Pain Assessment and Management in Neonates

First of all, while welcoming a newborn into the world is an exciting moment, it also entails a responsibility to ensure the well-being of these small people, particularly with regard to pain management. Preterm and term neonates both suffer pain, therefore it's critical to have a thorough understanding of how to assess and treat pain in this vulnerable population. We will discuss the nuances of newborn pain, the value of assessing it, and different approaches to pain management in this blog.

Understanding Neonatal Pain 

There is a myth that if a newborn doesn't react visibly, they aren't in pain. In fact, babies may feel pain even while they are still in the womb. Particularly in very unwell neonates, the physiological measures that are usually employed to assess pain can be unreliable. Therefore, when assessing pain in newborns, composite measures that incorporate both physiological indicators and observed distress behaviours are frequently used.

Consequences of Untreated Pain 

Neonates who experience pain untreated may suffer grave effects that impact their physiological condition and result in maladaptive behavior. Stress and pain during infancy can affect a baby's neurodevelopment, which can affect how the baby interprets and reacts to pain in the future. Since untreated pain during the newborn era can cause infants to become less receptive to painful stimuli even at 18 months of corrected age, it becomes clear how important it is to avoid and control pain.

Principles of Pain Prevention and Management 

The neonate's physiological systems are sufficiently developed to transmit painful stimuli, according to the American Academy of Pediatrics (AAP), and prolonged or severe pain exposure might increase morbidity. It's important to remember, though, that the absence of behavioral reactions like sobbing or moving around doesn't always mean that pain isn't present.

Evaluating Neonatal Pain  

Observing behavioral responses and tracking physiological changes are two methods used to assess pain in neonates. The Premature Infant Pain Profile (PIPP) and other newborn pain measures are essential tools for measuring pain in this population.

Neonatal Pain Scales 

To evaluate newborn pain, a variety of pain scales are used, each with a distinct function. These comprise the recently released EVANDOL scale in addition to PIPP, N-PASS, COMFORT, and EDIN. These scales take into account postures, facial expressions, interaction with the surroundings, and vocal and linguistic expressions.

Also Read: Retinopathy of Prematurity- Mechanism and Treatment

Management

Non-Pharmacological Measure

Neonatal pain management requires both non-pharmacological interventions and environmental changes. Controlling sound and light, holding a baby close to the skin, nursing, nonnutritive sucking, and using sweet solutions like sucrose or glucose are a few of these.

Pharmacological Approaches

An essential component of healthcare is the control of neonatal pain, particularly when it comes to the use of medications during various medical procedures. We'll examine the use of pharmaceuticals to manage pain in newborns in this thorough guide, covering various situations and emphasizing important factors.

1. EMLA Cream: Tailored for Specific Procedures

EMLA cream, well-known for its effectiveness in lumbar punctures and vein pricks, offers a complex image. It works well for some situations, like these treatments, but not for heel pricks. Furthermore, babies younger than a year old who are receiving methemoglobin-inducing medications such as acetaminophen, phenobarbitone, or sulpha should use caution. The combination of 4% tetracaine and 4% liposomal lidocaine is an alternative that is worth taking into consideration. While it is faster, it is not as effective as EMLA.

2. Analgesia for Invasive Procedures

While there is no obvious benefit to routine opioid infusion during mechanical breathing, morphine and fentanyl are often utilized opioids as needed. Depending on the demands of the patient, other choices including alfentanil, remifentanil, sufentanil, and tramadol might also be taken into account.

3. Intubation: A Delicate Balancing Act

Fentanyl, also known as remifentanil, is the drug of choice when it comes to intubation. When necessary, muscle relaxants are used sparingly, and infants older than 35 weeks are given consideration when prescribed midazolam.

4. Circumcision: A Three-Phase Approach

Pain management after circumcision must be done gradually. During pre-circumcision, oral sucrose (24%) and paracetamol are used. A ring or dorsal penile block with lidocaine is advised during the process, and paracetamol may be necessary after the circumcision.

5. Opioids: Post-Operative Analgesics

Without regional anesthetic, opioids are the mainstay of post-operative pain management following moderate to large procedures. Two drugs that stand out are morphine and fentanyl, each with unique benefits and drawbacks.

6. Benzodiazepines and Other Sedatives: Cautious Use Advised

Research on rodent benzodiazepine exposure raises the possibility of long-term behavioral and cognitive deficits. It is advised to use with caution, particularly in the early stages of brain development. Contradictory outcomes from midazolam infusion in preterm/neonates call for cautious assessment.

7. Naloxone for Reversal of Opioid Side Effects: A Vital Tool

When it comes to treating the negative effects of opioids, especially respiratory depression, naloxone is an essential tool. It's critical to be aware of possible adverse effects like pruritus and emesis.

8. Epidural Analgesia 

 It is a helpful choice for newborns as well. It provides early extubation and good analgesia at reduced opioid dosages. Among the issues that can arise after surgery is the inadvertent infusion of a local anesthetic into the intravascular system. Air embolism in the veins.  Infection on a localized system. Meningitis.

Contraindication of Sweet Tasting Analgesic 

These comprise:

• NEC, or necrotizing enterocolitis;
• Short bowel syndrome;
• Metabolic disorders involving carbohydrates; 
• Unidentified gastrointestinal symptoms
  

Analgesic Indication of Sweet Tasting

The following conditions can be treated with sweet-tasting analgesics: skin puncture, heel stick, suction, circumcision, NG insertion, IV injection, immunisation, and ocular examination. Urine gathering

Also Read: Non-Immune Hydrops-Etiology, Investigations And Treatment

Pain Control While ROP Screening

A combination of 0.5% proparacaine eye drops applied 30 seconds prior to the examination (TA, or topical anesthetic).  To minimize pain during the ROP screening process, an oral combination of 24% sucrose or 25% dextrose administered at a dose of 0.5 milliliters per kilogram should be utilized right before the insertion of the eye speculum.

Also Read: Hearing Loss in Nicu Graduates

Hope you found this blog helpful for your NEET SS Pediatrics Neonatology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.