NEONATAL PAIN MANAGEMENT
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Contents
Non-Pharmacological Methods. 6
Neonatal Pain Management
Newborns, including preterm and terms, experience pain and thus have the right to receive adequate and effective pain reliefs. When newborns are compared to an adult, a neonate demonstrates more sensitivity towards sensory stimuli and therefore is much more prone to the consequences of pain. Neonates cannot also verbalize when in pain and depend on the caretaker’s skill to assess, recognise, and manage the pain effectively. There are instances whereby clinicians have been accused of not practicing the correct approaches when managing pain in neonates. In this study, there will be an evaluation of current guidelines on assessing, preventing, and managing pain in a neonate. This review aims to improve how clinicians evaluate and treat pain in neonates through the utilisation of specialized pain assessment tools with particular focus on acute pain associated with medical and surgical ailments. This is a critical issue since there is not much literature on proper mechanisms on pain relief in neonates
Assessment of Pain
Assessing pain in a neonate is challenging, and although there are different pain scoring systems, there still lacks a universal approach for evaluating pain in neonates (Witt 2016). There also seems to be minimal understanding of different ways pain is perceived by neonates and the adverse effects that follow if the pain is left untreated (Witt 2016). The American Academy of Pediatrics, in conjunction with the Canadian Pediatric Society, established a policy in 2006 indicating that all health care centers were to create neonatal pain programs to assess pain frequently, reducing the painful procedures conducted and reducing and preventing acute pain in invasive procedures (Witt 2016).
Developed countries have advanced medical and technological advancement, which means that extremely vulnerable premature babies and term babies with advanced diseases often survive. (Bhalla & Shepherd 2014). However, diagnostic procedures and treatment can cause pain in the neonate. All newborns have to go through at least one procedure that is painful in their initial days of life. The impact of this pain may have short and long-term implications. Despite this, pain in neonates is sometimes undertreated, underrecognized, and regularly not reassessed or evaluated (Bhalla & Shepherd 2014). Pain management remains unevolved in developing countries since there can be assumptions that neonates cannot experience pain (Witt 2016).
Pain assessment in a neonate or a nonverbal child is a challenging task and requires skill. There are pain scales that make this process less daunting. However, there are differences in the scales and methods available since there still lacks a universal method for assessment. Objective data, such as blood pressure, heart rates, and cortisol levels, can be utilized. Still, they rarely are used since most physicians rely on crying, grimace, and the overall mannerisms of the neonate to make a diagnosis (Witt 2016). In addition to the variations existing in pain scales, they are many other variations that can affect the pain perception in neonates. Anxiety is a significant factor in pain perception in children and adults (Witt 2016). It can be challenging to establish the impact of being in a new environment such as emergency or exam rooms in a neonate (Coakley & Wihak 2017). It is also often overlooked in the assessment of pain on whether the clinician has adequate skills and willingness to assess signs of illness in children.
The Joint Commission has a set of standards implemented in health care facilities making pain assessment compulsory for all patients (Witt 2016). The standard numeric scale is usable in verbal children, and there are scales validated to assess pain in children as young as three years old. Revised FACES scales such as the Wong-Baker Faces scale plus the 10 cm visual analog scale are utilized in different health care facilities to assess pain in pediatric patients (Witt 2016). Apart from assessing pain through physiologic frameworks in neonates, there are other varied pain scales utilized in newborn intensive care units (NICUs):
Examples being the neonatal infant pain scale (NIPS), neonatal pain, agitation and sedation scale(N-PASS), neonatal facial coding system (NFCS) and cry, required oxygen, increased vital signs, expression, sleeplessness scale (CRIES) which are all used to assess neonates (Witt 2016, p. 2).
Pharmacological Methods
Pain in neonates is managed best when there is the utilisation of different approaches, including pharmacological and non-pharmacological ways (Bhalla & Shepherd 2014). Although it is well studied in adults, few studies have attempted to evaluate the pharmacodynamics and pharmacokinetics in infants and neonates in general. There are different variables in a neonate, including drug interactions, malnutrition, and low plasma proteins that affect how the drug is distributed in the body (Bhalla & Shepherd 2014). There are no specific guidelines set to help identify these problems and the effects they cause on specific analgesics. These factors should be considered when picking an appropriate dose or route of administration.
The most basic mechanism of action of non-steroidal anti-inflammatory drugs (NSAIDs) such as Acetaminophen is inhibition of cyclooxygenase, an enzyme responsible for producing prostaglandins (Lucas 2019). This occurs in the central nervous system and the peripheral system. NSAIDs are said to have a longer half-life in infants and neonates since their hepatic enzymes are still immature, and there is still minimal glomerular filtration rates (GFRs) (Luca 2019). Currently, there are three types of NSAIDs available in IV form, including ibuprofen, ketorolac, and Indomethacin (Witt 2016). Indomethacin and ibuprofen pharmacokinetics have been studied extensively in neonates regarding the closure of patent ductus arteriosus (PDA) but haven’t been studied as extensively in investigating their analgesic effect in neonates (Witt 2016).
In preterm infants diagnosed with PDA, the occurrence of renal insufficiency and necrotizing enterocolitis is less when ibuprofen is preferred to indomethacin, but a prophylactic dose of indomethacin in high-risk neonates is associated with a decreased rate of intraventricular hemorrhage than the administration of ibuprofen (Witt 2016). Neither medication has been associated with improvements when used in the long term to treat PDA (Witt 2016). Ketorolac remains the most commonly used NSAID in infants and neonates, but data on the drug’s efficacy and safety are usually retrospective and anecdotal. In one of the retrospective studies that included infants below six months, there were reports of no adverse effects of the drug on the neonates despite the drug being known to alter renal and platelet functions.
. Meanwhile, the use of opioids in neonates is minimal, with pharmacokinetics being altered, accompanied by significant interpatient variability (Bhalla & Shepherd 2014). Decreased GFR in neonates leads to lower plasma clearance, a decrease in protein binding, and increased volume of distribution (Bhalla & Shepherd 2014). These factors are compounded by other complications related to acute diseases and prematurity, which all lead to change in opioid pharmacokinetics. The widely used medications in the neonatal population are morphine and fentanyl (Witt 2016). Requirements of Opioids are highly variable in neonatal patients, and clinicians are thus responsible for the careful titration to achieve adequate levels of sedation while preventing adverse effects.
Non-Pharmacological Methods
Nonpharmacological methods of pain control are also useful in neonates. Some of these methods include administration of oral glucose or sucrose, breastfeeding, or skin to skincare contact, which is also referred to as Kangaroo care, sensorial saturation, swaddling, and nutritive suckling (Witt 2016). The most investigated non-pharmacological way has been the use of glucose with the hypothesis that different forms of glucose can lead to the endogenous release of opioids through mechanisms that are unknown (Silva 2011). It has been established that glucose can significantly lower pain secondary to procedures. Measures of physiologic response, including heart rates, vagal tone, and oxygen saturation, are affected when different neonates were given placebos and some forms of glucose (Silva 2011). When sucrose is preferred against breast milk or pacifiers, there was much more change in behavioral indicators of pain like grimacing or pain.
If a neonate is going through a painful procedure, then an alternative to glucose is breastfeeding or breast milk (Witt 2016). It has been determined that breast milk is helpful in one-time procedures. Neonates, being breastfed during venipunctures and heel stick procedures, demonstrated a substantial decrease in their physiologic responses like holding on to the mother and swaddling (Silva, 2011). The used parameters measured and showed decreased heart rates and reduced time neonates took to calm down after crying. In this population of neonates’ diverse environmental interventions have proved to be effective in reducing pain, particularly when combined with other adjunctive therapies like breastfeeding or sweet solutions (Witt 2016). Kangaroo care is an effective tool for reducing pain in all physiologic parameters. Facilitated tucking involving flexing a neonate’s arms and legs manually and swaddling have been known to stimulate self-soothing and are useful measures to reduce pain. Nonnutritive suckling has also been researched in term and preterm infants, and it has been established as an effective way of reducing pain in neonates (Witt 2016). When compared against swaddling alone, it was established that nonnutritive suckling caused low heart rates as well as decreasing the duration a neonate cried (Witt 2016).
References
Bhalla, T., and Shepherd, J.D.T., 2014. Neonatal pain management. Saudi journal of anesthesia, 8(Suppl 1), p.S89.
Coakley, R., and Wihak, T., 2017. Evidence-based psychological interventions for the management of pediatric chronic pain: new directions in research and clinical practice. Children, 4(2), p.9.
Lucas, G.N.C., Leitão, A.C.C., Alencar, R.L., Xavier, R.M.F., Daher, E.D.F. and Silva Junior, G.B.D., 2019. Pathophysiological aspects of nephropathy caused by non-steroidal anti-inflammatory drugs. Brazilian Journal of Nephrology, 41(1), pp.124-130.
Witt, N., Coynor, S., Edwards, C., and Bradshaw, H., 2016. A guide to pain assessment and management in the neonate. Current emergency and hospital medicine reports, 4(1), pp.1-10.
Silva, P., 2011. Benefits and limitations of the use of glucose for the treatment of pain in neonates: a literature review. Rev Bras Ter Intensiva, 23(2), pp.228-237.