The American Academy of Pediatrics (AAP) has released a statement pertaining to the prevention and management of procedural pain in babies. Pain that newborns experience from routine medical procedures can be significant, especially in premature infants with more intensive health needs. Research suggests that repeated exposure to pain early in life can create changes in brain development and the stress response systems that can last into childhood. Premature infants are especially at risk. The AAP policy statement recommends that every health facility caring for newborns use strategies to minimize the number of painful procedures performed, and routinely monitor and treat pain with greater emphasis on proven non-drug interventions. The policy statement, “Prevention and Management of Procedural Pain in the Neonate: An Update,” appeared in the February 2016 issue of Pediatrics (published online Jan. 25).
As noted in the AAP statement, pain pathways are “active and functional as early as 25 weeks’ gestation” and premature newborns thus may have a generalized or even an exaggerated response to pain. The repetition of sensory stimuli can be physiologically stressful, particularly in these sensitive preterm infants. Investigators demonstrated that even simple procedures, such as routine heel puncture for blood draw or tape removal from the skin, can adversely affect future pain perception. The cortical pain processing that occurs in preterm and term infants is affected by multiple factors involving excitatory and inhibitory feedback mechanisms.
The AAP strongly recommends using the neonatal pain assessment tools, which have been proven to be reliable and reproducible. A number of rating scales factor prematurity into the pain rating system. In addition to these observation assessments, new technologies to measure neonatal pain are being investigated, including near-infrared spectroscopy, amplitude-integrated electroencephalography, functional MRI, and heart rate variability assessments. Most of the tools used to measure acute pain in neonates use a combination of physiologic and behavioral signs to gauge pain levels. Published studies using current rating scales included infants from 23 weeks prematurity through 2 months of age. These studies support the existence of pain in infants midway through gestation and beyond.
The AAP recommends routine pain management during procedures such as circumcision, chest drain insertion and removal, and nonemergency intubations. More studies of the dosing and long-term effects of analgesics in the newborn period are needed. As the AAP states, there is a critical need to achieve adequate pain control in newborns, “both as an ethical duty and because painful experiences in the NICU can have long-term adverse effects.” Preventing or minimizing pain in neonates should be the goal of pediatricians and other health care professionals who care for babies.
Colleen Malloy, M.D. is Associate Professor in Clinical Pediatrics/Neonatology, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine.