Chapter 15: Pain in the Neonate

INTRODUCTION

Before the 1980s, it was a common belief that preterm infants lacked the neurodevelopmental capacity to feel pain. This resulted in severe undertreatment of pain in the neonate during hospitalization. It is now known that infants have the required neuroanatomical connections to feel pain, and actually experience a higher degree of sensitivity to pain as compared to children and adults. Neonates are subject to many painful procedures, especially the most immature infant. Although neonatology has made strides in the past 20 years to understand pain, it remains a challenge to effectively assess and treat the various types of pain experienced in the neonatal intensive care unit (NICU). A recent study revealed that there is a worldwide trend of undertreatment of neonatal pain and that more attention should be given to pain prevention, assessment, and treatment. Countries with nationally accepted guidelines for pain management (such as France, Sweden, and the Netherlands) do a better job in treating neonatal pain than those countries without guidelines. The American Academy of Pediatrics (AAP) recently updated the recommendations for managing procedural pain in neonates. These recommendations include the following:

1. Every institution caring for neonates should implement a pain prevention program that includes written guidelines for a stepwise pain prevention and a treatment plan.

2. Validated neonatal pain assessment tools should be used consistently before, during, and after painful procedures.

3. Nonpharmacologic strategies decrease pain scores during short-term mild to moderately painful procedures and should be used. These include facilitated tucking, breast feeding or providing expressed human milk, nonnutritive sucking, sensorial stimulation, and others.

4. Oral sucrose/glucose solutions are effective with mild to moderately painful procedures, either alone or combined with other pain-relief strategies. If used, these solutions need to be tracked as medications.

5. Healthcare providers need to weigh actual benefits and burdens when using pharmacologic treatment methods. It is important to remember that some of the medications can potentiate the hypotension and respiratory depression that can occur with opioid use. Use caution when using newer medications that do not have data in neonates.

6. All providers should receive continuing education on the recognition, assessment, and management of pain.

7. More research needs to be done in this area.

Some have suggested that pain assessment should be considered the fifth vital sign, so with each vital sign determination, pain assessment should be done and recorded.

I. PHYSIOLOGY OF PAIN IN THE NEONATE

1. Definition. Pain has been defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms of such damage.” An infant’s response to pain involves a collection of biochemical, physiologic, and behavioral reactions. There are many different layers of an infant’s response that can be understood by gestational age and development. Noxious stimuli lead to tissue damage, causing the release of sensitizing substances such as prostaglandins, bradykinin, serotonin, substance ...