TREATMENT OF PAIN IN THE NEONATAL INTENSIVE CARE UNIT

doi:10.1016/S0031-3955(05)70230-3

Pediatric Clinics of North America

Volume 47, Issue 3, 1 June 2000, Pages 633-650

https://doi.org/10.1016/S0031-3955(05)70230-3 Get rights and content

In the past decade, interest in pain in infants hospitalized in the neonatal ICU (NICU) has increased dramatically. This interest has emerged from a rapidly expanding body of evidence that (1) supports infants' neuroanatomic, neurochemical, and functional ability to respond to painful stimuli and (2) emphasizes the immediate and long-term consequences of pain. Infants' pain responses have provided the basis for the development of comprehensive assessment measures that can be used for evaluating the effectiveness of pain-management strategies, yet the optimal approach for assessing pain in infants remains elusive. This elusiveness perpetuates inconsistency in the implementation of pharmacologic, environmental, and behavioral pain-reducing strategies. Ideally, health professionals would like to eliminate pain through the prevention of painful procedures and conditions; however, this strategy may not always be possible in settings in which neonates are regularly exposed to numerous painful and stressful procedures to evaluate and enhance their clinical status. Therefore, when prevention or elimination of pain is not possible, a more realistic goal may be to aggressively intervene to minimize pain and its effects. This approach requires early intervention when pain is anticipated and before pain becomes intense. This article reviews the most recent research on treating pain in infants in the NICU. Specifically, the nature of pain in the NICU, pharmacologic pain management strategies, and behavioral and environmental pain management strategies are discussed.

Section snippets

NATURE AND FREQUENCY OF PAIN IN THE NEONATAL ICU

Preterm and term neonates admitted to the NICU are exposed to numerous and varied sources of pain and stress.⁷⁷ Barker and Rutter¹⁰ reported that, in 54 infants admitted consecutively to the NICU, more than 3000 procedures were recorded, 74% in infants born at less than 31 weeks of gestational age (GA). One infant born at 23 weeks' GA was reported to undergo 488 procedures. Similarly, Stevens et al⁹⁵ noted that 124 infants in the NICU, between 27 to 31 weeks' GA at birth, underwent an average

PHARMACOLOGIC PAIN-MANAGEMENT STRATEGIES

Pharmacologic pain management for anticipated painful events (e.g., surgery) and some medical conditions has improved considerably for infants over the past decade. The use of continuous infusions of opioids, epidural analgesia, and peripheral nerve blockade has enhanced the ability of health professionals to treat postoperative and medical pain safely and effectively. Local anesthetics and nonopioids (including nonsteroidal anti-inflammatory drugs [NSAIDs]) also have been instituted for the

ENVIRONMENTAL AND BEHAVIORAL PAIN-MANAGEMENT STRATEGIES

Environmental and behavioral interventions (also referred to as nonpharmacologic interventions) have wide applicability for neonatal pain management alone or in combination with pharmacologic interventions. These interventions are not substitutes or alternatives for pharmacologic interventions but rather are complementary so should be considered as the basis for all pain management. Environmental and behavioral interventions can reduce neonatal pain indirectly by reducing the total amount of

SUMMARY

Pain is a disruptive influence on infants in the NICU. The most obvious and effective strategy to decrease infant pain in the NICU is to stringently limit the frequency of painful procedures, especially those that are most commonly reported (i.e., heel lances and endotracheal suctioning), and have these performed on infants that are most unstable or critically ill by the most experienced person available. Organizational concerns over the cost of NICU care have forced a re-evaluation of the

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Cited by (78)

The effect of expressed breast milk, swaddling and facilitated tucking methods in reducing the pain caused by orogastric tube insertion in preterm infants: A randomized controlled trial
2020, International Journal of Nursing Studies
Citation Excerpt :
Swaddling, which is one of these methods, not only reduces the pain in preterm and term newborns but also helps the development of motor organization (Shu et al., 2014; Ho et al., 2016; Leng et al., 2016). Theories have suggested that swaddling alleviates pain through sensory or multisensory stimulation (Stevens et al., 2000). Meek and Huertas (2012) state that preterm infants calmed down and stabilized immediately by swaddling in a systematic review of 3396 participants (Meek and Huertas, 2012).
Orogastric tube feeding is used to support the nutrition of preterm infants. Although nonpharmacological methods are effective in reducing the pain caused by orogastric tube insertion, only limited studies have been found addressing this pain. No study has used combined nonpharmacological methods to reduce this orogastric tube insertion pain.
This randomized controlled study aims to compare the effects of expressed breast milk, swaddling, facilitated tucking, expressed breast milk+swaddling, expressed breast milk+facilitated tucking and routine care methods on preterm infant pain and the physiological parameters (i.e., heart rate, oxygen saturation) before, during and after orogastric tube insertion procedures.
Randomised controlled trial.
Three level III neonatal intensive care units in Turkey.
Preterm infants born at 32–34 weeks gestation were randomly assigned to six groups: routine care (n = 33), swaddling (n = 30), facilitated tucking (n = 32), expressed breast milk (n = 31), swaddling+expressed breast milk group (n = 30), and facilitated tucking+expressed breast milk group (n = 31). Orogastric tube insertion included four phases: baseline (the last one minute of 30 min without stimuli), the insertion, recovery (one minute after insertion), and recovery (two minutes after insertion). The four phases were videotaped. Premature infant pain profile score, heart rate and oxygen saturation were assessed by two independent evaluators who were blinded to the purpose of the study. Data were assessed by analysis of variance for the multiple repeated measurements, bonferroni and generalised estimating equation logistic regression.
There was a significant main effect of the intervention groups for all the pain and physiological parameters (heart rate: F = 3.99, p = 0.001; oxygen saturation: F = 5.22, p<0.001; pain profile 1 score: F = 9.55, p<0.001; pain profile 2 score: F = 9.74, p<0.001). The use of the nonpharmacological methods combined or alone was more effective in reducing infants’ pain profile score and physiological variables than routine care. Infants receiving swaddling+expressed breast milk had significantly lower pain profile scores during the insertion (phase2) (5.2 ± 1.7) than those receiving routine care (9.5 ± 3.6), swaddling (8.8 ± 2.9), facilitated tucking (7.2 ± 3.2), expressed breast milk (7.9 ± 2.6), facilitated tucking+expressed breast milk (6.6 ± 2.3) (p<0.001). The breast milk group had 6.195 times more pain than the swaddling+expressed breast milk, while the facilitated tucking group had 6.301, the facilitated tucking+expressed breast milk group had 3.107, the control group had 13.015, and the swaddling group had 7.892 times more pain.
The swaddling+expressed breast milk method is clinically better pain relief nonpharmalogical option and is the recommended method to nurses for the orogastric tube insertion procedures, preterm infants.
A randomized controlled trial of eye shields and earmuffs to reduce pain response of preterm infants
2015, Journal of Neonatal Nursing
Citation Excerpt :
Evidence also implies that reducing preterm infants' exposure to non-painful sensory stimulations in the NICU, thereby diminishing their stressful experience, might be beneficial to reduce their pain response while undergoing painful stimulation (Anand and Scalzo, 2000; Holsti et al., 2006; Porter et al., 1998). More than a decade ago, it was recognized that few studies have evaluated the efficacy of environmental interventions on the pain response of preterm infants while experiencing painful procedures (Stevens et al., 2000). As hospitalized preterm infants periodically experience procedural pain for therapeutic purposes (Carbajal et al., 2008; Roofthooft et al., 2014), there is still a need to evaluate the efficacy of interventions reducing the preterm infants' exposure to NICU light and noise on their response to painful procedures.
The purpose of this study was to evaluate the pain response of 28–32 weeks gestational age preterm infants during a heel lance following a 4-h period where they had worn eye shields and earmuffs as a light and noise reduction intervention. A randomized controlled trial was conducted on 44 preterm infants recruited from four level III NICU. Heart rate and heart rate variability were collected continuously during the heel lance. At the end of the painful procedure, the time HR took to return to baseline was calculated. ANCOVA indicated that preterm infants who wore eye shields and earmuffs 4-h before the heel lance did not show a significant reduction in their pain response during the procedure in comparison to those who did not. Confounders such as handling in the hours preceding the painful procedure and the time it took to collect the blood might have influenced the results.
Turkish pediatric surgical nurses' knowledge and attitudes regarding pain assessment and nonpharmacological and environmental methods in newborns' pain relief
2013, Pain Management Nursing
Effective pain management requires accurate knowledge, attitudes, and assessment skills. The purpose of the present study was to describe Turkish pediatric surgical nurses' knowledge and use of pain assessment and nonpharmacologic and environmental methods in relieving newborn's pain in hospital. The sample consisted of 111 pediatric surgical nurses employed in pediatric surgical unit in 15 university hospitals located in Turkey. A questionnaire was used to measure the nurses' knowledge and use of pain assessment, nonpharmacologic, and environmental methods. Data were analyzed with the use of descriptive statistics. Of the nurses that participated in the study, 83.8% were between the ages of 20 and 35 years, 54.1% had a bachelor degree, and 75.7% had a nursing experience ≤10 years. 50.5% stated that physiologic and behavioral indicators used in the assessment of pain in infants. The most commonly used nonpharmacologic methods were giving nonnutritive sucking, skin-to-skin contact, and holding. The most commonly used environmental methods were avoiding talking loudly close to the baby, minimal holding, care when opening and closing of the incubator, avoiding making noise when using wardrobe, drawers, trash, or nearby devices, such as radio and television, avoiding sharp fragrances, such as alcohol, perfume, near the baby, and reducing light sources. Although Turkish pediatric surgical nurses used some of the nonpharmacological and environmental methods in infant's pain relief, there remains a need for more education about pain management and for more frequent use of these methods in clinical care.
Neonatal arthritis disturbs sleep and behaviour of adult rat offspring and their dams
2010, European Journal of Pain
This study aims to evaluate the impact of neonatal arthritis on adult pain threshold, sleep and general behaviours in rats and their lactating dams. Male pups were injected in the hind paw with complete Freund’s adjuvant or saline on postnatal day (PN) 1. After weaning, dams were tested for anxiety, sleep recording or hormone profiling (ACTH, corticosterone and prolactin) and brain sampling (pineal melatonin and hippocampus serotonin). At adulthood (PN90), distinct subgroups of neonatal arthritic (AR) and control rats (CR) were also assessed for anxiety and pain thresholds, sleep recording, and blood/brain sampling. Compared to their respective controls at PN12, dams of arthritic rats (DAR) showed a longer latency in expressing pup retrieval and dam–pup interaction. DAR and AR showed a lower pain threshold, anxiety-like behaviour, and sleep fragmentation. Compared to controls, DAR displayed longer sleep latency, reduced paradoxical sleep latency and sleep efficiency, a decrease in prolactin and serotonin levels and increased melatonin levels. This model of unilateral hindpaw inflammation has a wide range of long-term effects in both lactating dams and their adult offspring.
Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP)
2023, PLoS ONE
Neonatal Pain
2020, Emerging Topics and Controversies in Neonatology

View all citing articles on Scopus

Address reprint requests to Bonnie Stevens, RN, PhD, 50 St. George Street, Toronto, Ontario, Canada M5S 3H4, e-mail: [email protected]

Funding is acknowledged from the NIH, NINR (Grant NR 03916 RO1), the Ontario Ministry of Health (B. Stevens, Career Scientist Award), and NIH PCRC grant at UCSF and CHO research sites (L. Franck), and the Hospital for Sick Children, Research Training Centre Restacomp Grant (S. Gibbins).

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TREATMENT OF PAIN IN THE NEONATAL INTENSIVE CARE UNIT

Section snippets

NATURE AND FREQUENCY OF PAIN IN THE NEONATAL ICU

PHARMACOLOGIC PAIN-MANAGEMENT STRATEGIES

ENVIRONMENTAL AND BEHAVIORAL PAIN-MANAGEMENT STRATEGIES

SUMMARY

Pediatr Clin North Am

J Obstet Gynecol Neonatal Nurs

J Pain Symptom Manage

J Pediatr

J Am A Child Psychiatry

J Clin Anesth

Lancet

Child Adolesc Psychiatr Clin North Am

Pain

Pain

Oral sweet solution reduces pain-related behavior in preterm infants

Acta Paediatr

Sucrose as an analgesic agent for infants during immunization injections

Arch Pediatr Adolesc Med

Individualized behavioral and environmental care for the very low birthweight preterm infant at high risk for bronchopulmonary dysplasia: Neonatal intensive care unit and developmental outcome

Pediatrics

Individualized developmental care for the very low birth weight preterm infant: Medical and neurofunctional effects

JAMA

Routine analgesic practices in 109 Neonatal Intensive Care Units (NICUs) [abstract]

Pediatr Res

EMLA cream package insert

Dollops

Exposure to invasive procedures in neonatal intensive care unit admissions

Arch Dis Child

Heel blood sampling in preterm infants: Which technique?

Arch Dis Child

Capillary blood sampling: Should the heel be warmed?

Arch Dis Child

Topical anesthesia during circumcision in newborn infants

JAMA

Pediatric pain management

Effects of cycled light on activity state and cardiorespiratory function in preterm infants

Journal of Perinatal and Neonatal Nursing

Behavioral and physiological consequences of suckling in rat and human newborns

Acta Pediatr Suppl

Milk-induced hypoalgesia in human newborns

Pediatr

Sucrose as an analgesic for newborn infants

Pediatrics

Pain-reducing properties of sucrose in human newborns

Chem Senses

Mother as shield: Differential effects of contact and nursing on pain responsivity in infant rats—evidence for nonopioid mediation

Behav Neurosci

Phases diagram and aqueous solubility of the lidocaine-prilocaine binary system

J Pharm Sci

Sucrose reduces pain reaction to heel lancing in preterm infants: A placebo-controlled, randomized and masked study

Pediatr Res

Development and evaluation of a new instrument for safe heelstick sampling of neonates

Lab Med

Attentional influences on noxious and innocuous cutaneous heat detection in humans and monkeys

J Neurosci

Rocking and pacifiers: Two comforting interventions for heelstick pain

Res Nurs Health

Soothing pain-elicited distress in infants with swaddling and pacifiers

Child Dev

Effects of waterbed flotation on indicators of energy expenditure in preterm infants

Nurs Res

Swaddling after heel-lance: Age specific effects on behavioral recovery in preterm infants

J Dev Behav Pediatr

Pacifying effects of nonnutritive sucking on term and preterm neonates during heelsticks

Pediatrics

Tactile/kinesthetic stimulation effects on preterm neonates

Pediatrics

Central nervous system mechanisms of pain modulation

Issues regarding the use of analgesia and sedation in critically ill neonates

ACCN Clinical Issues

A national survey of assessment and treatment of pain and agitation in the neonatal intensive care unit

J Obstet Gynecol Neonatal Nurs

Pharmacokinetics of fentanyl in neonatal humans and lambs: Effects of age

Anesthesiology

Combined sucrose and carrying reduces newborn pain response more than sucrose or carrying alone

Arch Pediatr Adolesc Med

Infant Stress Under Intensive Care: Environmental Neonatology

Environmental lighting, behavioral state, and hormonal response in the newborn