Prevention and management of pain in the neonate: An update

Question 1

What are the clinical implications for pain and stress in th7byhe neonate?

Answer 1

1. Caregivers should be trained to assess newborns for pain using multidimensional tools.
2. Newborns 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.

Question 2

What are the recommendations for reducing pain for bedside care procedures?

Answer 2

1. Care protocols for neonates should incorporate a principle of minimizing the number of painful disruptions in care as much as possible.
2. A combination of oral sucrose/glucose and other nonpharmacological pain reduction methods (nonnutritive sucking, kangaroo care, facilitated tuck, swaddling and developmental care) should be used for minor, routine procedures.
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. Repeated use of topical anesthetics should be limited.
4. The routine use of continuous infusions of morphine, fentanl or midazolam in chronically ventilated preterm neonates is not recommended due to concern about short term side effects and lack of long-term outcome data.

Question 3

What are the recommendations for reducing neonatal pain from surgery?

Answer 3

1. Any health care facility providing surgery for newborns should have an established protocol for pain management. This 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 using a scale designed for postoperative or prolonged pain in newborns.
4. Opioids should be the basis for postoperative analgesia after major surgery in the absence of regional anesthesia.
5. Postoperative analgesia should be utilized 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 under 28 weeks to permit calculation of appropriate dosages.

Question 4

What are the recommendations for reducing pain from intercostal drains?

Answer 4

1. General nonpharmacologic measures
2. Slow infiltration of the skin site with a local anesthetic before incision unless there is life-threatening instability. If there is inadequate time to infiltrate before the insertion of the chest tube, local skin infiltration after achieving stability may reduce later pain responses and later analgesic requirements.
3. Systemic analgesia with a rapidly acting opiate, such as fentanyl.

Question 5

What are the recommendations for reducing pain from chest tube removal?

Answer 5

1. General nonpharmacological measures

2. A short-acting, rapid-onset systemic analgesic.

Question 6

What are the recommendations for reducing pain from retinal examination and surgery for retinopathy of prematurity?

Answer 6

1. Although there are insufficient data to make a specific recommendation, retinal examinations are painful, and pain relief measures should be utilized. A reasonable approach would be to administer local anesthetic eye drops and oral sucrose.
2. Retinal surgery should be considered major surgery, and effective pain relief, based on opiates, should be provided.

Question 7

What are the recommendations regarding pain relief for circumcision?

Answer 7

Always provide pain relief