We are privileged this month to reprint the statement on newborn pain management published by the American Academy of Pediatrics (AAP) in November 2006. The National Association of Neonatal Nurses (NANN) participated in writing this document via NANN's representative to the Committee on Fetus and Newborn, Carol Wallman, MS, NNP, RNC. This is a great example of collaboration between NANN and other organizations with which the association has alliances. NANN had input into the statement prior to publication, and it reflects the views of all the participating organizations that have a vested interest in caring for newborns.
The days when we did not believe newborns feel pain and stories of newborns having surgery with paralytic agents only are (it is hoped) behind us. We know that infants do, in fact, feel pain and that chronic, repetitive pain can have lasting neurological effects.1 Neonates who undergo surgical procedures are obvious candidates for pain medication, and they usually receive appropriate pain management. However, I don't think many of us would agree that we are doing everything we can to treat pain in the newborn in all circumstances. Infants undergoing routine, but painful, procedures such as heel sticks and intravenous catheter placement are frequently undertreated. The appropriate treatment of chronic pain and stress in neonates on long-term ventilation is unclear and needs further research.
A prospective study of procedural pain and analgesia in neonates found that on average, neonates in a neonatal intensive care nursery (NICU) were exposed to a mean of 14 painful procedures per day, with smaller and sicker infants receiving these procedures more frequently.1 Only 35% of these infants received preemptive analgesic therapy. Nearly 40% of the NICU infants in the study received no analgesic therapy at all.1 I don't think any of us find this acceptable. Yet we continue to undertreat pain in neonates for a variety of reasons, including difficulty in assessing chronic pain in preterm infants, confusion about which pain measurement tool to use, and lack of knowledge of pharmacokinetics in neonates.
How often do you provide pharmaceutical or nonpharmaceutical pain relief prior to doing a heel stick or attempting an IV? What about the neonate who requires more than one attempt to start an IV or obtain a sample of cerebral spinal fluid? One approach to reducing procedural pain in the neonate that is mentioned in the policy statement is to reduce the number of procedures performed.2 We can evaluate the number of laboratory tests and radiographic procedures we order, work to eliminate factors that require laboratory blood draws to be repeated, and minimize the number of attempts for procedures such as IV starts.
There are a number of instruments available for measuring pain in the neonate. None of them are ideal for all neonates in all circumstances.3 This adds to the difficulty in measuring pain consistently and accurately, particularly in instances of chronic pain and stress. Using a tool that is multidimensional and has been tested for reliability and validity is important. Practicing with the tool one is using is vital to avoid variability in results.3 Perhaps the most essential ingredient is a commitment from all those caring for infants to assess neonates on a regular basis and recognize that much of what we do causes significant pain and discomfort and should be addressed. This seems obvious, but research suggests that caregivers discount the amount of pain a procedure causes or the trauma associated with pain in neonates. The responses seen in preterm infants in response to chronic pain or repeated painful procedures can make it difficult for caregivers to recognize pain and distress and to assess the effect of analgesia.4
The Joint Commission guidelines state that patients "have the right to appropriate assessment and management of pain."5 Specific recommendations include regular assessment of neonatal pain along with vital signs or more often, as indicated by pain scores. A standardized pain assessment tool that is specific to neonates should be used. Neonates should have their pain assessed after each potentially painful procedure or intervention and assessed again for efficacy of pharmaceutical or nonpharmaceutical interventions.5
The AAP policy statement has a number of practical recommendations that should be implemented in our NICUs. These include assessment of pain with multidimensional tools, including both physiologic and behavioral indicators of pain. We should make every effort to minimize the number of painful procedures we do. Methods of pain control should include nonpharmacologic pain reduction methods for minor procedures. For more invasive procedures, topical anesthetics and pharmacological interventions are appropriate. A number of procedures that cause pain and distress in the neonate are discussed.
I would urge all of us to distribute this information in our NICUs and assess how well we are doing in treating our neonates. We have an obligation to our babies and families to ensure that all of the neonates in our care have adequate, appropriate pain control.
References