Painful Experiences

The NICU is full of painful experiences. Several studies have examined the frequency of painful experiences to which an infant in the NICU is exposed. Simons and his team reported that in the first 14 days following a NICU admission, neonates were subjected to a mean of 14 painful procedures per day.¹ Carbajal et al reported that neonates at 33 weeks gestational age admitted to the NICU experienced an average of 10 painful procedures per day.²

In addition, studies have demonstrated how neuronal development is different based on painful experiences. Mitchell & Boss discuss the short and long term effects of neonatal pain.³ We have all seen the short term effect of increased physiologic instability. This physiologic instability also increases the risk of intraventricular hemorrhage in the preterm infant. Other effects include sleep disturbances, feeding difficulties and inability to self-regulate. Long term effects they discuss include attention deficit disorder, learning disorders and behavioral problems later in childhood. Often these experiences cannot be isolated from other adverse events that may happen during the NICU stay. Bhutta & Anand discuss painful experiences as well as other experiences in the NICU that may lead to altered neuronal development and outcomes leading to greater need for health care later in life.⁴ Taddio et al compared infants of diabetic mothers with normal term infants.⁵  These IDM infants experienced additional heel lances, the source for the painful events. They found that within 24 to 36 hours, these infants learned to anticipate pain and exhibited more painful behaviors than the infants who did not experience as many heel lances.

So, the question is, how can these experiences be reduced?

Methods of managing these painful episodes may include simply preventing them altogether. Evaluating the need for an additional heel lance, a peripheral IV for saline lock, suctioning and other painful or potentially painful experiences is always a good idea. In the 2001 Consensus Statement for the Prevention and Management of Pain in the Newborn, alternative measures are discussed for various types of painful and potentially painful procedures.⁶

If the painful procedure is required, use of behavioral methods to assist the infant in managing the pain effectively may be helpful. Behavioral methods that have shown a decrease in painful responses include use of a pacifier, swaddling, kangaroo care and facilitated tuck to mention a few.

The use of sucrose has become a standard of care and common practice. However, concern has been raised of late about the use of sucrose. It is indicated for painful experiences and many older studies have established that it is effective.⁷ However, it is often used for irritability as well. Pain and irritability are very difficult to differentiate in a pre-verbal infant. Both may be manifested by restlessness, crying, increased heart rate and other signs. Pain may also result in lack of behavioral symptoms making it difficult to identify. The long-term effects of sucrose use in the neonatal period are unknown. Does this early sweet taste predispose the infant to a preference for sweets? Does it interfere in any way with feeding readiness or interest?

A quick survey of what actually happens in your unit may be informative. Perform an audit for a 24 hour period and document each painful procedure for each infant. Then, evaluate opportunities to manage the pain and/or to decrease or prevent these experiences.

 

References:

1. Simons SH, van Dijk M, Anand KJS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in the neonates. Archives of Pediatrics and Adolescent Medicine, 2003;157(11):1058-1064.

2. Carbajal R, Rousset A, Danan C, Coquery S, Nolent P, Ducrocq S, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008; 300(1):60-70.

3. Mitchell A & Boss BJ. Adverse effects of pain on the nervous systems of newborns and young children: a review of the literature. Journal of Neuroscience in Nursing. 2002; 34(5):228-236.

4. Bhutta AT & Anand KJ. Vulnerability of the developing brain. Neuronal mechanisms. Clinics in Perinatology. 2002; 29(3):357-372.

5. Taddio A, Shah V, Gilber-MacLeod C, Katz J. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002; 288(7):857-861.

6. Anand KJ, International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Archives in Pediatric and Adolescent Medicine. 2001; 155(2):173-180.

7. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001069. DOI: 10.1002/14651858.CD001069.pub3