Neonatal Pain

Summary by Sharon Tran DO, 03.15.22

The first was a landmark paper (1987) that changed the practice of acknowledging and treating neonatal pain

Pain and its Effects in the Human Neonate and Fetus - https://pubmed.ncbi.nlm.nih.gov/3317037/
Take Home Point:

  • There was a historical belief that fetuses and neonates could not perceive pain. Prior to the 1980s, it was common practice to perform procedures with minimal to no analgesic/anesthetic agents, especially in premature infants

  • This paper summarized that pain pathways in the peripheral and central nervous systems were well-developed by late gestation.

  • Neurochemical systems for pain transmission and modulation were also fully functional.

  • Neonates demonstrate hormonal, metabolic, physiologic changes in response to painful stimuli. These effects were potent enough to persist in their memory and alter subsequent behavior

  • The paper recommended evaluating the risks and benefits of analgesic/anesthetic technique in order to treat pain in neonates as aggressively as in children/adults.

Since then, there's been agreement in treating pain in neonates. However, objectively evaluating pain in neonates proves challenging. There's also limited data in neonatal safety/efficacy of analgesic strategies commonly used in adults. nother review (2014) that primarily focuses on pain in the NICU setting:

Pain Management in Newborns - https://pubmed.ncbi.nlm.nih.gov/25459780/

Take Home Point:

  • Failure to treat pain leads to long-term consequences including altered pain processing, behavioral problems, delayed development.

  • Methods for assessing persistent or prolonged pain have not been developed or validated. Challenges for developing a systematic way to evaluate pain in newborns include: subjective variability among evaluators, variations in behavioral responses to pain among neurologically impaired or paralyzed neonates

  • Non-pharmacologic strategies for treating pain include minimizing invasive procedures, non-nutritive sucking w/wo sucrose, skin-skin contact, massage therapy

  • Opioids form the mainstay for treatment of severe pain; morphine and fentanyl are the most commonly used drugs. Limited data exists for pharmacologic analgesics and their adjuncts for neonates including local anesthetics, benzodiazepines, phenobarbital, propofol, ketamine, dexmedetomidine, acetaminophen, and NSAIDs. As a result, providers may be under-treating pain with concern for pharmacologic adverse effects.