Pain in Newborns -- Compassion & Common Sense Yeah, Baby!
Neonatal pain Suzanne S. Toce, MD Professor of Pediatrics Saint Louis University Medical Director, FOOTPRINTS Gary Allegretta, M.D. Medical Director The Jason Program Web: www.jasonprogram.org Add Your Logo Here ! Call for Details !
State of the Art Prevention and Management of Pain and Stress in the Neonate (RE9945) -- AMERICAN ACADEMY OF PEDIATRICS Committee on Fetus and Newborn Committee on Drugs Section on Anesthesiology Section on Surgery -- Pediatrics Volume 105, Number 2 February 2000, pp 454-461
Studies indicate a lack of awareness among health care professionals of pain perception, assessment, and management in neonates. 9-11 When analgesics were used in infants, they often were administered based only on the perceptions of health care professionals or family members. Fear of adverse reactions and toxic effects often contributed to the inadequate use of analgesics. In addition, health care professionals often focused on treatment of pain rather than a systematic approach to reduce or prevent pain. 12,13 More recent surveys have demonstrated increased awareness among health care professionals of pain in neonates and infants and its assessment and management. 14-16 Several textbooks on pain in neonates and infants have been published, 17-19 and measures for assessing pain have been developed and validated. 20-24 However, despite the advances in pain assessment and management, prevention and treatment of unnecessary pain attributable to anticipated noxious stimuli remain limited. 25-27 Several important concepts must be recognized to provide adequate pain management for the preterm and term neonate:
Painful or stressful procedures should be minimized and, when appropriate, coordinated with other aspects of the neonate’s care. Furthermore, consideration of the least painful method is important. For example, when performed by trained personnel, obtaining blood by venipuncture may be less painful than heel lancing. 56-58 Skillful placement of peripheral, central, or arterial lines reduces the need for repeated intravenous punctures or intramuscular injections. Thus, in some such cases, the risk-benefit balance may favor the more invasive indwelling catheters. Whenever possible, validated noninvasive monitoring techniques (e.g., pulse oximetry) that are not tissue damaging should replace invasive methods.
Effect of Oral Sucrose Solution on Venipuncture Pain Abad, et al Acta Paediatr, 1996 Time crying (sec)
Effect of sucrose and procedure on circumcision pain AJOG 2002;186:564-8
Percent time crying (Median) Effect of solution and route on heelstick pain Ramenghi, et al ADC (Fetal Neonatal Ed), 1999 NG sucrose Oral sucrose NG water Oral water
Pacifier and Sucrose in Procedural Pain Median pain scale score Carbajal, et al. BMJ, 1999
Glucose for Analgesia Crossover Trial of Analgesic Efficacy of Glucose and Pacifier in Very Preterm Neonates During Subcutaneous Injections --- Ricardo Carbajal, MD, et.al.; PEDIATRICS Vol. 110 No. 2 August 2002
40 very preterm neonates receiving erythropoietin injections SQ
Conclusions. A small dose of 0.3 ml of 30% oral glucose has an analgesic effect in very preterm neonates during subcutaneous injections. This effect is clinically evident because it can be detected by a behavioral pain rating scale. The synergetic analgesic effect of glucose plus sucking a pacifier is less obvious in very preterm infants.
Fig 1. Individual pain evaluations with DAN scale. Overall, glucose gives lower scores than sterile water ( p 0.03); however, 8 infants did not show a reduction of pain scores . Solid black lines indicate infants who did have a reduction in pain. Red lines indicate infants who did not have a reduction in pain scores with 30% glucose as compared to sterile water.
Breastfeeding is Analgesic in Healthy Newborns -- Gray, et.al, Pediatrics Vol. 109, No. 4, April 2002
The purpose of this study was to unite the different components of nursing (taste, suckling, and skin-to-skin contact), which have been shown to be individually analgesic, by allowing newborns to suckle their nursing mothers before, during, and after a standard heel lance procedure for blood collection.
The efficacy of this intervention was determined by evaluating video recordings of infant crying and facial expressions and by assessing blockade of heart rate increases that normally accompany the blood collection procedure.
30 healthy, term, breast-fed infants @ Boston Medical Center Hospital
Randomized to breast-fed and control
Heel lance performed while swaddled, with and without nursing
Pharmacological analgesia should be chosen carefully based on comprehensive assessment of the neonate, efficacy and safety of the drug, the clinical setting, and experience of the personnel using the drug. Drug doses, including those for local anesthetics, should be calculated carefully based on the current or most appropriate weight of the neonate, and initial doses should not exceed maximal recommended amounts. Subsequent doses should be modified based on multiple factors, including the cause of the pain, previous response, clinical condition, concomitant drug use, and the known pharmacokinetics and pharmacodynamics of the sedative and analgesic drugs administered. Medications that might result in the loss of protective reflexes or cause cardiorespiratory instability should be used only by appropriately trained persons in an environment equipped to handle emergencies.
Continued Studies are lacking on the management of pain in neonatal conditions associated with extensive tissue damage and those resulting in recurrent or chronic pain (e.g., necrotizing enterocolitis, meningitis, fractured bones). The effects of the use of analgesics or sedation during the neonatal period on long-term neurodevelopmental and psychological outcomes has not been well studied. 49 No differences in intelligence, motor function, or behavior at 5 to 6 years of age were found between neonates who received morphine for sedation during mechanical ventilation and placebo-treated neonates. 62
Pain in newborns is unrecognized and under-treated. Prescribe analgesia when indicated during their medical care.
If a procedure is painful in adults, it should be considered painful in newborns, even if they are preterm. Newborns may experience a greater sensitivity to pain and are more susceptible to the long term effects of painful stimulation.
Treatment of pain may be associated with decreased clinical complications and decreased mortality.