Pain in Newborns -- Compassion & Common

Sense

Yeah, Baby!

Neonatal pain

Suzanne S. Toce, MDProfessor of PediatricsSaint Louis UniversityMedical Director, FOOTPRINTS

Gary Allegretta, M.D.Medical DirectorThe Jason ProgramWeb: www.jasonprogram.org

Outline

Fundamental principles of neonatal painMeasuring neonatal painDevelopmental aspects of painPharmacologic treatment of painNon-pharmacologic treatment of pain

State of the Art

Prevention and Management of Pain and Stress in the Neonate (RE9945)

--AMERICAN ACADEMY OF PEDIATRICS

Committee on Fetus and NewbornCommittee on DrugsSection on AnesthesiologySection on Surgery

-- Pediatrics Volume 105, Number 2 February 2000, pp 454-461

Studies indicate a lack of awareness among health care professionals of pain perception, assessment, and management in neonates.9-11 When analgesics were used in infants, they often were administered based only on the perceptions of health care professionals or family members. Fear of adverse reactions and toxic effects often contributed to the inadequate use of analgesics. In addition, health care professionals often focused on treatment of pain rather than a systematic approach to reduce or prevent pain.12,13 More recent surveys have demonstrated increased awareness among health care professionals of pain in neonates and infants and its assessment and management.14-16 Several textbooks on pain in neonates and infants have been published,17-19 and measures for assessing pain have been developed and validated.20-24 However, despite the advances in pain assessment and management, prevention and treatment of unnecessary pain attributable to anticipated noxious stimuli remain limited.25-27 Several important concepts must be recognized to provide adequate pain management for the preterm and term neonate:

• Babies feel pain despite established myths.

• Severity of pain and effects of analgesia can be assessed in the neonate.20-24,42-46

• Neuroanatomical components and neuroendocrine systems are sufficiently developed to allow transmission of painful stimuli in the neonate.28-32

Exposure to prolonged or severe pain may increase neonatal morbidity.33-36

Infants who have experienced pain during the neonatal period respond differently to subsequent painful events.37-41

Neonates are not easily comforted when analgesia is needed.8

• So, lets fix that.

Fundamental Concepts

Newborns don’t feel pain Newborns can’t react to painNewborns can’t remember pain

Dispelling the myths

Neonatal Pain ScalesValidated and Reliable Scales ExistThe Perception Problem - Do we measure

pain?Measure Physiologic Parameters

Heart rate, resp rate, BP, O2 sats, sweating,vagal tone, plasma cortisol & catechols

Measure Behavioral Parameters Facial expressions, body movements, crying

Examples

The Perception Problem

Green Red Yellow

Green Red Yellow

Premature Infant Pain Profile Facial Actions

Brow bulge Eye squeeze Nasolabial furrow

Physiological Indicators Heart rate Oxygen saturation

Context Gestational age Behavioral state

Inter-rater reliability >.93

PIPP Scale

CRIES scoring

CryingRequirement for oxygen (to keep SaO2 >95%)Increased heart rate and BPExpressionSleeplessnessInter-rater reliability >.72

CRIES Scale

Common Sense

=Babies Feel

Pain

I.M.H.O.

Developmental Aspects of Pain Perception

Pain Pathways ReminderAnatomic DevelopmentPhysiologic Development

Descending pathways

Ascending pathways

Peripheral receptorsNeural pathwaysSpinal cord tractsBrainstem, thalamus, & beyond

Pain Pathways

Anatomic developments Dendritic arborization 21 weeks PCA

Nerve tracts in spinal cord 22 weeks PCA and brainstem

Connections with 22 weeks PCA thalamocortical fibers

:

Physiologic Development

Lower pain threshold in neonatal rats

Neurotransmitter receptors are up-regulated in the neonatal period

Neonatal pain processing: Early development of the excitatory mechanisms & later development of inhibition

Normal development of the pain system occurs in the absence of noxious stimuli

0

5

10

15

20

25

30

<28Wks 28-32 Wks 32-36 Wks >36 Wks

Effect of GA on HR Response (tested at <1 week of life)

Porter, et al.Pediatrics, 1999

Mild

Moderate

High

Chan

ge in

HR

(+ S

E)BP

M Stimulus

-5

0

5

10

15

20

25

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<28Wks 28-32 Wks 32-36 Wks >36 Wks

Mild

Moderate

High

Cha

nge

in H

R (+

SE

)B

PM

Porter, et al.Pediatrics, 1999

Effect of GA on HR Response (tested at >36 weeks of life)

Stimulus

Prolonged Effects of Pain Alvares, D., et.al. Modeling the Prolonged Effects of Neonatal Pain Progress

in Brain Research, Vol. 129, Ch. 27, 2000

Previous Work: Preterm infants show prolonged hyperalgesia within an

area of local tissue damage and secondary hyperalgesia in the contralateral limb.

Circumcision results in increased pain behavior 3 months later.

Birth trauma linked to increased acute stress responses to pain in infancy.

This Study

Normal Mouse Nerve

The Problem

Repair Response to Wound

First, an Attitude

Reasons Cited for Not Providing Analgesia During Circumcision

Concern over risks (54%) Not warranted (44%)Lack of familiarity with techniques (18%)Increased time (9%)Pain is inflicted during anesthesiaAnesthesia is inadequate/ineffective

Pediatrics 1998

Official AAP Policy

Nonpharmacologic treatment of neonatal pain

“How sweet for those faring badly to forget their misfortunes for even a short time.”

--- Sophocles

Avoid Painful Procedures

Painful or stressful procedures should be minimized and, when appropriate, coordinated with other aspects of the neonate’s care. Furthermore, consideration of the least painful method is important. For example, when performed by trained personnel, obtaining blood by venipuncture may be less painful than heel lancing.56-58 Skillful placement of peripheral, central, or arterial lines reduces the need for repeated intravenous punctures or intramuscular injections. Thus, in some such cases, the risk-benefit balance may favor the more invasive indwelling catheters. Whenever possible, validated noninvasive monitoring techniques (e.g., pulse oximetry) that are not tissue damaging should replace invasive methods.

Endogenous analgesic pathways

Generalized tactile

Orotactile

Orogustatory

Swaddled weighing Less physiologic distress

p<0.002 More effective self-regulatory ability

p<0.037 Downside: males can’t do this

Tactile: Swaddling

0

10

20

30

40

50

60

70

%Grimace %Cry

Contact

Control

Tactile: skin-skin contact

Gray, et alPediatrics 2000

Per

cent

of t

ime

Grimace Cry

Orotactile pathways

Non-nutritive sucking

Tested during heelstick procedure

Heelstick caused no effect on respiratory rate and oxygen saturations

Sucking reduced time of crying and heart rate increases

--Corbo, et al. Biol Neonate, 2000

Orogustatory

0 20 40 60 80

Water

12% Sucrose

24% Sucrose

Effect of Oral Sucrose Solution on Venipuncture Pain

Abad, et alActa Paediatr, 1996Time crying (sec)

Effect of sucrose and procedure on circumcision pain

AJOG 2002;186:564-8

0 5 10 15 20 25 30

Oral water

NG water

Oral sucrose

NG sucrose

Percent time crying(Median)

Effect of solution and route on heelstick pain

Ramenghi, et alADC (Fetal Neonatal Ed), 1999

NG sucrose

Oral sucrose

NG water

Oral water

Pacifier and Sucrose in Procedural Pain

0 2 4 6 8

No treatment

Water

30% Glucose

30% Sucrose

Pacifier

30% Sucrose

Median pain scale score Carbajal, et al. BMJ, 1999

Glucose for AnalgesiaCrossover Trial of Analgesic Efficacy of Glucose and

Pacifier in Very Preterm Neonates During Subcutaneous Injections

--- Ricardo Carbajal, MD, et.al.; PEDIATRICS Vol. 110 No. 2 August 2002

• 40 very preterm neonates receiving erythropoietin injections SQ• Primary outcome measure: Douleur Aigue¨ Nouveau-ne´ scale (0-10)

•Conclusions. A small dose of 0.3 ml of 30% oral glucose has an analgesic effect in very preterm neonates during subcutaneous injections. This effect is clinically evident because it can be detected by a behavioral pain rating scale. The synergetic analgesic effect of glucose plus sucking a pacifier is less obvious in very preterm infants.

Details

Fig 1. Individual pain evaluations with DAN scale. Overall, glucose gives lower scores than sterile water (p 0.03); however, 8 infants did not show a reduction of pain scores. Solid black lines indicate infants who did have a reduction in pain. Red lines indicate infants who did not have a reduction in pain scores with 30% glucose as compared to sterile water.

Sugar for analgesiaDose

0.12-.48 grams sucroseDrug

Sucrose most effective 2ml of 24% solution

Dispensing oral only

Breastfeeding is Analgesic in Healthy Newborns -- Gray, et.al, Pediatrics Vol. 109, No. 4, April 2002

The purpose of this study was to unite the different components of nursing (taste, suckling, and skin-to-skin contact), which have been shown to be individually analgesic, by allowing newborns to suckle their nursing mothers before, during, and after a standard heel lance procedure for blood collection.

The efficacy of this intervention was determined by evaluating video recordings of infant crying and facial expressions and by assessing blockade of heart rate increases that normally accompany the blood collection procedure.

Method: 30 healthy, term, breast-fed infants @ Boston Medical Center Hospital Randomized to breast-fed and control Heel lance performed while swaddled, with and without nursing Measured crying, grimace, heart rate

Results - Crying & Grimace

Results - Heart Rate

Pharmacologic Treatment Pharmacological analgesia should be chosen carefully based

on comprehensive assessment of the neonate, efficacy and safety of the drug, the clinical setting, and experience of the personnel using the drug. Drug doses, including those for local anesthetics, should be calculated carefully based on the current or most appropriate weight of the neonate, and initial doses should not exceed maximal recommended amounts. Subsequent doses should be modified based on multiple factors, including the cause of the pain, previous response, clinical condition, concomitant drug use, and the known pharmacokinetics and pharmacodynamics of the sedative and analgesic drugs administered. Medications that might result in the loss of protective reflexes or cause cardiorespiratory instability should be used only by appropriately trained persons in an environment equipped to handle emergencies.

Continued

Studies are lacking on the management of pain in neonatal conditions associated with extensive tissue damage and those resulting in recurrent or chronic pain (e.g., necrotizing enterocolitis, meningitis, fractured bones). The effects of the use of analgesics or sedation during the neonatal period on long-term neurodevelopmental and psychological outcomes has not been well studied.49 No differences in intelligence, motor function, or behavior at 5 to 6 years of age were found between neonates who received morphine for sedation during mechanical ventilation and placebo-treated neonates.62

A Simple Guideline

Potential Adverse Effects of

Supportive Medication

s

Recommendations

Pain in newborns is unrecognized and under-treated. Prescribe analgesia when indicated during their medical care.

If a procedure is painful in adults, it should be considered painful in newborns, even if they are preterm. Newborns may experience a greater sensitivity to pain and are more susceptible to the long term effects of painful stimulation.

Treatment of pain may be associated with decreased clinical complications and decreased mortality.

Arch Ped Adoles Med Feb 2001

Recommendations

The appropriate use of environmental ,behavioral, and pharmacologic Interventions can prevent, reduce or eliminate neonatal pain in many clinical situations.

Sedation does not provide pain relief and may mask the neonate’s response to pain.

Health care professionals have the responsibility for assessment, prevention and management of pain in newborns.

Clinical units providing health care to newborns should develop written guidelines and protocols for the management of neonatal pain.

Thanks for Listening

Because of you…