Medical Professional Publications

How To Better Manage Pain in Newborns

Columbus, OH - September 2016

Babies undergo painful procedures for a host of good reasons, but with a potential cost. Poorly managed pain can affect neurodevelopment, behavior and cognitive function.

A recent policy statement from the American Academy of Pediatrics’ Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medication found neonatal pain continues to be inconsistently assessed and inadequately managed, and offered guidelines to improve. Those recommendations focus on skin-to-skin care, breast feeding and other nonpharmacologic interventions to limit newborns' suffering.

"We have to continue to build the foundation for nonpharmacologic care; we should be doing it for every baby every time they undergo a procedure," says Erin Keels, DPN, APRN, NNP-BC, program manager of nurse practitioners in the Division of Neonatology at Nationwide Children's Hospital and primary author of the update.

"There's a lot of opportunity to pull the families into assisting at the bedside, utilizing these interventions," she says. "That strengthens their relationship and improves outcomes for the baby."

To prevent or limit pain, the AAP committee recommends judicious use of procedures. When painful procedures are necessary, caregivers are urged to consistently use validated assessment tools before, during and after. To manage pain, the committee recommends nonpharmacologic interventions and careful use of pharmaceuticals.

"Even though we've had morphine and other opiates for decades, we still need to learn the long term outcomes so we can be more confident when we use them," Keels says.

The committee also says oral sucrose or glucose solutions used to ease pain should be treated as pharmacological interventions. Research on their effects is lacking.

Recommended nonpharmacologic interventions include:

  • skin-to-skin contact
  • facilitated tucking
  • sensorial stimulation
  • swaddling
  • non-nutritive sucking
  • positioning
  • massaging
  • breast-feeding

Outside of hospitals, pediatricians could use nonpharmacologic interventions during injections and other simple procedures at an office or outpatient clinic, Keels says. The policy may also be a resource when counseling a family whose baby will require a stay in the NICU after birth.

Keels, a former bedside nurse, studies pain prevention and management practices across the country to help set protocols in the Neonatal Intensive Care Unit (NICU) at Nationwide Children’s.

"We're one of the largest neonatal service lines in the country and have a very large surgical service here... there are ample opportunities to improve outcomes of pain management," Keels says. "I find when I'm going around the country, some of our pain management techniques or approaches are sort of ahead of the curve."

Keels is The National Association of Neonatology Nurses’ liaison to the AAP Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medication, which produced the new policy — the first in a decade.

"I think the policy guidelines are terrific," says Kristina Reber, MD, associate division chief of Neonatology at Nationwide Children's Hospital, who was not involved in drafting the update. "We're recognizing and appreciating more and more the need to be proactive about treating pain, how we treat, and minimizing the pharmacologic exposure to the baby.

"As the guidelines point out, we still need a lot of research to better understand how to best manage neonatal pain," Dr. Reber says.

Reference:
AAP Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: an update. Pediatrics. 2016(137)2:e20154271.

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