am going to Canada to work as a visiting professor with Dr. Anna Taddio at the University of Toronto this year. My intention is to work with her to analyze preliminary data I have collected from a study working with community health centers about pain management during immunizations, from both health professional and parental perspectives.
I want to thank colleagues like Dr. Mariana Bueno, Dr. Denise Gastaldo, and my advisor, Dr. Harrison, for their support over my career. I have worked with a lot of great people. That’s why, once I return to Brazil, I hope to collaborate with colleagues from all over Brazil, as well as people in other countries, to help those who are interested to adopt recommended strategies to relieve pain in babies and children.
But ultimately, my dream is to create a center of excellence in the study of pain here in Pelotas. I started my work in pain management more than 30 years ago. But when I started to use social media, I saw the possibility of reaching so many more people and colleagues, in my own country and beyond. I hope to obtain funding to create a center that will teach undergraduates in traditional medicine, nursing, psychology, and other health fields about effective pain management.
Kayt Sukel is a freelance writer based outside Houston, Texas.