Pain in Newborns Compassion

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Pain in Newborns -- Compassion Common Sense
Yeah, Baby!
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Neonatal pain

• Suzanne S. Toce, MD
• Professor of Pediatrics
• Saint Louis University
• Medical Director, FOOTPRINTS

Gary Allegretta, M.D. Medical Director The Jason
Program Web www.jasonprogram.org
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Outline

• Fundamental principles of neonatal pain
• Measuring neonatal pain
• Developmental aspects of pain
• Pharmacologic treatment of pain
• Non-pharmacologic treatment of pain

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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
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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
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Fundamental Concepts

• 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.

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Newborns dont feel pain
Newborns cant react to pain
Newborns cant remember pain
Dispelling the myths
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Neonatal Pain Scales

• Validated and Reliable Scales Exist
• The 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

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The Perception Problem
Green Red Yellow
Green
Red
Yellow
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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

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PIPP Scale
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CRIES scoring

• Crying
• Requirement for oxygen (to keep SaO2 95)
• Increased heart rate and BP
• Expression
• Sleeplessness
• Inter-rater reliability .72

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CRIES Scale
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Common SenseBabies Feel Pain
I.M.H.O.
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Developmental Aspects of Pain Perception

• Pain Pathways Reminder
• Anatomic Development
• Physiologic Development

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Pain Pathways
Descending pathways Ascending pathways Periphera
l receptors Neural pathways Spinal cord
tracts Brainstem, thalamus, beyond
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Anatomic developments

• Dendritic arborization 21 weeks PCA
• Nerve tracts in spinal cord 22 weeks
  PCA
• and brainstem
• Connections with 22 weeks PCA
• thalamocortical fibers

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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

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Effect of GA on HR Response (tested at of life)
Stimulus
Change in HR ( SE) BPM
Porter, et al. Pediatrics, 1999
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Effect of GA on HR Response (tested at 36 weeks
of life)
Stimulus
Change in HR ( SE) BPM
Porter, et al. Pediatrics, 1999
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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.

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This Study
Normal Mouse Nerve
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The Problem
Repair Response to Wound
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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 anesthesia
• Anesthesia is inadequate/ineffective
• Pediatrics 1998

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Official AAP Policy
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Nonpharmacologic treatment of neonatal pain
How sweet for those faring badly to forget
their misfortunes for even a short time.
--- Sophocles
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Avoid Painful Procedures

• Painful or stressful procedures should be
  minimized and, when appropriate, coordinated with
  other aspects of the neonates 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.

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Endogenous analgesic pathways

• Generalized tactile
• Orotactile
• Orogustatory

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Tactile Swaddling

• Swaddled weighing
• Less physiologic distress p
• More effective self-regulatory ability p
• Downside males cant do this

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Tactile skin-skin contact
Contact
Percent of time
Control
Grimace Cry
Gray, et al Pediatrics 2000
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Orotactile pathways
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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

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Orogustatory
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Effect of Oral Sucrose Solution on Venipuncture
Pain
Abad, et al Acta Paediatr, 1996
Time crying (sec)
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Effect of sucrose and procedure on circumcision
pain
AJOG 2002186564-8
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Effect of solution and route on heelstick pain
NG sucrose Oral sucrose NG water Oral water
Percent time crying (Median)
Ramenghi, et al ADC (Fetal Neonatal Ed), 1999
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Pacifier and Sucrose in Procedural Pain
Median pain scale score
Carbajal, et al. BMJ, 1999
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Glucose for Analgesia
Crossover 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
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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.
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Sugar for analgesia

• Dose
• 0.12-.48 grams sucrose
• Drug
• Sucrose most effective
• 2ml of 24 solution
• Dispensing
• oral only

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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 _at_ Boston
  Medical Center Hospital
• Randomized to breast-fed and control
• Heel lance performed while swaddled, with and
  without nursing
• Measured crying, grimace, heart rate

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Results - Crying Grimace
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Results - Heart Rate
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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.

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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
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A Simple Guideline
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Potential Adverse Effects of Supportive
Medications
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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

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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 neonates 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.

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