Neonatal Pain Management

Key Points

• Neonates experience pain and demonstrate physiological and behavioral responses to noxious stimuli
• Untreated pain can lead to both short-term and long-term consequences
• Systematic approach using validated assessment tools is essential
• Combined pharmacological and non-pharmacological strategies are most effective
• Regular reassessment and documentation is crucial

Clinical Significance

Neonates admitted to NICUs experience an average of 10-14 painful procedures daily. Untreated pain can lead to:

• Altered pain sensitivity
• Changes in brain development
• Modified stress response systems
• Impaired neurodevelopmental outcomes
• Poor feeding behaviors
• Sleep disruption

Pain Assessment Tools

Validated Pain Scales

• PIPP (Premature Infant Pain Profile)
  • 7 indicators including behavioral and physiological measures
  • Validated for gestational age 28-40 weeks
  • Scores range 0-21; score ≥6 indicates pain
• NIPS (Neonatal Infant Pain Scale)
  • 6 behavioral indicators
  • Useful for procedural pain assessment
  • Scores range 0-7; score >3 indicates pain
• N-PASS (Neonatal Pain, Agitation and Sedation Scale)
  • Assesses both pain/agitation and sedation
  • Particularly useful for ventilated infants
  • Includes scoring adjustments for gestational age

Pain Indicators

Physiological

• Increased heart rate
• Decreased oxygen saturation
• Blood pressure changes
• Respiratory rate variations
• Hormonal responses (↑ cortisol, catecholamines)

Behavioral

• Facial expressions (brow bulge, eye squeeze, nasolabial furrow)
• Body movements
• Crying patterns
• Sleep-wake patterns
• Changes in feeding behavior

Pharmacological Management

Opioids

Morphine

• Dosing: 0.05-0.1 mg/kg IV q4h PRN
• Continuous infusion: 10-20 mcg/kg/hr
• Considerations:
  • Monitor for respiratory depression
  • Risk of hypotension
  • May require dose adjustment in renal impairment

Fentanyl

• Dosing: 0.5-2 mcg/kg IV q2-4h PRN
• Continuous infusion: 0.5-2 mcg/kg/hr
• Advantages:
  • Rapid onset
  • Short duration
  • Less histamine release

Non-Opioid Analgesics

Acetaminophen

• Oral dosing: 10-15 mg/kg q6h
• IV dosing: Loading 20 mg/kg, then 10 mg/kg q6h
• Maximum daily dose: 60 mg/kg/day

Local Anesthetics

• EMLA cream: Apply 1-2g, 60 minutes before procedure
• Lidocaine 1%: Maximum 5 mg/kg

Sedatives

Midazolam

• Dosing: 0.05-0.1 mg/kg IV q2-4h PRN
• Precautions:
  • Associated with adverse neurological outcomes in premature infants
  • Use with caution in hemodynamically unstable patients

Non-Pharmacological Management

Environmental Measures

• Minimize light exposure
• Reduce noise levels
• Cluster care activities
• Maintain appropriate temperature
• Position optimization

Behavioral Interventions

• Kangaroo Care
  • Skin-to-skin contact
  • Promotes stability of vital signs
  • Reduces stress responses
• Non-nutritive Sucking
  • Use of pacifier during procedures
  • Reduces pain scores
  • Stabilizes heart rate
• Swaddling
  • Promotes self-regulation
  • Reduces physiological distress

Nutritive Interventions

• Breastfeeding
  • Effective during minor procedures
  • Combines sucking, skin contact, and sweet taste
• Sweet Solutions
  • 24% Sucrose: 0.2-0.5 mL
  • Give 2 minutes before procedure
  • Maximum 6-8 doses/24 hours

Procedural Pain Management

Minor Procedures

Heel Lance

• First line: Sweet solution + non-nutritive sucking
• Additional measures:
  • Automated lancet devices
  • Warm heel
  • Kangaroo care if possible

Venipuncture

• Recommended:
  • EMLA cream
  • Sweet solution
  • Comfort positioning

Major Procedures

Central Line Placement

• Required:
  • Local anesthetic infiltration
  • Systemic analgesia (opioid)
  • Consider sedation

Chest Tube Insertion

• Recommended:
  • Rapid-acting opioid (fentanyl)
  • Local anesthetic
  • Consider sedation if not emergent