PAIN IN NEONATE

A. Dwi Bahagia Febriani,

Neonatology Division,
Dept of Child Health,
Medical Faculty,
Hasanuddin University

Introduction
Twenty years ago : withholding anesthesia
during neonatal period because:
Newborns did not feel pain pain
transmission required complete nerve
myelinization and a mature cerebral cortex
to interpret the pain signal,
or if they did, the pain was not significant
and had no long-lasting consequences.
narcotics to treat pain in the newborn has
potentially dangerous side effects, such as
respiratory depression and hypotension.

Pain :

an unpleasant sensory and

emotional experience
associated with actual or
potential tissue damage

Objective
Identify common sources of pain in healthy
and sick neonates.
Physiologic of neonatal pain
Developmental consequences of untreated
pain.
Pain assessment tools
Pharmacologic and non-pharmacologic
pain management strategies
Prevention of neonatal pain

PHYSIOLOGY
NOCICEPTOR
(nociceptor)
(nos[ibreve]-sep
t[schwa]r) [noci- +
-ceptor]
a receptor for pain
caused
by injury
to
Dorland
Medical Dictionary:
www.mercksource.com
body tissues

Nerve fibers
Fiber
type

Function

Diamet
er (mu)

CV
(m/s)

A Proprioception,
12-20 100
somatomotor
Touch, pressure
5-12 30-70
Motor to muscle spindle
3-6 15-30
Pain: cold, touch
2-5 12-30
B
Preganglionic autonomic < 3
3-15
C
Thermal pain,
0.4- 0.5-2
mechanoreceptor
1.2
Wright GH. www.medscape.com.
Postganglionic
0.30.7-200

 7wk-sensory:perioral
11wk 12wk-Central ~
sensory:face,palm,sole
15wkperipheral

Timeline for
nociception

20wk-sensory:mucous
24wk-thalamic track
membrane
30-37wkcomplete

Peripheral Nociceptors:
A. Substance PPain:
1. A nerve fibers
2. C fibers
B. Glutamatetouch:
1. A fibers
A pain in the foot sends
messages to the spinal cord
which are relayed to stimulate
the flexor muscles
which pull the limb toward the
body and to inhibit the
extensor muscles which take
the limb away. Result: a reflex
action to pull away from the
cause of pain.
The reflex message is
projected to the brain where it
can be measured to indicate

Surface
nerve
birth can=
Tissue
damage
damage
dendriticat
sprouting
kill spinal nerve
cells.
hyperinnervation
that
lastNearby
to adulthood
surviving
nerve may
cells lead
then to
sprout
to
Repeated
heel sticks
an abnormal
gait in
make new connections which can
childhood
make the child hypersensitive to

dynia : pain caused by stimulus not normally associated with

Pain carrying A, C fibers

Touch carrying A fibers

Sources of neonatal pain

Birth event
scalp lacerations, severe head
molding, and clavicular fractures

Sources of neonatal pain

Invasive Procedures in NICU
Heel sticks, venipuncture, endotracheal
tube suctioning, peripheral arterial line
placement or chest tube placement.

Major Surgery
cardiac or bowel surgery, that are
accompanied by intense pain.

The Effects of Pain

Short term
(acute pain)
Long term
(chronic
pain)

Acute Pain Effect

Acute pain causes changes in physiologic
parameters:
1. stress hormone level ( cortisol,
catecholamine, growth hormone and
glucagon)
2.Changes of behavioral state
3.Crying, facial expression
4.Changes in sleep state
5.Changes in responses to
developmentally supportive care
6.Causes autonomic responses: BP,

Neonatal factors leading to shortterm adverse neurologic sequelae

Acute
painf
ul
stimu
li

Crying

excitability
Diaphragm
Handlin in the SC
atic
g,
splinting
nursing
HR,BP,
procedu
Stimulat
vagal
HR,
re
e HP
tone
BP

Chronic
axis
Cerebral
Cerebral
pain&stre
blood
blood O2, CO2,
ss
Early
IVH
flow
volume pneumothor
Hyperglycemia,
ax
lactic acidosis,
Late IVH
White matter
catabolism,
damage, reperfusion
PVL
apoptosis
injury

Neonatal factors leading to long-term

adverse neurologic sequelae

Repetitive
Normal Neonate
/ chronic
Maternal Infant
pain
Interaction
pain sensitivity
Plasticity in the neonatal
Afferent input
brain
Lack of NMDA activity
Hyperexcitability
Developmental
Apoptosis
Windup
apoptosis, pruning,
phenomenon
differentiation
Behavioral development
NMDA
Cognitive abilities
activation
Suicides / violence
Excitotoxic
Anxiety
pain sensitivity
damage
HyperCognitive impairment
exploration
responsive HP
Behavioral problems
ADHD
pain
Poor socialization skills
Maternal
separati
on

Biochemical responses to
pain
Increased :
Cortisol
Epinephrine
Norepinephrine
Growth hormone

Decrease:
Prolactin
Insulin
Metabolic
response:
Protein
catabolism
Fat utilization
Hyperglycemia

Measurement of Pain
Behavioral
Physiologic/autonom
ic
Neuroendocrine

Behavioral response to
pain

Facial expression
Cry
Body movements
Fussiness/sleeples
sness
Sudden state
changes

Facial expression of pain

Eyes:
squeeze
d shut

Forehead
:
Brow
bulge

Cheeks:
raised

Brows:
low,
drawn
together

Mouth:
open,
squarish

Nose:
broaden,
bulging

Facial
expressio
n

Physiologic
manifestation

Increased heart rate

Increased blood pressure
Increased respiratory rate
Shallow respirations
Pallor/flushing
Diaphoresis
Palmar sweating
Decreased Oxygen
saturation

Measurement of Pain
Neonatal Infant Pain Scale (Lawrence
et al 1993)
CRIES (Krechel & Bilner 1995)
Premature Infant Pain Profile
(Stevens et al 1996)
COMFORT scale (Ambuel et al 1992)
Modified Infant Pain Scale (Buchholz
et al 1998)

N-PASS
Neonatal Pain, Agitation & Sedation Scale
Assessment
Criteria

Sedation
-2

Normal
-1

Pain/ Agitation
1

Crying
Irritability

No cry with Moans or

painful
cries briefly
stimuli

Not irritable

Crying at Inconsolable
interval
Consolable

Behavior
State

No
Little
spontaneou spontaneou
s movement s movement

Appropriate
for
gestational
age

Awakens
frequently

Constantly
awake

Facial
expression

No
expression

Minimal

Relaxed

Intermitten
t

continuous

Extremities
Tone

Flaccid

tone

Relaxed

Intermitten
t tense

Continuous
body tense

HR, RR,
BP, SaO2

No
variation

10%
variability

Normal for
age

10-20%
SaO2 7685%

>20%
baseline

Neonatal Infant Pain

Scale(NIPS)

Swaddling
Nesting

Prevention of pain
(Environmental & Behavioral)

Environmental modification :
1. lighting
2. noise from equipment & personnels
3. handling
4. Limit or group procedures
Behavioral strategies:
1. Positioning : nesting, swaddling,
boundaries
2. Non-painful sensory stimulation:
massage, stroking, music/ talking
3. Non nutritive sucking
4. sucrose

Management
Non Pharmacological
- Oral sucrose
- Breastfeeding
- Non-nutritive sucking
- Facilitated tucking(FT)
- Kangaroo Care
- Swaddling

 Non-Nutritive sucking

 Kangaroo Care

 Facilitated Tucking
FT is described as holding the
infant by placing a hand on his
or her
hands
and
feet
and
by
positioning the
infant in a flexed midline
position while
in either a side-lying, supine, or
prone
position

 Swaddling

Pharmacologic
management of neonatal
pain
Continous opioid infusion
(morphine/fentanyl)
May use combination of sedation
(midazolam, benzodiazepine:
Lorazepam (shorter half life ~ 40
hours than diazepam), Diazepam
(Valium)

Recommended analgesic for

neonates
Agent
Dose
Opioid analgesic
Morphine sulfate
Fentanyl citrate

0.05 - 0.1 mg/kg IV or 0.01 - 0.03 mg/kg/hr

0.5 - 3 mcg/kg IV or 0.5 - 2 mcg/kg/hr

Sedative
Midazolam
Chloral hydrate

0.05 0.15 mg/kg IV 0.01 0.06 mg/kg/hr

25-75 mg/kg/dose PO/PR

Anesthetic
Lidocaine
EMLA
Ketamine
Thiopental sodium

2 5 mg/kg SQ 0.5 1 mg/kg ET

0.5 2 g 1 hr before procedure
0.5 2 mg/kg IV 0.5 to 1 mg/kg/hr
2 5 mg/kg IV

Nonopioid analgesic
Acetaminophen
10-15 mg/kg PO 20-30 mg/kg PR

Recommended approach
Sucrose (pacifier) swaddling, EMLA
(Eutetic Mixture of Local
Anesthetics )cream (when not
urgent), Lidocaine SQ (when
appropriate) for heel lance,
venipuncture, arterial puncture, LP,
NG insertion
Above + opioid analgesic for central
line, ET suction, circumcision
Above + sedative for: intubation,

Summary
Neonates fell pain and in preterm
infants the pain is amplified
Acute and chronic sequelae of pain in
neonates increase the short and long
term morbidity and mortality
especially among the perterm infants
Tools to assess pain in neonates are
numerous
Pharmacologic and nonpharmacologic approaches are

References

Prevention and management of pain and stress in the neonate.

American Academy of Pediatrics. Committee on Fetus and
Newborn. Committee on Drugs. Section on Anesthesiology. Section
on Surgery. Canadian Paediatric Society. Fetus and Newborn
Committee. 2000 Pediatrics 105(2):454
Puchalski and Hummel. The reality of neonatal pain. Advances in
Neonatal Care. 2002. 2(5):233-247
Hall RW and Anand KJS. Physiology of Pain and Stress in the
Newborn. Neoreviews. 2005. 8(2) : c61
Hall RW and Anand KJS. Short and long term impact of neonatal
pain and stress. Neoreviews. 2005. 8(2) : c69
Khurana S, Hall RW and Anand KJS. Treatment of pain and stress in
the neonate:When and How. Neoreviews. 2005. 8 : c76
Whitfield MF and Grunau RE. Outcome of VLBW infant: behavior,
pain perception and the ELBW survivor. Clinics in Perinatology.
2000. 27(2): 363-379

Thank You