Procedural Pain in the Newborn

1. Summary
2. Background
3. Non-Pharmacological Measures
   3.1 Prevention
   3.2 Breastfeeding
   3.3 Skin to skin/kangaroo care
   3.4 Swaddling/containment holding
   3.5 Non-Nutritive Sucking (NNS)
   3.6 Sucrose
   3.7 Environment
   3.8 Topical anaesthesia
4. Procedures
5. Assessment

1.0 Summary

Newborn infants on the neonatal unit (NNU) or postnatal wards experience many painful procedures throughout their stay. Neonates cannot verbalise their pain so it is the responsibility of the healthcare professional to recognise, assess and manage it. There is high level evidence that prolonged, repeated painful conditions may cause short and long term adverse effects¹
Every child has the right to be kept from harm and it is our responsibility to ensure every step is taken to prevent unnecessary pain²

Back to top

2.0 Background

Within the Leeds Teaching Hospitals there are approximately 1700 admissions to the neonatal unit in 2017³. These infants can have up to 10-20 procedures done per day⁵. These can range from basic cares, such as nappy cares and physical examinations, up to more invasive procedures such as cannulation, chest drains and ventilation. Pain negatively affects the neonate in a variety of ways. It raises cortisol levels, impacts the creation of neural connections, impairs growth and can lead to poorer cognitive and motor scores¹² The effects of multiple painful procedures can result in adverse psychological outcomes not just for the infant but for the families including development of conditioned anxiety responses¹³. Managing procedural pain is best done with a multidimensional approach combining pharmacological and non-pharmacological measures.

Benefits of using pain relief

• Improved short term growth and feeding outcomes
• Have a decreased requirement for respiratory support
• A decreased stay in hospital
• Have improved neurodevelopment outcomes

Term infants undergoing painful procedures have shorter cry times and lower pain scores when measures are taken to reduce pain and stress.

Treatment / Management

Back to top

3.0 Non-pharmacological measures

Simple interventions have the potential to reduce measured responses to pain. Evidence supports their use when appropriate and should be used first and should be used alongside pharmacological measures. These are all measures that can involve parents empowering them by involving them in their babies care and comfort⁶

Before a procedure consider whether it really needs doing at that time or if another time would be more appropriate.

Measures include:

• Prevention
• Breastfeeding
• Skin - to - skin/kangaroo care
• Swaddling/Containment Holding
• Sucrose
• Non-Nutritive Sucking

Back to top

3.1 Prevention

One way of preventing pain in the neonate is to prevent the procedure from happening if you can. We don’t advocate clustering of cares as such - FINE⁸ would advocate not commencing or continuing any (delayable) procedures if a baby is demonstrating disengagement cues/autonomic instability. Interventions should be pursued on an individualised basis.

Back to top

3.2 Breastfeeding

Breastfeeding during heel pricks was found to be the most effective form of pain relief compared to other measures such as sucrose and NNS, containment, bottle feeding and the ones who had no pain relief⁹. Breast milk is sweet providing analgesic effects and has been found to be more effective than sucrose (although if no EBM available then Sucrose is preferred over no pain relief) however breast milk given via syringe doesn’t have the same effect as breastfeeding¹⁰. The effects of the sugar, fats and nutrients combined with NNS reduces the pain and combines skin to skin and self soothing effects of suckling taking attention away from the painful stimulus1 Also the smell of breastmilk (as well as lavender) helped prevent heart rates from rising and saturations from falling¹¹. It also reduced Neonatal Infant Pain Scores (NIPS) during the invasive procedure.

Back to top

3.3 Skin to Skin/Kangaroo Care

Skin to skin is beneficial to babies in reducing pain scores as it releases endorphins and increases oxytocin levels¹ During skin to skin the baby is comforted by familiar smells, sounds, touch and motion when nestled with the mother or father. Some procedures such as heel pricks can be done during skin to skin as well as during breastfeeding. Given that parents report finding their loss of role and their baby experiencing pain  the most stressful aspects of NICU; providing skin to skin for their baby during minor painful procedures can be positive for parents

Back to top

3.4 Swaddling/Containment Holding

Swaddling or containment holding have been proven to provide comfort for preterm and low-birthweight infants during minor painful procedures. They show a significantly faster return to baseline heart rate after heel pricks than those within control groups. This practise works well when used alongside other forms of pain relief. 

Back to top

3.5 Non-Nutritive Sucking

• Helps to keep baby calm, promoting rest
• A calmer baby is more medically stable eg. Heart Rate, Blood Pressure
• Reduces pain scores during painful procedures or drug withdrawal

The use of a dummy during painful procedures provides the baby with the ability to self soothe and has been demonstrated to be effective in reducing pain responses.

Back to top

3.6 Sucrose

Sucrose has been extensively evaluated for its effectiveness in the relief of procedural pain, particularly in the context of routine neonatal intensive care unit procedures. Both animal and human studies support  a mechanism of action where sucrose mediates release of endogenous opioids ^17,18, although this has been challenged ¹⁹ Literature suggests that oral sucrose reduces pain responses in the newborn, and is ‘safe and effective for reducing procedural pain from single painful events’ ⁴ .

The most recent Cochrane review in 2016 [29] provides a comprehensive review of the literature on this subject. Whilst most studies are in well babies >28 weeks CGA, there is evidence using sucrose as low as 24 weeks CGA [26].  Effects are of most value when combined with non pharmacological nursing measures. e.g during breastfeeding²⁰ , whilst skin to skin ²⁰, using a pacifier^4,16,21, with containment or swaddling^14,15.

Practitioners should not be led to consider that sucrose replaces other non-pharmacological measures in providing pain relief for infants, and should be used as an adjunct to them and not necessarily in isolation. Although Liu ¹⁶ supports that sucrose is better than nothing at all, it is important to note that; Both breastfeeding and/or skin to skin are more effective than sucrose alone^9,23  and breastfeeding is as effective as sucrose with pacifier⁷. Syringed breast milk is not as effective as sucrose but has demonstrated analgesic effect ⁹. These factors should be considered, especially in the infant who is seeking to establish breastfeeding.

A concentration of 12-24% sucrose has been most commonly used in trials that show the greatest benefit. There is no good evidence for the maximum number of doses to be given, however repeated small dose is thought to be as effective as large single dosing [30].

The adverse effects of sucrose are limited to hyperglycaemia when used in the appropriate group of infants. Sucrose should not be given to infants with necrotising enterocolitis, gastro-intestinal surgery within the last seven days or infants with an impaired suck/swallow reflex (e.g. sedated babies or those with neurological concerns). There is however, no evidence to link sucrose with an increased rate of necrotising enterocolitis.

Sucrose key points

Dose

Sucrose can either be given via drops directly into the side of the mouth, or by using a pacifier either dipped in sucrose or sucrose dropped onto the teat (this prevents any risk of aspiration).

One dip of a pacifier is equivalent to 5 drops, which is the same as 0.1mL.

“Practitioners should not be led to consider that sucrose replaces other non-pharmacological measures in providing pain relief for infants, and should be used as an adjunct to them and not in isolation. Although Liu ¹⁶ supports that sucrose is better than nothing at all, it is important to note that; Both breastfeeding and/or skin to skin are more effective than sucrose alone^9,23  and breastfeeding is as effective as sucrose with pacifier⁷

Back to top

3.7 Environment

These following environmental measures can also be used in combination to help reduce pain in the newborn

• Avoid bright light, loud noise
• Limit the number of painful procedures and handling
• Distraction measures such as talking, music etc

Do not perform investigation for a routine. Consider utility of an investigation before you do it. If it is unlikely to change your management, it is unnecessary and potentially harmful by causing pain and increasing the infection risk. (Guideline for Supporting Optimal Developmental Care for Babies on the Neonatal Unit and Transitional Care)

Back to top

3.8 Topical Anaesthesia

Ametop has been shown to be effective for use on neonates during more invasive procedures such as lumbar punctures, immunisations and cannulation when used alongside other non-pharmacological techniques³¹. It works by blocking nerve conduction and acts upon specific receptors that prevents pain sensation from travelling to the central nervous system³²

Topical anaesthetics are unlikely to cause systemic side effects due to minimal absorption and have shown only few side effects when used on preterm infants <34 weeks³³ Ametop is a vasodilator so can cause erythema.

Gestation

Application

• Apply contents of the tube to the site of puncture - 1 tube covers 30sq.cm (6x5cm) apply appropriate amount for gestation
• Cover with occlusive dressing. Do not rub gel into skin.
• Remove dressing and gel after 30 minutes.
• Effects last 4-6 hours
• Reapplication minimum of 5 hours after last dose

Only 2 applications within 24 hours³⁴

When to use

• Lumbar punctures
• Cannulation
• Immunisations

Studies show side effects of tertracaine seem to be limited to erythema of the skin at the site. Do not apply to broken skin, ears, nose and lips³⁴. There is the potential in very rare cases for cardiac arrhythmias in extremely preterm infants³⁵ so its use should be discussed with the consultant.

Ametop is not recommended to be used for heel pricks as it has been shown in numerous studies to be ineffective³⁶ so for these procedures the use of non-pharmacological and sucrose is recommended.

Back to top

4.0 Procedures

Procedures which are known to cause pain and distress include

• Nasogastric tube insertion (NGT)
• Nappy cares/head turns
• Eye examinations
• Nasal/Oral/ET suctioning
• Dressing changes
• Heel Pricks
• Cannulations
• Line insertion
• Lumbar Puncture
• IM injections
• Treatment of Extravasation injury
• Tracheostomy Care
• Rectal Washout

Back to top

5.0 Frequency of assessment

Score all babies within an hour of admission and at the start of the shift

• ICU - Hourly with observations
• HDU - 6-8 hourly prior to cares or if signs of pain and discomfort
• Special care - If the baby shows signs of distress/discomfort not associated with routine cares

Repeat the score 30 minutes after intervention or action taken