NEONATAL PAIN OVERVIEW

1. ‫بسم ا الرحمن الرحيم‬

2. DR.ABDULKADER AL-JUHANI,MD,MHPE
ROYAL COMMISSION MEDICAL CENTER

3. What is the most beautiful scene that
capture your eyes?

4. What is the most beautiful scene
? that capture your eyes
 ?

8. VIDEO 1

9. Why neonates are so special ?

10. ?Why neonates are so special
 Vulnerable
 Too tiny to complain.
 Special life
 Special care
 Special feed
 Special pain

11. Are we doing good or bad to
our babies ?
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12. “An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described in
terms of such. Pain is subjective.”
International Association for the Study of Pain

13. Are we doing good or bad to
our babies ?
 What are the sources f pain ?
 What are the myths around pain in neonates?
 What are the facts?
 Is there a difference between full term and
preterm ?
 Is the pain measurable ?
 What are the interventions ?

14. NICU - RCMC

15. What are the sources of pain ?

16. What are the sources of
?pain

17. What are the sources of
?pain

18. What are the sources of
?pain

19. What are the sources of
?pain

20. Are we doing good or bad to
our babies ?

21. NICU- RCMC

22. PAIN MANAGEMENT MYTHS
 Neonates do not feel pain.
 Infants are less sensitive to pain than adults
 Neonates have no memory of pain.
 Neonates are not able to tolerate the effects
of analgesics.
 Infants become accustomed to pain.

23. ?what are the facts
 Newborn infants have functional nervous
systems which are capable of perceiving pain
 Physiologic means of assessing pain (VS) can
be an unreliable predictor of pain
 Infants often develop an increase in signs of
discomfort with repeated painful procedures

24.  Premature infants can have
unpredictable responses to painful
stimuli
 Unmanaged pain in the neonatal period
can cause long term developmental
complications

25. “Even if not expressed as conscious memory,
memories of pain may be recorded
biologically and alter brain development and
subsequent behavior”
-Journal of Paediatrics and Child Health 42 (2006)

26.  The prevention of pain in neonates should be
the goal of all caregivers, because repeated
painful exposures have the potential for
deleterious consequences.
Pediatrics 2006;118;2231

27. NICU- RCMC

29. The Effects of Pain
 Physiological Effects
 changes in vital signs,
pupils
 Behavioral Cues
 how the baby acts when
she is in pain
 Hormonal/Metabolic
Responses
 what happens
chemically

30. Physiological Responses
 variations in HR
 variations in BP
 increased ICP
 increased or decreased RR
 decreased sats or increase in oxygen requirement
 change in color (pale, poor perfusion or red, increased
perfusion)
 increased or decreased muscle tone

31. Behavioral Cues
 crying  body movements
 can vary from high  limb withdrawal
pitched, tense to soft  fist clenching
moaning  hypertonicity or
 facial expressions hypotonicity
 grimacing  state changes
 quivering of chin  changes in sleep-wake
 squeezing eyes shut cycles
 furrowed brow  changes in activity levels-
 difficult to comfort or calm increased fussiness or
irritability

32. Hormonal/Metabolic Responses
 increase in epinephrine and norepinephrine,
growth hormone and endorphins
 decrease in insulin secretion
 increased secretion of cortisol, glucagon, and
aldosterone…
 which leads to increased serum glucose, lactate,
& ketones
 can lead to lactic acidosis
Is the “stress response” secondary to the
surgery/procedure or the pain afterwards?

33. Hormonal/Metabolic Responses
Changes in hormone levels affect the absorption of fat,
protein, and glucose, which subsequently affect
HEALING AND GROWTH!
PAIN CONTROL IS MORE THAN A MATTER OF
COMFORT-
CONTROLLING PAIN DECREASES
COMPLICATIONS

34. Factors Affecting Pain Response
 Gestational age-as preterm infants develop,
their responses become more sustained and
interpretable
 Environmental factors-external noise,
temperature, light

35. Factors Affecting Pain Response
 Intensity and duration of insult-repeated
painful procedures decrease infant’s
ability to react to pain but not their
perception of it.
 Behavioral state-less reactive when in
sleep states than wake states

36. Long Term Effects of Untreated
Pain
 Newly studied area-until recently, babies
were not thought to “remember” pain
 Some experts believe that untreated pain in
the newborn period forces abnormal
pathways to form in the brain
 This aberrant brain activity results in impaired
social/cognitive skills and specific patterns of
self- destructive behavior

37. ?What can we do
Common sense tells us that not all crying babies
. are in pain
A chronically stressed baby in the NICU may not
.react at all to pain

39. Assessment of Pain in the Newborn
 Pain scales use behavioral cues such as
quality of cry, breathing pattern, facial
expression, & muscle tone, as well as
changes in VS & increase in oxygen
requirement.

40. Assessment of Pain in the Newborn
 Use of scales decreases nurse to nurse
variability of pain med administration
 Limitations include differentiating
between pain and agitation, difficulty
assessing premature infants’ behavior,
and few scales for use with
intubated/sedated patients

41. FLACC Scale
 F-face (expression)
 L-legs (tone)
 A-activity
 C-cry
 C- consolability
score is tallied, similar to APGAR (0,1, or 2 for
each category)
greater than 4 is indicative of pain

42. FLACC Scale

43. CRIES scale
 C-crying
 R-requires O2
 I-increased VS
 E-expression
 S-sleepless
Simple and easy to use-uses a scale of 1-10,
similar to APGAR scoring
score of 4 or greater requires intervention

44. CRIES scale

45. NIPS (Neonatal Infant Pain
(Scale
 Behavioral cues scale
 rates crying, facial expression, breathing
patterns, tone of arms and legs, and state of
arousal at one minute intervals
 should be used taking other physiologic
factors into account

47. PIPP (Premature Infant Pain
(Profile
 Uses both behavioral and physiologic
reactions to pain
 Measures behavioral state, HR, sat, and 3
facial expressions which are indicative of
pain in preemies (brow bulge, eye squeeze,
and nasolabial furrow)
 Takes into account gestational age
(postconceptual)

49. Prevent or Minimize Pain
 Cluster blood draws or use
arterial line whenever possible
to minimize sticks
 Use smallest gauge needle
possible
 Use minimal amounts of
tape/use tape remover to
remove it
 Premedicate prior to painful or
invasive procedures

50. Pain Management
 Developmental support is the first step in
managing all levels of pain
 facilitated tuck-support infant in a flexed
position
 parental involvement-give parents a chance to
help support their baby

52.  facilitate hand to mouth contact, offer pacifier-
sucking causes endorphins to be released
 swaddling, holding
 minimize external stimuli such as noise & light

54. Circumcisions
 ASPMN statement
 circumcisions are painful
 Unrelieved pain from circs can cause
adverse stress responses such as breath
holding, apnea, gagging, and vomiting
 neonates have the right to an anesthetic to
prevent the pain of the procedure
 suggest use of blocks or EMLA cream as
well as sucrose pacifier and developmental
support to assist these babies with coping

55. AAP Recommendations
1. Caregivers should be trained to assess
neonates for pain using multidimensional
tools.
2. Neonates should be assessed for pain
routinely and before and after procedures.
3. The chosen pain scales should help guide
caregivers in the provision of effective pain
relief.

56. Reducing Pain From Bedside
Care Procedures
1. Care protocols for neonates should
incorporate a principle of minimizing the
number of painful disruptions in care as much
as possible.
2. Use of a combination of oral sucrose/glucose
and other nonpharmacologic pain-reduction
methods (nonnutritive sucking, kangaroo
care, facilitated tuck , swaddling …)

57. 3-Topical anesthetics can be used to reduce
pain associated with venipuncture, lumbar
puncture, and intravenous catheter insertion
when time permits but are ineffective for
heel-stick blood draws, and repeated
use of topical anesthetics should be limited.

58. 4. The routine use of continuous infusions of
morphine, fentanyl, or midazolam in
chronically ventilated preterm neonates is
not recommended because of concern
about short-term adverse effects and lack of
long-term outcome data.

59. Reducing Pain From Surgery
 1. Any health care facility providing surgery
for neonates should have an established
protocol for pain management. Such a
protocol requires a coordinated,
multidimensional strategy and should be a
priority in perioperative management.

60. 2. Sufficient anesthesia should be provided to
prevent intraoperative pain and stress
responses to decrease postoperative
analgesic requirements.
3. Pain should be routinely assessed by using a
scale designed for postoperative or
prolonged pain in neonates.

61. 4-Opioids should be the basis for postoperative
analgesia after major surgery in the absence
of regional anesthesia.
5. Postoperative analgesia should be used as
long as pain-assessment scales document
that it is required.

62. 6. Acetaminophen can be used after surgery as
an adjunct to regional anesthetics or opioids,
but there are inadequate data on
pharmacokinetics at gestational ages less
than 28 weeks to permit calculation of
appropriate dosages.

63. Reducing Pain From Other Major
Procedures
1. Analgesia for chest-drain insertion comprises
all of the following:
a. general nonpharmacologic measures;
b. slow infiltration of the skin site with a local
anesthetic before incision unless there is life-
threatening instability (if there was
inadequate time toinfiltrate before insertion
of the chest tube, local skin infiltration after
achieving stability may reduce later pain
responses and later analgesic requirements);

64. Reducing Pain From Other
Major Procedures
 c. systemic analgesia with a rapidly acting
opiate such as fentanyl.

65.  2. Analgesia for chest-drain removal
comprises the following:
 Analgesia for chest-drain removal comprises
the following:
 a. general nonpharmacologic measures and
 b. short-acting, rapid-onset systemic
analgesic.

66. 3. Although there are insufficient data to make
a specific recommendation, retinal
examinations are painful, and pain-relief
measures should be used. A reasonable
 approach would be to administer local
 anesthetic eye drops and oral sucrose.
 4. Retinal surgery should be considered major
surgery, and effective opiate-based pain relief
should be provided

67. GOALS OF MANAGEMENT
 Decrease pain and suffering
 Promote family bonding
 Increase patient comfort
 Promote normal coping mechanisms
 Decrease patient risk from complications
 Prevent negative long term developmental outcomes
HAPPY, HEALTHY BABIES!

68. !HAPPY, HEALTHY KIDS

69. Do you agree ?

70. !Last words
Babies are unable to communicate their pain to the
…untrained eye
However, you have the tools to assess your babies
!!for pain and make it better

71. VIDEO

72. Thank you