Neonatal Pain

Anne Martinez RNC-NIC

 With acknowledgment of Renee Hunt ARNP, for sharing information on neonatal pain.

Objectives
Become familiar with pain assessment and management in neonates. Identify behavioral and physiologic signs of pain in the neonate. Discuss non-pharmacologic/pharmacologic management of pain in neonates.

Historical Perspective
Lawson case-patent ductus arteriosus (PDA) surgery without anesthesia in mid 1980s Edward case-ventriculoperitoneal (VP) shunt performed using only curare. Baby survived but screamed if anyone touched his head

Definition of Pain
unpleasant sensory and emotional experience, causing potential or actual tissue damage acute pain-a constellation of unpleasant sensory, perceptual, emotional and mental experiences & certain associated autonomic, psychological & behavioral responses provoked by injury or acute disease (the International Association for the Study of Pain)

Definition of pain
Acute pain-normal predicted physiologic response to adverse chemical, thermal, or mechanical stimulus (KS State Board of Nursing, 2001) Chronic pain-chronic pathologic process that causes pain to continue or recur (KSBN) Whatever a patient says it is (McCaffery)

Detrimental Consequences
Increases in: plasma renin activity, epinephrine, norepinephrine, plasma cortisol, catecholamines, growth hormone, glucagon, and aldosterone Decrease in: insulin secretion May lead to:
severe hyperglycemia metabolic acidosis (increased lactate, pyruvate, ketone bodies, & fatty acids)

End Result of Pain

INCREASED MORBIDITY INCREASED MORTALITY (Anand & Hickey, 1986)

Consequences of Pain
Even brief periods of severe pain early in life may be responsible for prolonged sensory disturbances May cause altered pain responses These alterations may persist into adolescence and adulthood

Pain is Subjective
Pain is defined by the person experiencing the pain. Pre-verbal Neonates are unable to verbalize and describe pain. Assessment must be guided by physiological & behavioral cues.

Frequency of Neonatal Pain

Approximately 9% of live births are admitted to a NICU annually Painful procedures are required for treatment Heelsticks Arterial/venous punctures, IV/PICC/PAL Intubation/suctioning Lumbar punctures Chest tubes Surgery

Frequency of Neonatal Pain

Other sources of discomfort bright lights noise frequent handling REMEMBER-the most premature infants require the highest number of procedures

Historical Misconceptions
Nervous system too immature to perceive pain Fear of addiction Fear of side effects (hypotension, apnea, decreased GI motility, liver/kidney damage) Belief that infants had no memory of pain

Debunking the Myths

1. Nervous system of neonate too immature to perceive pain 7 wks-sensory nerve endings in perioral region 15 wks-sensory nerve endings on trunk & proximal extremities

20 wks-sensory nerve endings on mucous membranes & cutaneous areas. Fetus experiences pain.
24 wks-thalamic track is complete 30 wks-myelination of brain stem and thalamic tract 37 wks-myelination of nociceptive tract complete

Debunking the Myths

Recent research indicates newborns have exaggerated cutaneous responses that last longer compared to adults Neonates experience more pain to the same stimulus than older children or adults There is an increased density of peripheral nerves and immature descending pathway

Debunking the Myth of Addiction

Addiction-neuro-behavioral syndrome that results in psychological dependence for psychic effects *no documented evidence of this syndrome in infants Physical Dependence-expected result of continued opioid use, may cause withdrawal symptoms if abruptly stopped *gradually wean dose if opioids have been used for >5 days Tolerance-increased dosage needed to produce same effect

Debunking the Myth that infants have no memory of pain

Remember Baby Edwards (VP shunt) Current research showing increased pain responses to immunization injections in males circumcised with NO analgesia

Wind Up Phenomena
Altered excitability of CNS After exposure to noxious stimulus, multiple levels of spinal cord experience altered excitability. Activities such as handling or diaper changes may then be perceived as painful.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2001 guidelines

1. 2. 3. 4. 5. 6. Right to assessment/management of pain Record results, regular reassessments Educate providers and determine competency Establish policies and procedures Educate patients/families Collect data/monitor appropriateness/effectiveness of pain mgt.

National Association of Neonatal Nurses (NANN)-position statement on pain management in infants

1. Infants must be protected from adverse effects of pain 2. Analgesia or sedation when appropriate 3. Ongoing assessment 4. Nurses must be proactive in pain management 5. Inform and educate and parents 6. Interdisciplinary collaboration

American Academy of Pediatrics

1. Use an interdisciplinary approach 2. Personal values/beliefs of the health care professional must not stand in the way or recognition and treatment of pain in children

Agency for Health Care Policy & Research

1. Prevention is better than treatment 2. Use reliable & valid measurement tools 3. Include physical and behavioral assessment

Recent Findings
Impulses can travel along unmyelinated nerve tracts Apoptosis-pruning of unnecessary cells *in developing brains, an overstimulation of nociceptive pathway can lead to understimulation of another pathway (good touch or non-pain pathway)

Recent Findings, cont.

Plasticity-concept that every experience of the premature infant has the potential to alter brain development *may lead to abnormal development & behavior *may enable infant to recover from brain insults

Recent Findings, cont.

Allodynia-pain due to stimulus that normally does not provoke pain
*touch & pain fibers are very close together, allowing the impulse to jump tracts *handling or physical examinations may be perceived as noxious stimulus

Recent Findings, cont

Hyperalgesia-hypersensitivity to painful stimuli
*Sensitivity persists after the stimulus removed *May lead to new nerve endings in the injured area (hyperinnervation) & cause increased pain & hypersensitivity *Compounded by inadequate subcutaneous fat to prevent thermal/pressure insults

Innate Coping Mechanisms

Neonate has limited ability to block or cope with pain Primary coping method is sucking Limited ability to block light-iris does not constrict until 32 wk. gestation & eyelid is very thin Limited ability to block noise

Short term Effects of Pain

Pain causes stress-triggers fight or flight response Release of glucocorticoids (cortisol, epinephrine, norepinephrine) that are catabolic in nature-inhibiting cell division & growth, protein synthesis & neuronal myelination

Short term Effects of Pain, cont.

Heart rate & blood pressure may be increased Intracranial blood volume & cerebral blood flow may fluctuate leading to intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL)

Long Term Effects of Pain

Increased sensory innervation Altered pain behaviors in infancy Increased pain thresholds Hyperactivity/Attention deficit disorder Decreased cognitive performance Poor socialization, increased impulsivity

Pain Assessment
Physiologic indicators- increased heart rate and decreased oxygen saturation Behavioral indicators-facial activity, (brow bulge, eye squeeze, nasolabial furrow), crying, and body movements

Additional Physiologic Signs

Increased Blood Pressure Palmar Sweating Pallor/flushing Shallow Respirations Diaphoresis Dilated Pupils These signs less reliable & harder to measure.

Pain Assessment
Contextual factors modifying pain responses Gestational age Behavioral state Severity of illness Total number of painful procedures Environmental stress Sensitization after repeated stimulation Technician effects/procedural modifiers

Premature Infant Pain Profile

Multidimensional or composite instrument Altered responses due to prematurity are factored into the calculation (very preterm infants can have maximum score of 21 compared to term infant score maximum of 18) Based on research data

PIPP
Tested on babies from 24 to 40 weeks gestation Greater validity & reliability Generally considered best instrument for premature infants

PIPP
Physiologic indicators-Heart Rate -Oxygen Saturation Behavioral variables-Brow Bulge -Eye Squeeze -Nasolabial Furrow Contextual Factors-Gestational Age -Behavioral State

PIPP
Gestational age 0= >/= 36 wk 1= 32-35 6/7 wk 2= 28-31 6/7 wk 3= <28 wk

PIPP
Behavioral State
0= active awake state, eyes open, facial movement 1= quiet awake state, eyes open, no facial movement 2= active/asleep, eyes closed, facial movements 3= quiet/asleep, eyes closed, no facial movements

PIPP
Maximum Heart Rate Increase 0= 0-4 BPM 1= 5-14 BPM 2= 15-24 BPM 3= >/=25 BPM

PIPP
0xygen saturation decrease
0= 0-2.4% 1= 2.5-4.9% 2= 5-7.4% 3= >/=7.5%

PIPP
Brow Bulge 0= none (0-9% of the time) 1= minimum (10-39% of the time) 2= moderate (40-69% of the time) 3= maximum (70 to 100% of the time)

PIPP
Eye Squeeze 0= none (0-9%) 1= minimum (10-39%) 2= moderate (40-69%) 3=maximum (70-100%)

PIPP
Nasolabial Furrow 0= none (0-9%) 1= minimum (10-39%) 2= moderate (40-69%) 3= maximum (70-100%)

PIPP
Behavioral State scored immediately before the event Heart Rate, Saturation, Brow Bulge, Eye Squeeze, Nasolabial Furrow are scored in the 30 seconds immediately following the event

PIPP
Scores of 7-12 =Mild Pain Try nonpharmacologic measures
Scores > than 12=Moderate/Severe Pain Consider Pharmacologic Intervention

PIPP
New baseline heart rate & saturation entered every Saturday night Gestational age found on medical progress note, Kardex, SBAR tool

FLACC
Scores 0 to 2 for each category
Face Legs Activity Cry Consolability

FLACC
Face 0=No particular expression, smile, eye contact, interest in surroundings 1=Occasional grimace/frown, withdrawn, worried, eyebrows lowered, eyes partially closed, mouth pursed 2=Frequent frown, clenched jaw, quivering chin, furrowed forehead, eyes closed, mouth open, nasolabial furrows

FLACC
Legs 0=normal position, relaxed 1=uneasy, restless, tense, rigid, intermittent flexion/extension of limbs 2=kicking, legs drawn up, hypertonicity, exaggerated flexion/extension

FLACC
Activity 0=lying quietly, moving freely 1=squirming, shifting, guarding 2=arched, rigid, or jerking, fixed position

FLACC
Cry 0=no crying or moaning 1=moans, whimpers, occasional cry, sigh 2=crying steadily, screaming, sobs, grunts

FLACC
Consolability0=calm, content, relaxed 1=reassured by occasional touching or hugging 2=difficult to console or comfort

FLACC
Designed for newborns to 3 years of age Initiate FLACC at 38 weeks adjusted age Consider pharmacologic intervention for scores 5 or more

Goals of pain management

Minimize intensity, duration, and physiologic cost of pain Maximize neonates ability to cope with and recover from the painful experience

Nonpharmacologic approaches
Reduce total noxious stimuli Containment/ swaddling Non-nutritive sucking Sucrose pacifier Developmentally supportive care Cautious clustering of care

Sucrose
Theoretically works by releasing serotonin to modulate transmission of noxious stimuli Promotes activation of endogenous opioids that attenuate noxious stimuli at the dorsal horn Give 1-2 minutes before procedure Anterior tongue administration most effective

Sucrose
Research supports effectiveness in infants Research has not determined the absolute limit of safety in extremely premature infants 27 to 31 6/7 wk-1 to 2 dips per procedure (max in 24 hr. 8 dips) >/=32 weeks- 1 to 4 dips per procedure (max in 24 hr 24 dips)

Sucrose
Chart administration with number of dips on MAR Our 24 hour period starts at midnight Example-At midnight baby given 2 dips so chart 2/2 (second number is the total for the day)

Pharmacologic considerations
Analgesic use Sedatives Opioids EMLA cream Circumcision considerations End of life pain

Analgesics
Acetaminophen 20-25 mg/kg PO loading dose 12-15 mg/kg PO <32 weeks q 12 hr. >32 to 37 weeks q 8 hr. >37 weeks q 6 hr. Cautious use in liver disease Ibuprofen-not tested for analgesia in preterm/term infants Caution- may interfere with immune response

Analgesics
Topical Proparacaine eye drops Used for eye exams Onset 20 seconds Duration 15-20 minutes

Pain control during eye exams

Review of literature and studies by Samra and McGrath in June 2009 Advances in Neonatal Care (NANN) There are clear guidelines for performing eye exams There are no standard protocols for pain management during exams

Sedatives
Phenobarbital 5mg/kg IV or PO q 24 hr. Midazolam (Versed)-Very cautious use in prematures due to increased incidence of IVH & other neurological adverse effects according to the NO PAIN study Chloral hydrate 20 to 50mg/kg orally- on occasion may cause excitability

Opioids
Fentanyl 1-4mcg/kg IV q 2 to 4 hr. 1-5mcg/kg/hr continuous infusion Infuse over at least 15 min. Observe for chest wall rigidity. Compared to morphine, has less BP effects, less histamine release, and decreases pulmonary vascular resistance Can be reversed with Narcan Some references suggest using the paralyzing agent Pavulon to counteract chest wall rigidity

Opioids
Morphine 0.05 to 0.2 mg/kg IV q 4 hr. 0.01 to 0.015mg/kg/hr (may have loading dose ordered) Can be given PO (onset & duration unpredictable) Avoid rapid infusion-can decrease blood pressure and heart rate and cause bronchospasm. Decreases GI motility Can be reversed with Narcan Morphine is used for weaning from in utero drug exposure

Opioids
Metabolism of Fentanyl & Morphine altered by maturity of liver May need higher doses of opioids due to higher body water content Hypotension more likely in hypovolemia Wean opioids after prolonged use (5-7 days) Avoid Opiophobia!

EMLA
Mixture of lidocaine/prilocaine Approved for use in infants 37 wk. or more Used for circumcision, venipuncture, arterial puncture, PICC placement Apply 60 minutes before procedure

Circumcision Pain
AAP states-procedural analgesia necessary Subcutaneous Ring Block Dorsal Penile Nerve Block EMLA Sucrose Pacifier Acetaminophen Physiologic Positioning

Circumcision Pain
NEVER use Lidocaine with Epinephrine due to compromise of blood supply and potential for severe tissue damage Buffered Lidocaine stocked in Omnicell

End of Life Pain

Opioids to prevent unnecessary pain Palliative care orders include opioids and other medications for patient comfort Consider ethical and humane care for dying infants

Conclusion