Pain management in neonates

1. Dr. Lokanath Reddy

2.  International Association for Study of
Pain(IASP)
 An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage (note that the inability
to communicate verbally or nonverbally does
not negate the possibility that an individual
is experiencing pain and is in need of
appropriate pain relieving treatment)

3.  YES
 Pain system is intact and functional in both
preterm and term neonates.
 Acute pain is processed in the somatosensory
cortex which suggests “conscious perception”
 Behavioral responses to pain are complex and
you can observe “self expression.” Effective
mechanisms of hyperalgesia, allodynia and
referred pain occur in both preterm and term
neonates.

4.  Flexion and adduction of affected limb
 Distinct facial expressions
 Specific features of a pain “cry” that has
unique spectrographic characteristics to
distinguish it from other types of cry(pain cry
vs hunger cry)

6.  8 weeks -1st cutaneous sensory receptors –
perioral area
 20 weeks – Sensory receptors present in all
cutaneous and mucosal surfaces
 6 weeks - Synapses between peripheral sensory
afferents and dorsal horn neurons will appear
 20 weeks – Thalamocortical connections will
form that allow painful stimuli to reach the
somatosensory cortex.
 A current theory of pain postulates that pain
perception occurs at the level of “thalamus”

7.  NO
 Developmentally regulated processes and
behavioral reflexes suggest that pain
threshold increases progressively during
late gestation and postnatal period.
 Preterm neonates have much greater
sensitivity to pain than term neonates and
they manifest prolonged hyperalgesia after
tissue injury.

8.  Acute pain: Heel sticks, venipunctures,
tracheal suctioning,lumbar puncture,
circumcision.
 Prolonged/chronic pain: NEC, meningitis,
mechanical ventilation, birth trauma, chest
tubes.
 Post-operative pain: Hernia repair, ligation
of PDA, VP shunts, abscess drainage etc.
 Routine care : Diaper change, daily weights,
removing adhesive tapes, burns from
transcutaneous probes and cold light, rectal
stimulation.

9.  YES, but in a different manner.
 Although children may not directly recall painful
experiences from their NICU stay, they may
demonstrate altered behavioral states from
painful experiences that were not well managed.
 Pain will lead to long term and permanent
alterations in brain development depending on
type, duration and severity of pain, the
neurological maturity at which pain occurs and
the use of analgesia.
 Pathophysiology: Tissue damage  profound
and long lasting dendritic sprouting of sensory
nerve terminals  hyper-innervation that
continues in childhood and adolescents.

10.  Repeated heel sticks  Abnormal gait in
childhood
 Perioral and nasal suctioning  Oral aversion
syndrome
 Gastric suctioning  Irritable bowel syndrome
 Surgical sites  increased pain sensitivity
 Nerve injury in neonates does not lead to
neuropathic pain as in adults

11.  PRIMARY HYPERALGESIA: Neonates exposed
to acute short term pain at the areas where
injury occurred
 SECONDARY HYPERALGESIA: Hyperalgesia at
remote areas from the site of injury.
 Primary and Secondary hyperalgesia – several
months
 Visceral Hyperalgesia – several months to
years
 Signs of ADHD, impulsivity and socialisation
problems during early school years.
 Chronic pain syndromes in adult life.

12.  Similar to term babies have heightened pain
reactivity to painful procedures like heel
stick.
 Conversely, cumulative pain since birth was
significantly correlated with dampened
reactivity to heel stick and lower cortisol
levels to stress at 32 weeks, less pain
reactivity at 4 months, faster recovery at 8
months, decreased everyday pain behavior at
18 months, increased somatization at 4.5
years and increased affective responses to
depicted pain at 8-10 years.

13.  Acute procedural pain/post operative pain
 Intensity – Many pain scales
 PIPP(Premature Infant Pain Profile) (27 wks – term)
 NIPS(Neonatal Infant Pain Scale) (28-38 wks)
 NPASS(Neonatal Pain, Agitation and Sedation Scale)
 CRIES score (32-60 wks)
 Character, location, duration and rhythm
cannot be measured
 Chronic pain – No scales to assess.

14. Scale Variables Type of pain
PIPP (Premature Infant
Pain Profile)
(27 wks – term)
HR, SpO2, Facial expression, takes
state and GA into account
Procedural,
Postoperative (minor)
NIPS(Neonatal Infant Pain
Scale) (28-38 wks)
Facial expression, crying,
breathing pattern, arm and leg
movements, state of arousal
Procedural
NFCS (Neonatal Facial
Coding System)
Facial actions Procedural
N-PASS (Neonatal pain,
Agitation, and Sedation
Scale)
Crying, irritability, behavioral
state, facial expression, extremity
tone, vital signs
Postoperative,
Procedural,
Ventilated
CRIES (Cry, Requires O2,
Increased vital signs,
Expression, Sleeplessness)
Cry, Requires O2, Increased vital
signs, Expression, Sleeplessness
Postopetive
COMFORT Scale (0-3 yr
old)
Movement, Calmness, facial
tension, alertness, RR, HR, BP
Postoperative, critical
care, sedated,

15. Relaxed – restful face/neutral
expression
score - 0
Grimace – Tight facial muscles
furrowed brow, chin & jaw
Score - 1

16.  No Cry –Quiet, not crying – 0
 Whimper – Mild moaning, intermittent – 1
 Vigorous cry – Loud cry, shrill, continuous - 2

17.  Relaxed – Usual pattern for that baby - 0
 Change in breathing – Indrawing , irregular,
fast than usual, gagging, breath holding - 1

18.  Relaxed – No muscular rigidity, occasional
random movements – 0
 Flexed/Extended – Tense straight arms/legs,
rigid, rapid flexion/extension - 1

19.  Sleeping/awake – Quiet, peaceful sleeping,
occasional random legs/arm movements – 0
 Fussy – Alert restless and trashing - 1

20.  Neonatal infant pain scale = SUM(points for
the 6 parameters)
 Interpretation:
• minimum score: 0
• maximum score: 7
Pain Level Intervention
0-2 = mild to no pain None
3-4 = mild to
moderate pain
Non-pharmacological intervention
with a reassessment in 30 minutes
>4 = severe pain Non-pharmacological intervention
and possibly a pharmacological
intervention with reassessment in
30 minutes

21. PIPP (Premature Infant Pain Profile)
 (27 wks – term)
Indicators:
 (1) gestational age
 (2) behavioral state before painful stimulus
 (3) change in heart rate during painful stimulus
 (4) change in oxygen saturation during painful
stimulus
 (5) brow bulge during painful stimulus
 (6) eye squeeze during painful stimulus
 (7) nasolabial furrow during painful stimulus

23. Scoring instructions:
 (1) Score gestational age before examining
infant.
 (2) Score the behavioral state before the
potentially painful event by observing the
infant for 15 seconds .
 (3) Record the baseline heart rate and
oxygen saturation.
 (4) Observe the infant for 30 seconds
immediately following the painful event.
Score physiologic and facial changes seen
during this time and record immediately

26.  premature infant pain profile = SUM(points
for all 7 indicators)
Interpretation:
 minimum score: 0
 maximum score: 21
 The higher the score the greater the pain
behavior.

27.  Prevention is better than cure
Procedure Prevention/Management
Removing adhesive tapes Use ether, pull slowly
Burns from transcutaneous
probes and cold light.
Frequent change of probes
every 2 hrly. Careful use of cold
light.
Diaper change, daily weights Minimal handling
Rectal stimulation Xylocaine jelly
Heel sticks, venipunctures Sucrose 0.5ml 2 min before
Tracheal suctioning Sedation
Lumbar puncture EMLA patch, local anestetic
NEC, meningitis, mechanical
ventilation, chest tubes,
postoperative
Sedation

28. Non pharmacological interventions
 facilitated tucking (holding the infant’s
extremities close to the body, promoting
flexion), swaddling, nesting, use of
nonnutritive sucking
 minimal handling protocols
 lowering noise levels in the NICU
 avoiding exposure to bright lights
 promoting of day/night light cycles.