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This section of the clinical practice guidelines also should include how often pain scores must be recorded. At a minimum, a pain score should be documented every shift, before and after procedures, within an hour of administering medication, and anytime changes in condition are observed.⁷

Pharmacological and nonpharmacological measures

Anticipation and prevention of pain in the neonate are superior to later attempts to relieve pain. Before undergoing a painful procedure like circumcision, newborns should receive preemptive medication to prevent the adverse effects and suffering that result from uncontrolled, prolonged pain. Commonly prescribed pain relievers include sucrose, acetaminophen, fentanyl, and morphine.

Orders for pain medication should be written before a procedure occurs so the drug is on hand if needed. Clinical practice guidelines also should include a list of common procedures — such as heel lance, peripheral IV catheter insertion, lumbar puncture, intubation, and circumcision — plus recommendations for pain management. For each procedure, medication, dosage, and intervals of administration are under the direction of a physician or nurse practitioner.³

Nonpharmacological pain relief techniques include environmental measures, such as lowering the lighting and noise levels, playing soft music, and following minimal handling protocol. Comfort measures include nesting, swaddling, offering a pacifier, positioning strategies, and promoting rest.^1,5,8 For critically ill newborns, clustering care is recommended. This involves performing several procedures sequentially followed by extended periods of rest.⁹

Substantial research supports the use of sucrose for pain control in neonates who are at least 32 weeks of gestational age.^10,11 Sucrose has a two-stage effect, initially calming the infant and reducing crying time, then later producing an endogenous opioid effect. Only newborns stable enough to suck adequately on a pacifier and are not intubated or have no other contraindicated conditions will be offered sucrose.¹¹ The percentage of sucrose can range from a 12% to 24% solution, depending on weight. The standard dose is 1 mL to 2 mL dropped on the anterior part of the tongue two to five minutes before a painful procedure. Alternating sucrose with a pacifier can increase the effect.^6,12,13

Clinical practice guidelines may include recommendations for weaning neonates off narcotics. Tolerance and dependence must be anticipated with any prolonged use (three to five days).^14,15 Guidelines direct clinicians not to stop narcotics abruptly but instead use alternating combinations of reduction in dose and prolongation of dose intervals.^14,15 The nurse also monitors the infant for withdrawal signs, such as diarrhea, severe diaper rash, nasal congestion/sneezing, increased muscle tone, restlessness/inconsolability, and tremors. Finne­ gan’s tool is widely used for monitoring drug withdrawal.^2,16

Family role

Clinical practice guidelines can also include ways toinvolve the family in
caring for the newborn. Nurses can help families understand the need for pain assessment and treatment measures. They can teach several care concepts, such as minimal handling, nesting, and steady touch so parents can continue and complement the care given by the hospital staff.²

Likewise, nurses can reassure parents that babies recover faster with adequate pain management and can be safely tapered off medications as they stabilize and that newborns are not psychologically capable of narcotic addiction.

Education

The clinical practice guidelines also contain a section that details how hospital staff will be trained in the protocols outlined in the document. Inservice sessions and a self-learning packet should be created before the guidelines can be implemented. The staff will need to go through the same learning process that the multidisciplinary team experienced in developing the guidelines.

Nurses will probably encounter resistance to treating neonatal pain due to fear of narcotic side effects and misconceptions about pain in this patient population. But with persistence and education, fears and uncertainties can be allayed.

*Hypothetical patient.

Diane Saniski, RNC, is a staff nurse at Lehigh Valley Hospital, Allentown, Pa. She would like to thank her colleagues with whom she spent long hours revamping Lehigh Valley’s clinical practice guidelines for pain management in neonates: Jenny Boucher, PharmD; Andrea Keener, RN; Cherie Raub, CCRN, MSN; and Lynda Thom-Weis, RNC. Special thanks go to NICU Staff for their patience and support, particularly Medical Director Christopher Morabito and Nursing Director Cynthia Max, RN.

References

1. Jorgensen K, Hon D. Pain assessment and management in the newborn infant. J PeriAnesth Nurs. 1999;14(6):
349-356.

2.Academy of Pediatrics. Prevention and management of pain and stress in the neonate. Pediatr. 2000;105(2):454-461.

3. Anand K. The international evidence-based group for neonatal pain consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155(2):173-180.

4. National Association of Neonatal Nurses. Position statement #3019: Pain management in infants. April 1999. Available at: :www.nann.org/i4a/pages/ index.cfm?pageid=790. Accessed January 27, 2005.

5. McCaffery M, Pasero C. Pain in Infants. In:Pain: Clinical Manual. 2nd ed. St. Louis, MO: Mosby Year Book; 1999:627-673.

6. Gibbons S, Stevens B, Hodnett E, Pinelli J, Ohlsson A, Darlington G. Efficacy and safety of sucrose for procedural pain relief in preterm and term neonates. Nurs Res. 2002;51(6):375-82.

7. Acello B. Meeting JCAHO standards for pain control. Nurs. 2000;30(3).

8. Gibbons S, Stevens B, Asztalos E. Assessment and management of acute pain in high-risk neonates. [Expert opinion]. Pharmacother. 2003;4(4):475-483.

9. Simons S, van Djik M, Anand K, Roofthooft D, van Lingen R, Tibboel D. Do we still hurt newborn babies? a prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003;157:1058-1064.

10. Johnston C, Filion F, Snider L, et al. Routine sucrose analgesia during the first week of life in neonates younger than 31 weeks postconceptional age. Pediatr. 2002;110:523-528.

11. Grazel A. Neonatal pain management with sucrose. Online J Knowl Synth Nurs. 2002;9(6C).

12. Mitchell A, Waltman P. Oral sucrose and pain relief for preterm infants. Pain Manage Nurs. 2003;4(2):62-69.

13. Benis M. Efficacy of sucrose as analgesia for procedural pain in neonates. Adv Neonatal Care. 2002;2(2):93-100.

14. Suresh S, Anand K. Opioid tolerance in neonates:
mechanisms, diagnosis, assessment and management. Semin Perinatol. 1998;22(5):425-433.

15. Walden M. Pain Assessment and Management: Guideline for practice. Glenview, IL: National Association of Neonatal Nurses. 2001.

16. Finnegan L. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Rubaitoli FF, Granti B, eds. Neonatal Therapy: An Update. Amsterdam, Netherlands: Elsevier Science Publishers; 1986:122-146.

Bibliography

Merkel S, Voepel-Lewis T, Shayevitz J, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3).

Noerr B. Sucrose for neonatal procedural pain. Neonatal Network. 2001;20(7):63-7.