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MANAGEMENT OF PAIN

Mohamed Khashaba,MD
Professor of
Pediatrics/Neonatology
Head NICU
Objectives

• to provide the knowledge necessary
to effectively assess and manage
postoperative, procedural, and
disease-related pain in hospitalized
Neonate.
Why to relieve Pain ?
• Humanitarian considerations.
• Scientific principles.
• Definition and sources of pain

• Effects of pain on the neonate

• Neonatal pain assessment

• Management of neonatal pain
• Non pharmacological and
• Pharmacologic pain relief
• Definition and sources of pain

• Effects of pain on the neonate

• Neonatal pain assessment

• Management of neonatal pain
• Non pharmacological and
• Pharmacologic pain relief
Definition of Pain
• “an unpleasant sensory and
emotional
• experience associated with actual or
potential
• tissue damage, or described in terms
of such damage.”

• The International Association for the Study of Pain
(2004)
sources of pain
• Three main categories:
• 1.nociceptor
• 2.non nociceptor
• 3.psychogenic pain.
•  
Nociceptor pain
• tissue damage produces a stimulus that
sends an electrical impulse across a
pain receptor (nociceptor) by way of a
nerve fiber to CNS.
• Nociceptor pain
• 1.Visceral pain from the stimulation of
nociceptorsin abdominal cavity and
thorax,
• 2. Somatic pain which is divided into
deep somatic and cutaneous pain.
• Some tissues such as the lungs and the
brain have no nociceptors and some
Non nociceptor (neuropathic)
Pain
Caused by direct injury to the
structures of the nervous system.

Psychogenic pain
There is no or little physical evidence
of organic disease.
Modulation of pain

• Once the brain perceives the pain,
the body releases neuromodulators,
such as endogenous opioids
(endorphins and enkephalins),
serotonin, norepinephrine, and GABA.
• They hinder the transmission of pain
and produce an analgesic effect
(modulation).
Hormonal responses
• Preterm neonates have hormonal
stress responses such as
noradrenaline, cortisol, b-endorphin,
and corticotrophin. following invasive
interventions.
• These hormonal responses can be
prevented by analgesia.
Q of myelination
• Incomplete myelination merely
implies a slower conduction velocity
in the nerves or central nerve tracts
of neonates, which is offset
completely by the shorter
interneuron and neuromuscular
distances travelled by the impulse
Sources of Pain
• Infants born at 25–42 weeks
gestation experience an average of
14 painful procedures per day during
the first 2 weeks of life. (Gibbins et
al., 2006; Stevens et al.,2007).
• The most frequent procedures are
nasal, endotracheal, and
nasopharyngeal suctioning followed
by heelstick, intravenous and
nasogastric tube insertions.
• The inability to communicate
verbally does not negate the
possibility that an individual is
experiencing pain and is in need of
pain-relieving treatment.
• Newborns display physiologic and
behavioral cues to signal tissue
damage.
Failed Attempts
• failure rate for placement of CVC,
peripheral arterial catheters, and IV
cannulaeare 45.6%, 37.5%, and
30.9% (Simons el 2003)
• most of the procedures performed
• in this study were rated by
physicians and nurses to be painful
(>4 on a 10-point scale).
• Definition and sources of pain

• Effects of pain on the neonate

• Neonatal pain assessment

• Management of neonatal pain
• Non pharmacological and
• Pharmacologic pain relief
Effect of Pain
• 1. Effect on neonatal outcome.
• 2. Effect on neurodevelopmental
outcome.
Effect of Pain
• Increased demands on the cardio
respiratory system and metabolism.
• Marked changes in cerebral blood
flow and oxygen delivery and
elevation in intracranial pressure,
theoretically increasing the risk of
IVH.
Adverse neurodevelopmental
outcomes
• Decreased sensitivity to common
childhood pain.
• A higher incidence of somatic
complaints.
Parents’ perceptions of their
infant’s pain
• One of the most stressful
experiences reported by parents of
infants in (NICU) is seeing their infant
experience pain.
• Memories of the infant’s pain and the
mothers’ inability to protect the
infant from pain may continue to be
a source of stress.
• Definition and sources of pain

• Effects of pain on the neonate

• Neonatal pain assessment

• Management of neonatal pain
• Non pharmacological and
• Pharmacologic pain relief
Physiologic Measures of
Pain
• 1. Heart rate : the most reliable .
• 2. Other frequently used measures:
• a.oxygen saturation,
• b.blood pressure,
• c. breathing patterns.
• brief, acute noxious stimuli
• Heart rate and blood pressure generally
increase
Oxygen saturation decreases.
• Respiratory rate typically becomes
more rapid, shallow, or irregular .
Difficulty in Interpretetion
• They may be influenced by non noxious
stimuli, particularly in the ill or preterm
neonate.
• If they are observed simultaneously with other
behavioral and contextual indicators, they may
add significant information
• Physiologic responses are important
in
• pharmacologically paralyzed
• or who are neurologically impaired
• Physiologic measures reflect the
body’s
• nonspecific response to stress.
• should be used along with behavioral
measures.
Behavior response to pain
• Facial activity (i.e., brow bulge, eye
squeeze, nasolabial furrow, and
open mouth) is the most specific
indicator of acute procedural pain.
Cry
• Types of cries differ along a
continuum
• of intensity according to graded
levels of noxious stimuli that
correspond to adults’
• Its absence should not be equated
with absence of pain.
• Healthy, full-term newborns make
swiping motions toward a lanced foot
with the unaffected leg, as if trying to
push away the noxious stimulus.

Franck(1986)
• Preterm infants may uniquely
respond to
• acute pain by increased flexion and
extension
Very premature babies
Inadequate muscle strength,
posture, tone, and movement
compared to term infants
• Physiologic changes and behavior
cues are non reliable indicators.
• Awake or alert infants demonstrate a
more robust reaction to painful
stimuli than sleeping infant.

• Persistence of pain deactivates
sympathetic responses.
Contexual factors altering pain
expression
• Severity of illness,
• Technician expertise,
• Gender,
• Environmental stress,
• Procedural modifiers, and
• Initial threshold and sensitization
after repeated stimulation;
Premature Infant Pain
Profile PIPP
assigning points
• 3 behavioural (facial action: brow
bulge, eye squeeze and nasolabial
furrow),
• 2 physiological (heart rate and
oxygen saturation)
• 2 contextual (gestational age,
behavioural state)
• PIPP scores range from 0 to 21,
with each of the 7 indicators
scoring a possible 0 to 3 points,
depending on the amount of
PIPP Score
• The higher the score is, the more
pain that is experienced by the
neonate.
• scores < 6 represent minimal pain,
• PIPP scores > 12 represent moderate
to severe pain.
Fullterm Babies
• Behaviour pain score Assesses :
• Motor activity
• Cry consolability
• Sleep.
• Definition and sources of pain

• Effects of pain on the neonate

• Neonatal pain assessment

• Management of neonatal pain
• Non pharmacological and
• Pharmacologic pain relief
Pain Producing
interventions
A. Diagnostic

• Arterial puncture
• Bronchoscopy
• Endoscopy
• Heel lancing
• Lumbar puncture
• ROP examination
• Suprapubic bladder tap
• Venipuncture
B. Therapeutic
• Bladder catheterization
• Central line insertion/removal
• Chest tube insertion/removal
• Chest physiotherapy
• Dressing change
• Gavage tube insertion
• Intramuscular injection
• Peripheral venous catheterization
• Mechanical ventilation
• Postural drainage
• Removal of adhesive tape
• Suture removal
• Tracheal intubation/extubation
• Tracheal suctioning
• Ventricular tap
nonpharmacologic
approaches
• Behavioral and Environmental
strategies
• Reduce the number of painful
procedures performed on infants .
• Using noninvasive monitoring
techniques
• Critically evaluating the need for all
practices, such as the number and
grouping diagnostic procedures,
Windup phenomenon
• Painful procedures should not be
performed at the same time as other,
nonemergency routine care .
• Evidence suggests that after exposure
to a painful stimulus, a preterm infant’s
pain sensitivity is accentuated by an
increased excitability of nociceptive
neurons in the dorsal horn of the spinal
cord
• Grunau,Oberlander,&Whitfield, 2005).
• This sensory hypersensitivity, may exist
for prolonged periods after a painful
• Swaddling during and after a
heel stick reduces the
physiological and behavioral pain
indicators in preterm neonates
facilitated tucking
• Hand-swaddling technique
• (i.e., holding the infant’s extremities
flexed and contained close to the
trunk), during a painful procedure
may significantly reduce pain
responses in preterm infants

(Cignacco et al., 2007)
• Excessive and unpredictable sound
levels and
• bright or continuous lighting levels in
the NICU
• have been associated with increased
physiologic and behavioral stress
responses in preterm infants
• (Shiroiwa, Kamiya,&
Uchiboi, 1986).
Nonnutritive sucklig
(NNS)
• most widely studied
nonpharmacological approach to pain
management.
• mechanisms of action
• thought to be related to the activation
of nonopioid pathways as the infant
sucks on the
• pacifier.
• Pain-relieving effects of NNS cease after
• the pacifier is removed from the mouth
Sucrose
Safety and efficacy
• IN preterm and term infants .
• A systematic review of 21
randomized
• controlled trials found that sucrose
decreased
• crying time, heart rate, facial action,
and composite pain scores during
heel lance and venipuncture
• (Stevens, Yamada, &
Dose and method of
sucrose adminstration
• 0.05 - 2 ml of a 24% solution
. Approximately 2 minutes before the
painful stimulus.
• Effect lasting 5-10 minutes

(Stevens et al., 1999).
• optimally administered to the tip of
the tongue where sweet receptors
lie.
Babies less than 27 ws
• There is less evidence for the safety
and
• efficacy of sucrose for infants less
than 27
• weeks gestation.
Breast Milk
• If available, breast feeding or breast
milk should be used to alleviate
procedural pain in neonates
undergoing a single painful
procedure.
• glucose or sucrose had similar
effectiveness
• as breastfeeding for reducing pain.
• The effectiveness of breast milk for
repeated painful procedures is not
Pharmacologic pain
relief
• Pharmacological agents such as non
steroidal anti-inflammatory drugs
(NSAIDs) and paracetamol interfere
with the metabolic pathways
involved in the production of
prostaglandin, ultimately interfering
with the transmission of pain signals
even at this peripheral level.
• Paracetamol is safe and effective if
given in the correct dose, and
frequently enough
Sedatives
• They blunt behavioral responses to
noxious stimuli without providing
pain relief. Therefore, sedatives
should not be used unless pain has
been ruled out.
Take care of the dose
Immaturity of the baby’s nervous
system and metabolic pathways.
Different way in which the drugs are
distributed,
Reduced ability of the baby to excrete
the drug though the kidneys.
A correct dosage by mass for a baby of
6 months old would be quite wrong
for a premature neonate.
Heel stick Pain
• 1. Oral 24% Sucrose 0.5 -1.5 ml.
• 2. Topical lidocaine (0.5-1% ).
• 3. Automated devices.
• squeezing for blood collection is the
most painful part of the procedure.
• acetaminophen, and warming the
heel are ineffective for heel lancing;
Other minor procedures
• Venipuncture.
• Arterial puncture.
• IV placement.
• Immunization.
• Sucrose 24%
Umbilical Catheter
Insertion
 
• Consider the use of a pacifier with
sucrose.
• Use swaddling, containment, or
facilitated tucking.
• Avoid the placement of sutures or
hemostat clamps on the skin around
the umbilicus.
Spinal Tap
• 1. Lidocaine0.1-0.2 ml 1%
subcutaneously (optional).
• 2. Topical lidocaine (ELMA).
• And Morphia or fentanyl ( in
ventilated neonate ) .
EMLA 5% cream
• Eutectic Mixture of Local Analgesic.
• Smaller application dose for preterms
and LBW.
• Needs 40-60 min. for maximum
effect.
• 0.5-1.0 gm for 1-2 hours, then
remove excess.
• Local edema, methemoglobinemia
Lidocaine SQ
• 1ml/kg of 0.5% solution.
• 0.5 ml/kg of 1% solution.
opiates
morphine and fentanyl is most often
used in the hospital setting, while
codeine is effective for use at home
Analgesics (Opiates )

• Morphine
• 0.05-0.15 mg/kg IV or SQ.*
• Fentanyl
• 0.5-2 ug/kg IV**
• Routine continuous infusion is not
recommended.
• * 1/2 this dose in non ventilated.
• ** 1/3 this dose in non ventilated.
Fentanyl
• IV infusion over > 10 minutes.
• Dose repeated every 2-4 hours.
• Maximum conc. Is 10ug/ml.
Morphine
• IV Given over > 5 min.
• Can be given IM or SQ.
• Conc. 0.01-0.02 mg/kg/hr. infusion.
Indications of Opiates
• Elective intubation and ventilation.
• During ventilation.
• Chest tube insertion and removal.
• Umbilical catheterization.
• CVC placement.
• Pre and post operative.
Analgesics
( Acetaminophen)
• 10-15 mg/kg oral/PR /6 Hrs.
• Max. daily dose is 40mg/kg.
Sedatives
• Midazolam*
• Only in full terms.
• 0.05-0.1 mg/kg IV or nasal.
• Chloral Hydrate*
• 20-30 mg/kg PO
• Phenobarbital**
• PO,IV
• * short acting ** Long acting
Summary

• There is good scientific evidence that
babies feel as much pain as adults do
• treating established pain, and
ensuring adequate analgesia before
painful procedures, improves the
outcome of injuries and procedures
• Untreated pain in the newborn may
have harmful effects which last into
childhood and possibly longer.
• Ordinary loving physical care and
comforting has been scientifically
shown to be effective, and remains
the mainstay of managing infants in
pain.
• We should learn to use analgesics
appropriately. Infant should not be
given analgesics without a diagnosis
of their pain