Pain Management in Newborns

Abstract

All neonates in the Neonatal Intensive Care Unit (NICU) or during the first days of life undergo painful and stressful procedures. Epidemiologic studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Prevention is the first step of pain management, and practical guidelines should be used in the NICU. Assessment must be done with adequate tools that take into account the infant's pathology and gestational age. Distinguishing between acute and prolonged pain is important for both assessment and treatment. The most common drugs that have been studied for the treatment of pain and stress are opioids, hypnosedatives, and NMDA receptor antagonists. Morphine and fentanyl are most frequently used for acute or prolonged pain in the NICU. They have potent analgesic effects and few immediate or long-term adverse effects. Midazolam is a commonly used hypnosedative, but its adverse effects limit its use. Drugs such as propofol and ketamine have been used for acute painful procedures; however, further research is needed to assess their long-term effects. Use of non-pharmacologic pain management techniques has increased in recent years. These methods are easy, inexpensive, and effective in helping newborns recover from painful procedures. Sweet solutions and non-nutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and facilitated tucking are the most commonly employed and evaluated non-pharmacologic methods. Hospitals should promote and improve parent involvement in pain management. In-service education and well organized hospital teams are crucial for successful implementation of pain protocols in newborns.

Neonatal pain management: still in search for the Holy Grail

“…The general paradigm on pain management in neonates is driven by assessment, titration of a given intervention (non-pharmacological, pharmacological, or both) and subsequent re-assessment [3, 8]. Clinical pharmacology aims to predict (side) effects of compound specific pharmacokinetics (PK) and pharmacodynamics (PD) at the level of the population or – preferably – the individual.…”

“…Taking the shift towards less invasive neonatal care (e.g., insure procedure, i.e., intubation – surfactant administration – extubation instead of prolonged mechanical ventilation) into account, remifentanil and propofol have been introduced in neonatal intensive care [2, 8, 9, 33, 34]. …”

“…As a consequence, the management of neonatal pain remains in search of a new balance because these conflicting observations are the main drivers to tailor our current practices. To reach this new balance new treatment modalities, including non-pharmacological and pharmacological strategies, will need to be developed and validated [7, 8, 9]. …”

“…Non-pharmacological interventions stress the fact that not only what, but also how we perform painful procedures matters [8, 9, 14]. The focus needs to be on less invasive techniques, preventive strategies, or complementary techniques [14, 15].…”

“…Adaptations of procedural practices may be a very powerful approach to prevent pain. Such strategies also cover the use of central venous catheters instead of multiple peripheral perfusions, individualized monitoring techniques (blood pressure measurement interval, vital signs registration), adapted nursing techniques (e.g., frequency of endotracheal suctioning, skin and wound care, tape and wound dressing) or promoting skin-to-skin contact between newborn and parents [8, 9, 14, 15]. …”