Neonatal Pain Relief Protocols
in Their Infancy
Philosophies are changing about how — and whether — to treat neonates experiencing pain. New clinical practice guidelines are on the horizon.
By Diane Saniski, RNC
February 14, 2005
Shortly after John* was born in 1995, the nurses prepped him for circumcision. He was restrained for the procedure, which was done quickly and efficiently — but without pain relief measures. His newborn brother, Nicholas,* will have a much different experience when he undergoes circumcision next week. Before the procedure, nurses will swaddle his upper body and administer acetaminophen and sucrose. One staff member will be ready to offer the baby a pacifier and additional sucrose during the procedure if necessary. Nicholas will be restrained, and then the physician will administer a dorsal penile block using buffered lidocaine. Afterward, acetaminophen will be continued around the clock for 24 hours, and Nicholas might be given additional sucrose doses.
A progressive change in the culture of pain management in newborns is taking place. Research has proved incorrect the idea that neonates have a decreased sensitivity to painful stimuli and quickly forget any pain they do experience.1,2 Today, pain is considered “the fifth vital sign” in routine nursing assessments. As a result, many professional organizations — including the American Academy of Pediatrics, the Joint Commission on Accreditation of Healthcare Organ izations, and the National Association of Neonatal Nurses — have mandated pain treatment for newborns.2,3,4
Many nurses get involved with creating clinical practice guidelines to meet compliance recommendations. The process might take several months of planning and research by a multidisciplinary team of physicians, nurses, and pharmacists. The creation of these guidelines often begins with a change in philosophy about how the neonate perceives pain and how to treat newborns who experience it.
Dispelling misconceptions
Scientific studies have corrected several misconceptions, including the idea that newborns are incapable of feeling or expressing pain and the notion that they are less sensitive to pain than older children and adults. Research has found that a 20- to 22-week-old fetus has complete pain pathways and the ability to experience pain.1 In fact, pain might actually be exaggerated due to the unmyelinated fibers and immature modulating capabilities of
developing babies’ nervous systems.
Pain scoring tools developed by health care professionals show that the expression of pain is present and reliably observable. Although unable to verbally express pain, newborns respond with behavioral cues — such asfacial expressions, body movements, and crying — plus physiological indicators like increased blood pressure and heart rate and oxygen desaturation. Neonates also remember pain, which is apparent by observing their reaction to subsequent pain experience, such as immunizations.1,5
But even when nurses acknowledge the reality of neonatal pain, they are concerned about the adverse effects associated with analgesics and anesthetics, such as hypotension and depressed respiration. Yet, both analgesics and anesthetics can be safe when the health care team is properly trained in their use and supportive measures are available. To ensure that neonates are receiving adequate pain control, a cultural shift or change in practice from a reactive to a proactive approach must occur. This shift focuses on a preventive model instead of a
“rescue PRN” approach.
Selecting a pain assessment tool
A facility’s clinical practice guidelines should designate a specific pain assessment tool so that care is consistent. Several factors must be considered when selecting a tool, including assessment cues, validity, age range, ease of use, and copyright issues. Some pain assessment tools, for example, use behavioral cues only, while others include physiological cues.
Any assessment tool selected should have been validated by research and clinical trials and usable for a gestational age range that matches the unit’s population. No matter which staff member uses the tool, it should produce consistent and reliable scores. Some assessment tools may be reproduced for clinical use without incurring a fee for the facility, while others require written permission and royalty charges.
Three widely used scoring tools are the Premature Infant Pair Profile, Neonatal Postoperative Pain Measurement Score, and Face, Legs, Activity, Cry, and Consolability. PIPP and CRIES are multidimensional, whereas FLACC evaluates behavioral cues only. The PIPP scoring system assesses pain using gestational age, behavioral state, heart rate, oxygen saturation, and facial expression. CRIES gets its name from the five factors nurses document: crying, requires oxygen, increased vital signs, expressions, and sleeplessness.5
It is not always correct to assume that a quiet newborn is pain free. Many ill or very low-birth-weight infants are unable to mount or sustain an appreciable response to pain. This is known as “shut-down.” With these infants, heart rate, desaturation, and eye signs are the best indicators of pain1,3,6 (see illustration, “Eye Signs,” above).
Outlining guidelines
Once a pain assessment tool has been selected, the next step is to outline how members of the health care team may use it. Clinical practice guidelines are an effective means to improve the quality of care and provide consistency in neonatal pain management. They are official documents, created by a multidisciplinary team and based on scientific evidence and expert opinion. Each section of the clinical practice guidelines outlines a standard of care applicableto all members of the neonatal team.
Neonatal pain management guidelines should include, at a minimum, the following sections: definition and assessment of pain, pharmacological and nonpharmacological measures, family role, and education. Many of these sections contain subsections that outline specific procedures and philosophies of care.
Definition and assessment of pain
Pain in the neonate may be defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or it might be described in terms of such damage.5 The inability to communicate the feeling of pain in no way negates the possibility that an individual is experiencing it.
Linda Franck, RN, PhD, RGN, RSCN, professor and chair of Children’s Nursing Research at Great Ormond Street Hospital for Children in London, is an expert on infant pain. She narrows the focus to the infant population with her Golden Rule of Pain: “What is painful to an adult is painful to an infant, unless proven otherwise.”
This section includes the facility’s preferred pain assessment tool. There also needs to be a process in place to evaluate pain vs. stress and agitation. Agitation vs. pain decision trees are available for use in clinical practice. For proper management, pain behaviors must be distinguished from those caused by irritability and agitation, and pain must always be addressed first.5
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.
On the Web
For more information , visit these professional websites —
- American Academy of Pediatrics
www.aap.org - Joint Commission on Accreditation of Healthcare Organizations
www.jcaho.org - National Association of Neonatal Nurses
www.nann.org
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
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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.
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11. Grazel A. Neonatal pain management with sucrose. Online J Knowl Synth Nurs. 2002;9(6C).
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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
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