PAIN IN NEWBORNS

1. PAIN IN NEWBORNS Eileen Murray, RN, BSN

2. Objectives • Discuss and explain myths which have contributed to under treatment of pain in neonates • Understand the behavioral and physiologic effects of pain • Identify factors that influence patient responses to pain • Discuss assessment of neonatal pain • Familiarize yourself with pain scales and their use • Discuss treatment options for pain management in neonates

3. “Pain is whatever the person says it is and exists whenever he says it does.” Margo McCaffery

4. “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such. Pain is subjective.” International Association for the Study of Pain

5. If that was the person you loved MOST in the world, laying critically ill in that bed, what would you want for them?

6. PAIN MANAGEMENT MYTHS • Neonates do not feel pain. • Infants are less sensitive to pain than adults • Neonates have no memory of pain. • Children will tell you when they are having pain. • If a child can be distracted, he is not in pain. • Neonates are not able to tolerate the effects of analgesics. • Narcotics can lead to addiction in children. • Infants become accustomed to pain.

7. So, what are the facts? • Newborn infants have functional nervous systems which are capable of perceiving pain • Physiologic means of assessing pain (VS) can be an unreliable predictor of pain • Infants often develop an increase in signs of discomfort with repeated painful procedures • Premature infants can have unpredictable responses to painful stimuli • Unmanaged pain in the neonatal period can cause long term developmental complications

8. “Even if not expressed as conscious memory, memories of pain may be recorded biologically and alter brain development and subsequent behavior” -Journal of Paediatrics and Child Health 42 (2006)

9. The Effects of Pain • Physiological Effects • changes in vital signs, pupils • Behavioral Cues • how the baby acts when she is in pain • Hormonal/MetabolicResponses • what happens chemically

10. Physiological Responses • variations in HR • variations in BP • increased ICP • increased or decreased RR • decreased sats or increase in oxygen requirement • change in color (pale, poor perfusion or red, increased perfusion) • increased or decreased muscle tone

11. crying can vary from high pitched, tense to soft moaning or whining facial expressions grimacing quivering of chin squeezing eyes shut furrowed brow difficult to soothe, comfort or calm body movements limb withdrawal fist clenching hypertonicity or hypotonicity state changes changes in sleep-wake cycles changes in activity levels-increased fussiness or irritability Behavioral Cues

12. Hormonal/Metabolic Responses • increase in epinephrine and norepinephrine, growth hormone and endorphins • decrease in insulin secretion • increased secretion of cortisol, glucagon, and aldosterone…which leads to • increased serum glucose, lactate, & ketones • can lead to lactic acidosis Is your “stress response” secondary to the surgery/procedure or the pain afterwards?

13. Hormonal/Metabolic Responses Changes in hormone levels affect the absorption of fat, protein, and glucose, which subsequently affect HEALING AND GROWTH! PAIN CONTROL IS MORE THAN A MATTER OF COMFORT- CONTROLLING PAIN DECREASES COMPLICATIONS

14. Factors Affecting Pain Response • Gestational age-as preterm infants develop, their responses become more sustained and interpretable • Environmental factors-external noise, temperature, light • Intensity and duration of insult-repeated painful procedures decrease infant’s ability to react to pain but not their perception of it • Behavioral state-less reactive when in sleep states than wake states

15. Long Term Effects of Untreated Pain • Newly studied area-until recently, babies were not thought to “remember” pain • Some experts believe that untreated pain in the newborn period forces abnormal pathways to form in the brain • This aberrant brain activity results in impaired social/cognitive skills and specific patterns of self- destructive behavior • Studied MRI’s of newborns-reactions to pain transferred into similar electrical reactions to any kind of stressful situation

16. What can we do? Common sense tells us that not all crying babies are in pain. A chronically stressed baby in the NICU may not react at all to pain.

17. Assessment of Pain in the Newborn • Pain scales use behavioral cues such as quality of cry, breathing pattern, facial expression, & muscle tone, as well as changes in VS & increase in oxygen requirement. • Proponents maintain that use of scales decreases nurse to nurse variability of pain med administration • Limitations include differentiating between pain and agitation, difficulty assessing premature infants’ behavior, and few scales for use with intubated/sedated patients

18. FLACC Scale • F-face (expression) • L-legs (tone) • A-activity • C-cry • C-consolability score is tallied, similar to APGAR (0,1, or 2 for each category) greater than 4 is indicative of pain behaviorally based

19. C-crying R-requires O2 I-increased VS E-expression S-sleepless Simple and easy to use-uses a scale of 1-10, similar to APGAR scoring score of 4 or greater requires intervention objective and behavioral categories CRIES scale

20. NIPS (Neonatal Infant Pain Scale) • Behavioral cues scale • rates crying, facial expression, breathing patterns, tone of arms and legs, and state of arousal at one minute intervals • should be used taking other physiologic factors into account

21. PIPP (Premature Infant Pain Profile) • Uses both behavioral and physiologic reactions to pain • Measures behavioral state, HR, sat, and 3 facial expressions which are indicative of pain in preemies (brow bulge, eye squeeze, and nasolabial furrow) • Takes into account gestational age (postconceptual)

22. Prevent or Minimize Pain • Cluster blood draws or use arterial line whenever possible to minimize sticks • Use smallest gauge needle possible • Use minimal amounts of tape/use tape remover to remove it • Premedicate prior to painful or invasive procedures

23. Pain Management • Developmental support is the first step in managing all levels of pain • 4 handed care-support infant in a flexed position • parental involvement-give parents a chance to help support their baby • facilitate hand to mouth contact, offer pacifier-sucking causes endorphins to be released • swaddling, holding • minimize external stimuli such as noise & light

24. Circumcisions • ASPMN statement • circumcisions are painful • Unrelieved pain from circs can cause adverse stress responses such as breath holding, apnea, gagging, and vomiting • neonates have the right to an anesthetic to prevent the pain of the procedure • suggest use of blocks or EMLA cream as well as sucrose pacifier and developmental support to assist these babies with coping

25. Management of Mild Pain • developmental support • parental involvement • Acetaminophen-excellent choice for mild post operative pain (hernias, etc) especially in opioid-naïve patients • ibuprofen - analgesic, non-narcotic NSAID; no studies to assess safety in babies less than 3 months old • EMLA cream to prevent pain with planned procedures (circumcisions, etc.) recommended in babies >36 weeks GA or > 2 weeks old (don’t use with Tylenol)

26. Don’t you love Sucrose? • sucrose is the most studied treatment to help babies deal with mild or procedural pain • shown to help with LP’s, circumcisions, venipunctures, and heelsticks • sucrose and sucking each cause the release of endorphins-putting these 2 treatments together has been proven to decrease pain in newborns

27. Management of Moderate Pain • developmental support • parental involvement • acetaminophen with codeine-analgesic, narcotic only comes in PO form which limits its usability • ketorolac (torodal) - analgesic, non-narcotic, NSAID; time limited use, works best when given around the clock for 48 hours post op in addition to other analgesics

28. Management of Severe Pain • developmental support • parental involvement • pharmacological management • medications given on a prn basis result in peaks and valleys of pain relief • pain is better controlled if medication is given prior to the climax of pain • continuous drip or regularly scheduled doses maintain a constant level of analgesia

29. Management of Severe Pain • Morphine • Intermittent 0.05 mg-0.2mg/kg/dose may give q1-8 hours • Continuous load with 100mcg/kg, then 10-15 mcg/kg/hr • can have significant respiratory side effects • observe for abdominal distension, decreased bowel sounds, and urinary retention

30. Management of Severe Pain • Fentanyl • Intermittent 1-4mcg/kg/dose may give q2-4 hours • Continuous 1-5mcg/kg/hour • good choice for cardiac patients due to decreased CV side effects • can cause chest wall rigidity in neonates when given IVP • Meperidine (demerol) - not recommended for pediatrics 2° toxic CNS metabolites

31. Management of Severe Pain • Methadone • respiratory effects outlast analgesia at such dosing levels • drug of choice to support narcotic weaning • Hydromorphone (dilaudid) • analgesic, narcotic; not for patients with significant respiratory distress • the injectable form contains benzyl alcohol which is not recommended for neonates

32. GOALS OF MANAGEMENT • Decrease pain and suffering • Promote family bonding • Increase patient comfort • Promote normal coping mechanisms • Decrease patient risk from complications • Prevent negative long term developmental outcomes HAPPY, HEALTHY BABIES!

33. HAPPY, HEALTHY KIDS!

34. You are the KEY! Babies are unable to communicate their pain to the untrained eye… However, you have the tools to assess your babies for pain and make it better!!