Recognizing sources of neonatal pain…

Neonatal Pain
Original Authors: Jere O’Brien Kinne, RN, MN, CNS, CPNP
Kathy McKee, RN, BSN, MSM, Christine Cooper,
Update 2012: Kimberly Cooper, RN
What is Pain?
• Pain: “an unpleasant sensory
or emotional experience
associated with actual or
potential tissue damage”
• The inability to communicate
the feeling of pain in no way
negates the possibility that an
individual is experiencing it.
Pain Assessment & Treatment
• For decades, pain management for infants
was essentially non-existent, and various
procedures (including surgery) were
performed with paralytics and minimal
Jeffery Lawson’s
Jeffrey had holes cut on both sides of his neck, another cut in his right
chest, an incision from his breastbone around to his backbone, his ribs pried
apart, and an extra artery near his heart tied off. This was topped off with
another hole cut in his left side for a chest tube. This operation lasted
hours. Jeffrey was awake through it all. The anesthesiologist paralyzed him
with Pavulon, which left him unable to move but totally conscious. When the
anesthesiologist was questioned about her use of Pavulon, she said Jeffrey
was too sick to tolerate powerful anesthetics and that it had never been
demonstrated to her that premature babies feel pain. Jeffrey died a month
after surgery. His mother later reviewed her child’s medical chart and found
that at no point during the surgery had her son had anesthesia. She began
an impassioned crusade to change the practice of lack of anesthesia in
neonatal surgery. This story led to the examination of and changes in
neonatal pain practice in the United States.
Jeffry’s Legacy
• In 1986 into the 1990’s studies showed that
newborns do feel pain, remember pain, and
can safely be given anesthesia and analgesia.
• Many professional organizations (including the
AAP, the Joint Commission of Accreditation of
Healthcare Organizations, and NANN) have
mandated pain treatment for newborns.
• Today, pain is considered “the 5th vital sign”
• In 1999 JCAHO mandated standards for pain
assessment and management. Hospitals had
to comply by January 2001. In 2013, pain
management continues to be a global issue.
Golden Rule of Pain:
• “What is painful to
an adult is painful
to an infant,
unless proven
• Neonates don’t feel pain
• Research has shown that a 20-22 week fetus
has complete pain pathways and the ability to
experience pain.
• The youngest premature infant has the
anatomic and physiologic components to
perceive pain and demonstrates a severe
stress response to painful stimuli.
• Complete myelination of nerve pathways not
required for pain transmission
• Incomplete myelination results in slower
conduction velocity but is offset by shorter
• In fact, pain might actually be exaggerated
due to the unmyelinated fibers and immature
modulating capabilities of developing nervous
• The threshold for responding to cutaneous
stimulation is lowest in youngest neonates.
• Inhibitory pathways do not develop until after birth.
• Babies’ tolerance to pain actually INCREASES with
Effect of GA on HR Response
Change in HR (BPM)
(tested at >36 weeks of life)
28-32 Wks
32-36 Wks
>36 Wks
Porter, et al.
Pediatrics, 1999
• Newborns can’t remember pain
• Unrelieved pain in infants can permanently
change their nervous system and may
“prime” them for having chronic pain.
• When sensitized, receptors respond to new
forms of stimulation, eg, hyperalgesia.
• Long-term potentiation – cellular
“memory” for pain may lead to increased
receptor sensitivity.
• Neonates don’t react to pain
Physiologic Signs of Pain in the Neonate:
• shallow respirations
•  HR, RR, BP
•  vagal nerve tone (shrill cry)
•  pallor or flushing
• diaphoresis, palmar sweating
•  TcPO2 and  O2 saturation
• EEG changes
Biochemical changes associated with Pain
• stress hormones (corticosterone,
adrenaline, noradrenaline, glucagon,
• Metabolites (glucose, lactate,
• Analgesics are not safe to give to neonates
• Narcotics are no more dangerous for
children than adults.
• Addiction from narcotics (opioids) used
to treat pain is extremely rare in
adults; no reports substantiate this
fear in children; reports of respiratory
depression in children are rare.
Assessing neonates for pain is impossible
Pain is a subjective experience that cannot
be communicated by neonate
There are several validated pain assessment tools for
• Facial Expression
(most reliable sign)
• Vocalization
• Body Language
• Emotional State
Facial Expression
• Eyes tightly closed or
• Mouth opened, squarish
• Furrowing or bulging brow
• Quivering of chin
• Deepened nasolabial fold
The “eyes” have it…
Possible Behavioral Signs
of Pain in the Neonate
• Crying (often with apneic spells)
• Whimpering, groaning, moaning
Body Language
•Changes in sleep/wake/activity
•Agitation or listlessness
•Limb withdrawal/swiping/thrashing
•Clenching of fists
Evidence-based guidelines for the
management of neonatal pain
• Recognize the sources of
• Investigators found
infants in a NICU were
exposed to up to 53
painful procedures/day.
The investigators indicated also that ~40% of all neonates did
not receive any analgesia at all during the intensive care stay.
Recognizing sources of neonatal pain…
Recognizing sources of neonatal pain…
Diagnostic: Art stick, Bronchoscopy,
Endoscopy, Heel Stick, LP, ROP
Exam, Bladder Tap, Venipuncture
Therapeutic: Bladder
Catheterization, Central Line
Placement, Chest Tubes, Chest PT,
Dressing Change, Gavage Tube
Insertion, Injections, Mechanical
Ventilation, Tape Removal, Suture
Removal, Tracheal
Intubation/Extubation, Tracheal
Suctioning, Ventrical Tap
Surgical: Circumcision, other
Surgical Procedures
Recognizing sources of neonatal pain…
•The low risk nursery has
many of the same noxious
(and pleasant) stimuli found
in the high risk nursery.
•However, a healthy near- or
full-term baby is much
better equipped to manage
new stressors than their sick
Recognizing sources of neonatal pain…
• Environment is a
key factor affecting
the neonate’s
• It is the nurse’s
responsibility to
minimize noxious
stimuli to facilitate
optimal outcomes.
Take Cause of Pain
into Account
Use common sense and
Realize that for an infant,
punctures are proportionally
larger on their bodies.
Strategies to Minimize Pain
• Time blood draws to include as many tests as possible
to reduce the number of needle punctures.
• Use line draws whenever possible.
• Avoid invasive monitoring whenever possible.
• Use minimal amount of tape and remove tape gently.
• Ensure proper premedication before invasive
• Use appropriate equipment.
Pain Management
• Non-Pharmacological
– Goal
• Relieve pain when it is expected
to be of short duration
• Pharmacological
– Goal
• Control the pain as fast as
possible with the lowest
effective dose
• Positive Touch
• Kangaroo Care
• Non-nutritive sucking
• Sucrose
Differentiating Agitation & Pain
Pain Assessment Tools
• NIPS (Neonatal Infant Pain Scale) (Recommended for
children less than 1 year old) (adapted from the CHEOPS scale)
• CRIES (32-60 weeks gestational age) (Kretchel & Bildner, 1995)
• NPASS (Neonatal Pain, Agitation and Sedation
Scale) (prematurity) (Hummel & Puchalski, 2002)
• FLACC (full term neonate – 7 years) (Merkel & others, 1997)
• PIPP (Premature Infant Pain Profile) (Stevens B Johnston C et al., 1996)
Neonatal Infant Pain Scale
(Neonatal Pain,
Agitation and Sedation Scale)
Premature Infant Pain Profile
• Facial:
– Brow bulge
– Eye squeeze
– Nasolabial furrow
• Physiological:
– Heart rate
– Oxygen saturation
• Context
– Gestational age
– Behavioral state
• Inter-rater reliability
Take action.
Assess effectiveness.
The only reason to assess pain is TO
After intervention, assess child’s
response to pain relief measures.
Determine timing of assessment based
on expected onset and peak effect of
IV analgesic: assess after 5 minutes and
15 minutes
• Advocate for infants if they are exhibiting
pain cues
• Integrate research studies and research
findings into practice
• Develop hospital protocols to provide fair
and effective pain control to neonates
Heel Sticks
IV Insertion
“How sweet for those faring badly
to forget their misfortunes for even
a short time.”
--- Sophocles
Adamkin, David, et al. (2006) Prevention and management of neonatal pain. Pediatrics Vol. 118 No. 5 November 1,
2006 pp. 2231 -2241 (doi: 10.1542/peds.2006-2277.
Anand, K.J.S. (2007) Pain assessment in preterm neonates. Pediatrics Vol. 119 No. 3 March 1, 2007
pp. 605 -607 (doi: 10.1542/peds.2006-2723)
Beacham, Pamela S. (2004). Behavioral and physiological indicators of procedural and postoperative pain in high-risk
infants. JOGNN, 33 (2), 246-255.
Broome, Marion E. & Tanzillo, Heidi (1990). Differentiating between pain and agitation in premature neonates. Journal
of Perinatal and Neonatal Nursing, 4 (1), 53-62.
Cunningham, Nance (1990). Ethical perspectives on the perception and treatment of neonatal pain. Journal of Perinatal
and Neonatal Nursing, 4 (1), 75-83.
Gallo, Ana-Maria (2003). The fifth vital sign: Implementation of the Neonatal Infant Pain Scale. JOGNN, 32 (2), 199206.
Noerr, Barbara (2001). Sucrose for neonatal procedural pain. Neonatal Network, 20 (7), 63-67.
Puchalski, Mary & Hummel, Pat (2002). The reality of neonatal pain. Advances in Neonatal Care, 2 (5), 233-247.
Reyes, Sarah (2003). Nursing assessment of infant pain. Journal of Perinatal and Neonatal Nursing, 17 (4), 291-303.
Walden, Marlene & Gibbins, Sharyn(2008). Pain Assessment and Management: Guideline for Practice. Second edition.
National Association of Neonatal Nurses.
(Bozzette, 1993; Franck, 1986, 1998; Fuller, 1991; Grunau & Craig, 1987; Grunau et al., 1999; Johnston, Stevens,
Yang, & Horton, 1995; Levine & Gordon, 1982; Porter, Miller, & Marshall, 1986; Stevens, Johnston, & Horton,
1993, 1994)
Prevention and management of neonatal pain
Reprinted with permission from Elsevier from Gardner, S. L., Hagedorn, M. I. E., & Dickey, L. A. (2006).
Pain and pain relief. In G. B. Merenstein & S. L. Gardner, Eds., Handbook of neonatal intensive care, 7th
Ed., 2011. Table 12-4 p. 2438
Thank you for all you do…
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