2011 Pain in the Neonate

8/3/2019 2011 Pain in the Neonate

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Neonatal Pain

Anne Martinez RNC-NIC


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With acknowledgment of Renee Hunt

ARNP, for sharing information on neonatal

pain.


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Objectives

Become familiar with pain assessment and management in

neonates.

Identify behavioral and physiologic signs of pain in the

neonate.

Discuss non-pharmacologic/pharmacologic management of

pain in neonates.


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Historical Perspective

Lawson case-patent ductus arteriosus

(PDA) surgery without anesthesia in mid

1980s

Edward case-ventriculoperitoneal (VP)

shunt performed using only curare. Baby

survived but screamed if anyone touchedhis head


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Definition of Pain

unpleasant sensory and emotional experience,

causing potential or actual tissue damage

acute pain-a constellation of unpleasant sensory,perceptual, emotional and mental experiences &

certain associated autonomic, psychological &

behavioral responses provoked by injury or acute

disease (the International Association for theStudy of Pain)


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Definition of pain

Acute pain-normal predicted physiologicresponse to adverse chemical, thermal, or

mechanical stimulus (KS State Board ofNursing, 2001)

Chronic pain-chronic pathologic processthat causes pain to continue or recur(KSBN)

Whatever a patient says it is (McCaffery)


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Detrimental Consequences

Increases in: plasma renin activity, epinephrine,norepinephrine, plasma cortisol, catecholamines,growth hormone, glucagon, and aldosterone

Decrease in: insulin secretion

May lead to:

severe hyperglycemia

metabolic acidosis (increased lactate, pyruvate, ketonebodies, & fatty acids)


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End Result of Pain

INCREASED MORBIDITY

INCREASED MORTALITY

(Anand & Hickey, 1986)


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Consequences of Pain

Even brief periods of severe pain early in

life may be responsible for prolonged

sensory disturbances

May cause altered pain responses

These alterations may persist into

adolescence and adulthood


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Pain is Subjective

Pain is defined by the person experiencing

the pain.

Pre-verbal Neonates are unable to verbalize

and describe pain.

Assessment must be guided by

physiological & behavioral cues.


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Frequency of Neonatal Pain

Approximately 9% of live births are admitted to aNICU annually

Painful procedures are required for treatment

Heelsticks

Arterial/venous punctures, IV/PICC/PAL

Intubation/suctioning

Lumbar puncturesChest tubes

Surgery


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Frequency of Neonatal Pain

Other sources of discomfort

bright lights

noise

frequent handling

REMEMBER-the most premature infantsrequire the highest number of procedures


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Historical Misconceptions

Nervous system too immature to perceive pain

Fear of addiction

Fear of side effects (hypotension, apnea,

decreased GI motility, liver/kidney damage)Belief that infants had no memory of pain


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Debunking the Myths

1. Nervous system of neonate too immature

to perceive pain

7 wks-sensory nerve endings in perioral

region

15 wks-sensory nerve endings on trunk

& proximal extremities


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20 wks-sensory nerve endings onmucous membranes & cutaneous

areas. Fetus experiences pain.

24 wks-thalamic track is complete

30 wks-myelination of brain stem andthalamic tract

37 wks-myelination of nociceptive tractcomplete


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Debunking the Myths

Recent research indicates newborns have

exaggerated cutaneous responses that last

longer compared to adults Neonates experience more pain to the same

stimulus than older children or adults

There is an increased density of peripheralnerves and immature descending pathway


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Debunking the Myth of Addiction

Addiction-neuro-behavioral syndrome that results inpsychological dependence for psychic effects

*no documented evidence of this syndrome in infants

Physical Dependence-expected result of continued opioiduse, may cause withdrawal symptoms if abruptly stopped

*gradually wean dose if opioids have been used for >5days

Tolerance-increased dosage needed to produce same effect


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Debunking the Myth that infants

have no memory of painRemember Baby Edwards (VP shunt)

Current research showing increased pain

responses to immunization injections inmales circumcised with NO analgesia


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Wind Up Phenomena

Altered excitability of CNS

After exposure to noxious stimulus,

multiple levels of spinal cord experiencealtered excitability. Activities such as

handling or diaper changes may then be

perceived as painful.

J i t C i i A dit ti


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Joint Commission on Accreditation

of Healthcare Organizations

(JCAHO) 2001 guidelines

1. Right to assessment/management of pain2. Record results, regular reassessments

3. Educate providers and determine competency

4. Establish policies and procedures

5. Educate patients/families

6. Collect data/monitor

appropriateness/effectiveness of pain mgt.

N ti l A i ti f N t l


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National Association of Neonatal

Nurses (NANN)-position statement

on pain management in infants1. Infants must be protected from adverse effects of

pain

2. Analgesia or sedation when appropriate

3. Ongoing assessment

4. Nurses must be proactive in pain management

5. Inform and educate and parents

6. Interdisciplinary collaboration


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American Academy of Pediatrics

1. Use an interdisciplinary approach

2. Personal values/beliefs of the health care

professional must not stand in the way orrecognition and treatment of pain in

children


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Agency for Health Care Policy &

Research

1. Prevention is better than treatment

2. Use reliable & valid measurement tools

3. Include physical and behavioral

assessment


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Recent Findings

Impulses can travel along unmyelinated

nerve tracts

Apoptosis-pruning of unnecessary cells

*in developing brains, an overstimulation of

nociceptive pathway can lead to

understimulation of another pathway(good touch or non-pain pathway)


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Recent Findings, cont.

Plasticity-concept that every experience of

the premature infant has the potential to

alter brain development*may lead to abnormal development &

behavior

*may enable infant to recover from braininsults


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Recent Findings, cont.

Allodynia-pain due to stimulus that

normally does not provoke pain

*touch & pain fibers are very close together,allowing the impulse to jump tracts

*handling or physical examinations may be

perceived as noxious stimulus


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Recent Findings, cont

Hyperalgesia-hypersensitivity to

painful stimuli

*Sensitivity persists after the stimulus removed

*May lead to new nerve endings in the injured

area (hyperinnervation) & cause increased pain

& hypersensitivity*Compounded by inadequate subcutaneous fat

to prevent thermal/pressure insults


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Innate Coping Mechanisms

Neonate has limited ability to block or cope

with pain

Primary coping method is sucking

Limited ability to block light-iris does not

constrict until 32 wk. gestation & eyelid is

very thin

Limited ability to block noise


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Short term Effects of Pain

Pain causes stress-triggers fight or flight

response

Release of glucocorticoids (cortisol,epinephrine, norepinephrine) that are

catabolic in nature-inhibiting cell division &

growth, protein synthesis & neuronalmyelination


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Short term Effects of Pain, cont.

Heart rate & blood pressure may be

increased

Intracranial blood volume & cerebral bloodflow may fluctuate leading to

intraventricular hemorrhage (IVH) and

periventricular leukomalacia (PVL)


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Long Term Effects of Pain

Increased sensory innervation

Altered pain behaviors in infancy

Increased pain thresholds

Hyperactivity/Attention deficit disorder

Decreased cognitive performance

Poor socialization, increased impulsivity


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Pain Assessment

Physiologic indicators- increased heart

rate and decreased oxygen saturation

Behavioral indicators-facial activity,(brow bulge, eye squeeze, nasolabial

furrow), crying, and body movements


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Additional Physiologic Signs

Increased Blood Pressure

Palmar Sweating

Pallor/flushing

Shallow Respirations

Diaphoresis

Dilated Pupils

These signs less reliable & harder to measure.


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Pain Assessment

Contextual factors modifying pain responses

Gestational age

Behavioral state

Severity of illness

Total number of painful procedures

Environmental stress

Sensitization after repeated stimulation Technician effects/procedural modifiers


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Premature Infant Pain Profile

Multidimensional or composite instrument

Altered responses due to prematurity are

factored into the calculation (very preterminfants can have maximum score of 21

compared to term infant score maximum of

18) Based on research data


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PIPP

Tested on babies from 24 to 40 weeks

gestation

Greater validity & reliability

Generally considered best instrument for

premature infants


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PIPP

Physiologic indicators-Heart Rate

-Oxygen Saturation

Behavioral variables-Brow Bulge

-Eye Squeeze

-Nasolabial Furrow

Contextual Factors-Gestational Age

-Behavioral State


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PIPP

Gestational age

0= >/= 36 wk

1= 32-35 6/7 wk

2= 28-31 6/7 wk

3=


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PIPP

Behavioral State

0= active awake state, eyes open, facial

movement1= quiet awake state, eyes open, no facial

movement

2= active/asleep, eyes closed, facial movements3= quiet/asleep, eyes closed, no facial movements


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PIPP

Maximum Heart Rate Increase

0= 0-4 BPM

1= 5-14 BPM

2= 15-24 BPM

3= >/=25 BPM


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PIPP

0xygen saturation decrease

0= 0-2.4%

1= 2.5-4.9%

2= 5-7.4%

3= >/=7.5%


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PIPP

Brow Bulge

0= none (0-9% of the time)

1= minimum (10-39% of the time)

2= moderate (40-69% of the time)

3= maximum (70 to 100% of the time)


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PIPP

Eye Squeeze

0= none (0-9%)

1= minimum (10-39%)

2= moderate (40-69%)

3=maximum (70-100%)


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PIPP

Nasolabial Furrow

0= none (0-9%)

1= minimum (10-39%)

2= moderate (40-69%)

3= maximum (70-100%)


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PIPP

Behavioral State scored immediately before

the event

Heart Rate, Saturation, Brow Bulge, EyeSqueeze, Nasolabial Furrow are scored in

the 30 seconds immediately following the

event


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PIPP

Scores of 7-12 =Mild Pain

Try nonpharmacologic measures

Scores > than 12=Moderate/Severe Pain

Consider Pharmacologic Intervention


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PIPP

New baseline heart rate & saturation

entered every Saturday night

Gestational age found on medical progressnote, Kardex, SBAR tool


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FLACC

Scores 0 to 2 for each category

Face

Legs

Activity

Cry

Consolability


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FLACC

Face

0=No particular expression, smile, eye contact,interest in surroundings

1=Occasional grimace/frown, withdrawn, worried,eyebrows lowered, eyes partially closed, mouthpursed

2=Frequent frown, clenched jaw, quivering chin,furrowed forehead, eyes closed, mouth open,nasolabial furrows


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FLACC

Legs

0=normal position, relaxed

1=uneasy, restless, tense, rigid, intermittent

flexion/extension of limbs

2=kicking, legs drawn up, hypertonicity,

exaggerated flexion/extension


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FLACC

Activity

0=lying quietly, moving freely

1=squirming, shifting, guarding

2=arched, rigid, or jerking, fixed position


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FLACC

Cry

0=no crying or moaning

1=moans, whimpers, occasional cry, sigh

2=crying steadily, screaming, sobs, grunts


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FLACC

Consolability-

0=calm, content, relaxed

1=reassured by occasional touching or

hugging

2=difficult to console or comfort


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FLACC

Designed for newborns to 3 years of age

Initiate FLACC at 38 weeks adjusted age

Consider pharmacologic intervention for

scores 5 or more


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Goals of pain management

Minimize intensity, duration, and

physiologic cost of pain

Maximize neonates ability to cope withand recover from the painful experience


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Nonpharmacologic approaches

Reduce total noxious stimuli

Containment/ swaddling

Non-nutritive sucking

Sucrose pacifier

Developmentally supportive care

Cautious clustering of care


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Sucrose

Theoretically works by releasing serotonin

to modulate transmission of noxious stimuli

Promotes activation of endogenous opioidsthat attenuate noxious stimuli at the dorsal

horn

Give 1-2 minutes before procedure Anterior tongue administration most

effective


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Sucrose

Research supports effectiveness in infants

Research has not determined the absolute

limit of safety in extremely prematureinfants

27 to 31 6/7 wk-1 to 2 dips per procedure(max in 24 hr. 8 dips)

>/=32 weeks- 1 to 4 dips per procedure(max in 24 hr 24 dips)


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Sucrose

Chart administration with number of dips

on MAR

Our 24 hour period starts at midnight

Example-At midnight baby given 2 dips so

chart 2/2 (second number is the total for the

day)


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Pharmacologic considerations

Analgesic use

Sedatives

Opioids

EMLA cream

Circumcision considerations

End of life pain


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Analgesics

Acetaminophen 20-25 mg/kg PO loading dose

12-15 mg/kg PO

32 to 37 weeks q 8 hr.

>37 weeks q 6 hr.

Cautious use in liver disease

Ibuprofen-not tested for analgesia in preterm/terminfants

Caution- may interfere with immune response


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Analgesics

Topical Proparacaine eye drops

Used for eye exams

Onset 20 seconds

Duration 15-20 minutes


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Pain control during eye exams

Review of literature and studies by Samra

and McGrath in June 2009 Advances in

Neonatal Care (NANN) There are clear guidelines for performing

eye exams

There are no standard protocols for painmanagement during exams


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Sedatives

Phenobarbital 5mg/kg IV or PO q 24 hr.

Midazolam (Versed)-Very cautious use in

prematures due to increased incidence ofIVH & other neurological adverse effects

according to the NO PAIN study

Chloral hydrate 20 to 50mg/kg orally- onoccasion may cause excitability


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Opioids

Fentanyl 1-4mcg/kg IV q 2 to 4 hr.

1-5mcg/kg/hr continuous infusion

Infuse over at least 15 min.

Observe for chest wall rigidity.

Compared to morphine, has less BPeffects, less histamine release, and

decreases pulmonary vascular resistance

Can be reversed with NarcanSome references suggest using the paralyzing

agent Pavulon to counteract chest wall rigidity


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Opioids

Morphine 0.05 to 0.2 mg/kg IV q 4 hr.

0.01 to 0.015mg/kg/hr (may have

loading dose ordered)

Can be given PO (onset & durationunpredictable)

Avoid rapid infusion-can decrease blood pressure andheart rate and cause bronchospasm.

Decreases GI motility Can be reversed with Narcan

Morphine is used for weaning from in utero drug exposure


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Opioids

Metabolism of Fentanyl & Morphine alteredby maturity of liver

May need higher doses of opioids due tohigher body water content

Hypotension more likely in hypovolemia

Wean opioids after prolonged use (5-7days)

Avoid Opiophobia!


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EMLA

Mixture of lidocaine/prilocaine

Approved for use in infants 37 wk. or more

Used for circumcision, venipuncture,arterial puncture, PICC placement

Apply 60 minutes before procedure


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Circumcision Pain

AAP states-procedural analgesia necessary

Subcutaneous Ring Block

Dorsal Penile Nerve Block

EMLA

Sucrose Pacifier

Acetaminophen

Physiologic Positioning


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Circumcision Pain

NEVER use Lidocaine with Epinephrine

due to compromise of blood supply and

potential for severe tissue damage Buffered Lidocaine stocked in Omnicell


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End of Life Pain

Opioids to prevent unnecessary pain

Palliative care orders include opioids and

other medications for patient comfort Consider ethical and humane care for dying

infants


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Conclusion

2011 Pain in the Neonate

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