?Why neonates are so special Vulnerable Too tiny to complain. Special life Special care Special feed Special pain
Are we doing good or bad toour babies ?????????????????????????????
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such. Pain is subjective.” International Association for the Study of Pain
Are we doing good or bad toour babies ? What are the sources f pain ? What are the myths around pain in neonates? What are the facts? Is there a difference between full term and preterm ? Is the pain measurable ? What are the interventions ?
PAIN MANAGEMENT MYTHS Neonates do not feel pain. Infants are less sensitive to pain than adults Neonates have no memory of pain. Neonates are not able to tolerate the effects of analgesics. Infants become accustomed to pain.
?what are the facts Newborn infants have functional nervous systems which are capable of perceiving pain Physiologic means of assessing pain (VS) can be an unreliable predictor of pain Infants often develop an increase in signs of discomfort with repeated painful procedures
Premature infants can have unpredictable responses to painful stimuli Unmanaged pain in the neonatal period can cause long term developmental complications
“Even if not expressed as conscious memory, memories of pain may be recorded biologically and alter brain development and subsequent behavior” -Journal of Paediatrics and Child Health 42 (2006)
The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Pediatrics 2006;118;2231
The Effects of Pain Physiological Effects changes in vital signs, pupils Behavioral Cues how the baby acts when she is in pain Hormonal/Metabolic Responses what happens chemically
Physiological Responses variations in HR variations in BP increased ICP increased or decreased RR decreased sats or increase in oxygen requirement change in color (pale, poor perfusion or red, increased perfusion) increased or decreased muscle tone
Behavioral Cues crying body movements can vary from high limb withdrawal pitched, tense to soft fist clenching moaning hypertonicity or facial expressions hypotonicity grimacing state changes quivering of chin changes in sleep-wake squeezing eyes shut cycles furrowed brow changes in activity levels- difficult to comfort or calm increased fussiness or irritability
Hormonal/Metabolic Responses increase in epinephrine and norepinephrine, growth hormone and endorphins decrease in insulin secretion increased secretion of cortisol, glucagon, and aldosterone… which leads to increased serum glucose, lactate, & ketones can lead to lactic acidosis Is the “stress response” secondary to the surgery/procedure or the pain afterwards?
Hormonal/Metabolic ResponsesChanges in hormone levels affect the absorption of fat, protein, and glucose, which subsequently affect HEALING AND GROWTH! PAIN CONTROL IS MORE THAN A MATTER OF COMFORT- CONTROLLING PAIN DECREASES COMPLICATIONS
Factors Affecting Pain Response Gestational age-as preterm infants develop, their responses become more sustained and interpretable Environmental factors-external noise, temperature, light
Factors Affecting Pain Response Intensity and duration of insult-repeated painful procedures decrease infant’s ability to react to pain but not their perception of it. Behavioral state-less reactive when in sleep states than wake states
Long Term Effects of UntreatedPain Newly studied area-until recently, babies were not thought to “remember” pain Some experts believe that untreated pain in the newborn period forces abnormal pathways to form in the brain This aberrant brain activity results in impaired social/cognitive skills and specific patterns of self- destructive behavior
?What can we do Common sense tells us that not all crying babies . are in pain A chronically stressed baby in the NICU may not .react at all to pain
Assessment of Pain in the Newborn Pain scales use behavioral cues such as quality of cry, breathing pattern, facial expression, & muscle tone, as well as changes in VS & increase in oxygen requirement.
Assessment of Pain in the Newborn Use of scales decreases nurse to nurse variability of pain med administration Limitations include differentiating between pain and agitation, difficulty assessing premature infants’ behavior, and few scales for use with intubated/sedated patients
FLACC Scale F-face (expression) L-legs (tone) A-activity C-cry C- consolabilityscore is tallied, similar to APGAR (0,1, or 2 for each category)greater than 4 is indicative of pain
NIPS (Neonatal Infant Pain (Scale Behavioral cues scale rates crying, facial expression, breathing patterns, tone of arms and legs, and state of arousal at one minute intervals should be used taking other physiologic factors into account
PIPP (Premature Infant Pain (Profile Uses both behavioral and physiologic reactions to pain Measures behavioral state, HR, sat, and 3 facial expressions which are indicative of pain in preemies (brow bulge, eye squeeze, and nasolabial furrow) Takes into account gestational age (postconceptual)
Prevent or Minimize Pain Cluster blood draws or use arterial line whenever possible to minimize sticks Use smallest gauge needle possible Use minimal amounts of tape/use tape remover to remove it Premedicate prior to painful or invasive procedures
Pain Management Developmental support is the first step in managing all levels of pain facilitated tuck-support infant in a flexed position parental involvement-give parents a chance to help support their baby
facilitate hand to mouth contact, offer pacifier- sucking causes endorphins to be released swaddling, holding minimize external stimuli such as noise & light
Circumcisions ASPMN statement circumcisions are painful Unrelieved pain from circs can cause adverse stress responses such as breath holding, apnea, gagging, and vomiting neonates have the right to an anesthetic to prevent the pain of the procedure suggest use of blocks or EMLA cream as well as sucrose pacifier and developmental support to assist these babies with coping
AAP Recommendations1. Caregivers should be trained to assess neonates for pain using multidimensional tools.2. Neonates should be assessed for pain routinely and before and after procedures.3. The chosen pain scales should help guide caregivers in the provision of effective pain relief.
Reducing Pain From BedsideCare Procedures1. Care protocols for neonates should incorporate a principle of minimizing the number of painful disruptions in care as much as possible.2. Use of a combination of oral sucrose/glucose and other nonpharmacologic pain-reduction methods (nonnutritive sucking, kangaroo care, facilitated tuck , swaddling …)
3-Topical anesthetics can be used to reduce pain associated with venipuncture, lumbar puncture, and intravenous catheter insertion when time permits but are ineffective for heel-stick blood draws, and repeateduse of topical anesthetics should be limited.
4. The routine use of continuous infusions of morphine, fentanyl, or midazolam in chronically ventilated preterm neonates is not recommended because of concernabout short-term adverse effects and lack oflong-term outcome data.
Reducing Pain From Surgery 1. Any health care facility providing surgery for neonates should have an established protocol for pain management. Such a protocol requires a coordinated, multidimensional strategy and should be a priority in perioperative management.
2. Sufficient anesthesia should be provided to prevent intraoperative pain and stress responses to decrease postoperative analgesic requirements.3. Pain should be routinely assessed by using a scale designed for postoperative or prolonged pain in neonates.
4-Opioids should be the basis for postoperative analgesia after major surgery in the absence of regional anesthesia.5. Postoperative analgesia should be used as long as pain-assessment scales document that it is required.
6. Acetaminophen can be used after surgery as an adjunct to regional anesthetics or opioids, but there are inadequate data on pharmacokinetics at gestational ages less than 28 weeks to permit calculation of appropriate dosages.
Reducing Pain From Other MajorProcedures1. Analgesia for chest-drain insertion comprises all of the following:a. general nonpharmacologic measures;b. slow infiltration of the skin site with a local anesthetic before incision unless there is life- threatening instability (if there was inadequate time toinfiltrate before insertion of the chest tube, local skin infiltration after achieving stability may reduce later pain responses and later analgesic requirements);
Reducing Pain From OtherMajor Procedures c. systemic analgesia with a rapidly acting opiate such as fentanyl.
2. Analgesia for chest-drain removal comprises the following: Analgesia for chest-drain removal comprises the following: a. general nonpharmacologic measures and b. short-acting, rapid-onset systemic analgesic.
3. Although there are insufficient data to make a specific recommendation, retinal examinations are painful, and pain-relief measures should be used. A reasonable approach would be to administer local anesthetic eye drops and oral sucrose. 4. Retinal surgery should be considered major surgery, and effective opiate-based pain relief should be provided
GOALS OF MANAGEMENT Decrease pain and suffering Promote family bonding Increase patient comfort Promote normal coping mechanisms Decrease patient risk from complications Prevent negative long term developmental outcomes HAPPY, HEALTHY BABIES!