KAREEM EL- BASSIOUNY AWAD UNDER HELPFUL SUPERVISION OF: PROF. DR. SHADIA EL- SALLAB [email protected]
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KAREEM EL- BASSIOUNY AWADUNDER HELPFUL SUPERVISION OF:
PROF. DR. SHADIA EL- SALLAB
Definition
An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
The interpretation of Pain is subjective.
International association for the study of pain
“ IASP”
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Outdated professional attitudes
Neonates do not feel pain ( immaturity, incomplete myelinization)
Infants are less sensitive to pain than adultsNeonates have no memory of painChildren will tell you when they are having
painIf a child can be distracted, he is not in painNeonates are not able to tolerate the effects
of analgesicsNarcotics can lead to addiction in childrenInfants become accustomed to pain
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The Fact
Before the middle 1970’s, it was thought that neonates were incapable of experiencing pain due to the immaturity of the nervous system and incomplete myelinization, however since up to 80% of fibers responsible for transmitting pain remain unmyelinated in the adult.
it is conceivable that the potential for neonates to perceive pain exists
The Fact
By late gestation, the fetus has developed the anatomic, neurophysiologic, and hormonal components to perceive pain .
Preterm and term infants demonstrate similar or even exaggerated physiological and hormonal responses to pain compared with those observed in older children and adults .
Neonates who were exposed to painful stimuli, between post conceptual weeks 28 – 32 showed different behavioral and physiological responses to pain compared with neonates of similar post conceptual age who had not had such experiences
Developmental Aspects of Pain Perception
Pain Pathways ReminderAnatomic DevelopmentPhysiologic Development
Descending pathways
Ascending pathways
Peripheral receptorsNeural pathwaysSpinal cord tractsBrainstem, thalamus, & beyond
Pain Pathways
:
Physiologic Development
Lower pain threshold in neonatal rats.
Neurotransmitter receptors are up-regulated in the neonatal period.
Neonatal pain processing: Early development of the excitatory mechanisms & later development of inhibition .
Normal development of the pain system occurs in the absence of noxious stimuli.
Immediate Effects
Reduced TV and VC in the lungs .Increased demands in the CVS .Hypermetabolism resulting in neuroendocrine
balances, increased oxygen consumption, hypoxemia, myocardial ischemia .
Mobilization of endocrine and metabolic resources resulting in changes in blood pressure ( IVH ), changes in skin color and temperature .
Prolonged catabolic reactions as well as circulatory and metabolic complications after surgery when anesthetic agents were not administered or were inadequate
Long Term Effects of Untreated Pain
Newly studied area:until recently, babies were not thought to “remember” pain
Some experts believe that untreated pain in the newborn period forces abnormal pathways to form in the brain
This aberrant brain activity results in impaired social/cognitive skills and specific patterns of self- destructive behavior
Studied MRI’s of newborns: reactions to pain transferred into similar electrical reactions to any kind of stressful situation.
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Long Term Effects of Untreated Pain
Alteration in cerebral neuroanatomy .Avoidance and alteration in response to
stimuli.Developmental delays .CNS handicap .Emotional disorders .
Despite the clinical importance of neonatal pain, current medical practices continue to
expose infants to repetitive, acute, or prolonged pain.
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Painful Procedures in NICU
Therapeutic: Bladder catheterization . Central line insertion and
removal . Chest tube insertion and removal
. Chest physiotherapy . Mechanical ventilation . Dressing change . Gavage tube insertion . Intramuscular injection . Peripheral venous
catheterization . Tracheal intubation and
extubation Tracheal suctioning . Suture removal . Ventricular tap .
Diagnostic: Venipuncture Heel lancing Lumbar puncture ROP examination Endoscopy Bronchoscopy Suprapubic bladder tap
Surgical ; Circumcision . Others .
How the newborn responds to Pain
Physiological/autonomic responses. changes in vital signs,
pupils
Behavioral Cues. how the baby acts when
she is in pain
Hormonal/Metabolic Responses. what happens chemically
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Physiologic/autonomic responses
Variations in HRFluctuations in BP.Increase ICP.Increased or decreased muscle tone.Increased or decreased RR .Oxygen desaturation.Increase oxygen requirements.Palmar erythema.Pallor.Flushing.
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Behavioral Cues
crying can vary from high
pitched, tense to soft moaning or whining
facial expressions grimacing quivering of chin squeezing eyes shut furrowed brow
difficult to soothe, comfort or calm
body moveaments limb withdrawal fist clenching hypertonicity or
hypotonicitystate changes
changes in sleep-wake cycles
changes in activity levels-increased fussiness or irritability
Hormonal/Metabolic Responses
Increase in epinephrine and norepinephrine, growth hormone and endorphins.
Decrease in insulin secretion.Increased secretion of cortisol, glucagon,
and aldosterone…which leads to Increased serum glucose, lactate, & ketones. Can lead to lactic acidosis.
Hormonal/Metabolic Responses
Changes in hormone levels affect the absorption of fat, protein, and glucose, which subsequently
affect
HEALING AND GROWTH!
PAIN CONTROL IS MORE THAN A MATTER OF COMFORT-
CONTROLLING PAIN DECREASES COMPLICATIONS
Factors Affecting Pain Response
Gestational age : as preterm infants develop, their responses become more sustained and interpretable
Environmental factors:external noise, temperature, light
Intensity and duration of insult:repeated painful procedures decrease infant’s ability to react to pain but not their perception of it
Behavioral state:less reactive when in sleep states than wake states
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Factors leading to the development of assessment and treatment of pain
Proliferation of NICUs
Knowledge of influence of pain on the developing CNS.
Desires to have ethical management of neonatal pain
“Because neonates cannot verbalize their pain, they
depend on others to recognize, assess, manage
their pain.”
Prevention and Management of Pain and Stress in the Neonate (RE9945)
-- Pediatrics Volume 105, Number 2 February 2000, pp 454-461
Assessment of Pain
Concomitantly with the vital signs, assessment of neonatal pain must be undertaken every 4-6 hours or as indicated by the clinical condition of the neonate.
Pain assessment instrument should be sensitive and specific for infants of all gestational ages and/or acute, recurrent, continuous pain .
pain assessment should be comprehensive and multidimetional, including contextual, behavioral and physiological indicators .
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ABC scale for pain in newborns
Assess the characteristics of crying for different levels of pain.
Assessment parameters: Acuteness of the first cry. Burst rhythmicity . Constancy in time of the crying.
These parameters are modulated by different parts of the CNS.
Prevention of neonatal pain
Combining procedures. Programming procedures on the basis of patient’s need rather
than routine . placement of peripheral, central, or arterial lines reduces the
need for repeated intravenous punctures or intramuscular injections.
Avoiding heel prick. Venepuncture is better Use smallest gauge needle possible Use minimal amounts of tape/use tape remover to remove it
Decrease noise and bright light. Respect for the sleep-wake cycle. Whenever possible, validated noninvasive monitoring techniques
(e.g., pulse oximetry) that are not tissue damaging should replace invasive methods.
Satisfying the suckling reflex. Placing the baby in a comfortable natural position. Changing position from time to time ( including ventilated
babies) Maintaining physical contact( strocing, rocking, masasage) Glucose solution. Feeding before painful procedures.
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The goals of pain management are to minimize the pain experience and its
physiological cost, and to maximize the newborn’s capacity to cope with and recover from painful experience while maintaining
the risk/benefit ratio for treatment
Non Pharmacological Treatment
A growing interest has recently been developing in non pharamacological treatment because: Painful procedures are extremely frequent in preterm ,
sick neonates. Concerns exists regarding potential adverse effects of
pharmacological treatmentThis type of treatment can reduce pain by two
ways: Indirectly: reduce the total amont of noxious stimuli . Directly by :
blocking nociceptive transduction or transmission activation of descending inhibitory pathways activation of attention and arousal systems that modulate
pain
Environmental Interventions
Aim to decrease the environmental stress of the NICU. ( handling, light, noise,…)
Studies show reduction in illness severity with environmental interventions.
Reduction of light levels, and alternating day and light conditions can : Reduce stress Promote increased sleep. Weight gain. Development of circadian rhythm.
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Swaddling, Positioning and Touch
Swaddling is the wrapping of infants in cloth to restrict their movements.
Reduce pain-elicited distress during and after heel prick. Reduce protracted behavioral disturbance, Fearon et al
Facilitated tucking “ side lying or supine position with flexed arms and legs close to the trunk” significantly lower mean HR 6-10 min post stick, decrease mean crying time, decrease mean sleep disruption time and decrease sleep states changes, Corff et al
Prone position is not a suffecient environmental comfort for painful invasive procedures such as heel lance, Grunau et al
Nonnutritive Suckling “NNS”
Field and Goldson reported decreased crying with NNS in term and preterm infants.
NNS significantly decrease HR without stimulation, and during painful stimulation and significantly increase tcPO2, Shiao et al,1997
In VLBW infants, Stevens et al demonstrated that NNS is effective in reducing pain caused by frequent heel lance sampling.
Nonnutritive Suckling “NNS”
Corbo et al, investigated the effects of NNS during heel stick procedures in neonates of gestational age ranging from 26 – 39 weeks, NNS reduced the time of crying and the HR increase during procedure, but had no effect on RR or tcPO2.
Blass and watt, found that NNS is only effective when suck rate exceeds 30suck/min
NNS in preterm and high-risk full term infants does not seem to have any short term negative effects , Pinelli et al
SUCROSE
Blass and Hoffmeyer, reported in 1991 the effectiveness of sucrose as an analgesic agent for newborn infants during heel stick and circumcision.
Infants who drank 2ml of 12% sucrose solution (0.24g) prior to blood collection cried 50% less during the blood collection procedure than did control infants who had 2ml of sterile water prior to procedure.
Crying of infants who ingested sucrose returned to baseline levels within 30-60s after blood collection, compared to control infants who required 2.5-3min to return to baseline
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0 20 40 60 80
Water
12% Sucrose
24% Sucrose
Effect of Oral Sucrose Solution on Venipuncture Pain
Abad, et alActa Paediatr, 1996
Time crying (sec)
SUCROSE
Sucrose is safe and effective in reducing procedural pain from single painful events
( heel lance, venepuncture ).
Cochrane review April,2004
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SUCROSE ;dose
Very small doses of 24% sucrose ( 0.01-0.02g) were effective in reducing pain in VLBW infants
In term infants larger doses ( 0.24-.50g) reduced the proportion of time spent crying following the procedure.
Solutions should be administered 2min prior to procedure.
The analgesic effects lasts for about 5-7min
SUCROSE; repeated doses
Johnston et al, tested the effeicay of repeated doses versus single doses of sucrose. 2min prior lancing, just prior to lancing 2min after lancing.
The repeated dose has lower pain scores than single dose.
Sucrose; side effects
For repeated administration of sucrose in infants younger than 31week PCA, Johnston et al, reported that higher number of doses of sucrose, predicted lower scores for motor development, vigor, and for alertness and orientation at 36weks PCA .
Chocking.Desaturation.
GLUCOSE
Oral glucose has also to be effective in reducing pain.30% glucose has been effective both in term and
preterm infants.
Deshmukh and Udani,studied the analgesic effect of glucose in different concentration during venepuncture they found that :
Significant reduction in duration of cry in babies received 25% glucose compared to glucose 10%
There was no difference between glucose 10% and sterile water
The coadministation of glucose and sucrose solutions with a pacifier has been found to be synergistic
Assosiation of sweet solution and a pacifier provide a stronger analgesic effect than either one alone.
Multisensory Stimulation
Also called “ sensory saturation”Developed by Belllieni et alConsists of:
Facilitated tucking Looking the infant in the face, close up, to attract
attention. Massage infant’s face,back. Speaking to the infant gently but firmly Letting the infant smell the fragrance of a baby
perfume on the therapist’s hands
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Multisensory stimulation plus oral glucose
In a randomized study, conducted on 120 term neonates , authors found that multisensory stimulation plus glucose was more effective in reducing pain from heel lance, than glucose, sucking, suckling plus glucose.
So, sensory saturation is an effective analgesic technique that potentiates the analgesic effect of oral glucose
Skin to skin contact ( kangaroo care )
Gray et al, found that 10-15min skin to skin contact between mothers and their newborns reduces crying, grimacing, HR during heel lance procedure in full term.
0
10
20
30
40
50
60
70
%Grimace %Cry
Contact
Control
Skin-skin contact
Gray, et alPediatrics 2000
Pe
rce
nt o
f tim
e
Breast feeding
Breast feeding during a painful procedures has been found to be a potent analgesic.
In one study, neonates who were held and breast fed by their mothers during heel lance, had a reduction in crying of 91% and grimacing of 84% as compared to infants who have been swaddled in their bassinets
Some studies show that if breast feeding is not continued during the procedure, it has no analgesic effect.
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Breast milk
Most of the studies found that The available evidence does not support supplemental breast milk as the sole intervention to alleviate procedural pain .
Blass and colleagues, found that although colostrum did not reduce crying and grimacing relative to control group who received sterile water, it did prevent the increase in HR.
Supplemental breast milk did not compare favorably to concentrated glucose and sucrose, as reflected by higher increases in HR and duration of crying in breast milk group.
Music therapy “ MT ”
Music defined as an intentional auditory stimulus with organized elements including melody, rhythm, harmony, timbre, form and style.
By contrast, environmental sounds that exist with out controls for volume or cause/effect relations are perceived as noise .
Although methodological limitations exist, results of published studies suggest that music may be useful in reducing procedural pain.
It should be not provided for longer than 15min per intervention due to the risk of sensory overload
Pharmacologic analgesia
Local analgesia .
General analgesia . Non narcotic drugs . Narcotic drugs .
Future perspectives.
Local analgesia
Prevent transmission of noxious stimuli either at the peripheral receptor site or at the spinal cord.
Local infiltration : Bupivacaine and lidocaine most commonly used. Bupivacaine are longer acting but more cardiotoxic .
Epidural catheter infusion : Bupivacaine and ropivacine. Regional techniques has been investigated for efficacy
and safety in neonates and infants . Adding opoids to epidural infusion reduces toxicity .
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Local analgesia
EMLA “ euthetic mixture of local anesthetics”
Emulsion containing lidocaine and prilocaine .
Continuous or repeated use may cause methemoglobinemia because methemoglobin reductase is deficient in the newborn .
EMLA is not recommended for heel prick because it produces local vasoconstriction .
Nonnarcotic drugs
Acetaminophen and NSAIDs .
Provide mild to moderate analgesia .
Don’t relief surgical pain if given alone .
Narcotic drugs
They are the standard drugs for pain relif in major invasive procedures .
Use of sedatives as Midazolam and Lorazepam increase the effect of narcotics, but don’t by themselves produce analgesia
Narcotic drugs
Target steady state concentration is influenced by : gestational age .
Age since birth.
Weight.
Fraction of drug bound to plasma protein.
Morphine Fentanyl
NaturalInduce histamine
release hypotention, bradycardia.
70 – 80 times less potent than fentanyl
Less toleranceLess withdrawal efects
Synthetichas beneficial
effects on haemodynamic stability.
Heel lance
Consider use of venipuncture instead of heel lance in full term, more mature preterm neonates . Because it is : Less painful More efficient Less resampling
Use a pacifier with sucrose ( 12% - 24% ) given 2 minutes before the procedure.
Use swaddling, containment, facilitated tucking.Consider skin to skin contact with the mother .Use a mechanical spring-loaded lance e.g., autolance .EMLA, Acetaminophen, warming the heel are not
effective with heel lancing .
Percutaneous venous catheter insertion& venipuncture
Use a pacifier with sucrose .Use swaddling, containment, facilitated
tucking.Apply EMLA to the proposed site “when non
urgent”Consider opoid dose (s) , if IV access is
available.
UVC & UAC insertion
Consider the use of pacifier with sucrose .Use swaddling, containment, facilitated
tucking .Avoid the placement of sutures or hemostat
clamps on the skin around the umbilicus .
PICC insertion
Use a pacifier with sucrose .Use swaddling containment, facilitated
tucking .Apply EMLA to the proposed site “when non
urgent”Consider opoid dose (s) , if IV access is
available.
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Central venous line placement
Use a pacifier with sucrose .Use swaddling containment, facilitated tucking .Apply EMLA to the proposed site “when non
urgent”Consider subcutaneous infiltration of
lidocaine .Consider IV opoid slow infusion “ morphine
sulphate or fentanyl citrate .Consider use general anesthesia for the
procedure .
Peripheral arterial or venous cut down
Use a pacifier with sucrose .Use swaddling containment, facilitated
tucking .Apply EMLA to the proposed site “when non
urgent”Consider subcutaneous infiltration of
lidocaine , Avoid intravascular injection .Consider opoid dose (s) , if IV access is
available.
Lumbar puncture
Use a pacifier with sucrose .Apply EMLA to the proposed siteConsider subcutaneous infiltration of
lidocaine
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SC or IM injection
Avoid both and give drugs IV whenever possible .
If necessary :Use a pacifier with sucrose .Use swaddling containment, facilitated
tucking . Apply EMLA to the proposed site “ evidence
for this approach is available from studies in children, but not from studies in neonates.”
ETT insertion
Many variations in clinical approach have been noted.
The superior efficacy of any one technique is not supported by current evidence .
Tracheal intubation without the use of analgesia or sedation, should be performed only for resuscitation in the DR or for other life threatening situations associated with unavailable IV access .
ETT insertion
Use combination of atropine sulphate and ketamine hydrochloride .
Use combination of atropine, thiopental sodium, succinylcholine chloride .
Use combination of atropine, morphine, or fentanyl and non depolarizing muscle relaxant “ e.g. pancuronium”.
Consider using a topical lidocaine spray if available.
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ETT suction
Use a pacifier with sucrose .Use swaddling containment, facilitated
tucking .Consider opoid dose (s) , if IV access is
available.
Nasogastric or orogastric tube insertion
Use a pacifier with sucrose .Use swaddling containment, facilitated
tucking .Use a gentle technique and appropriate
lubrication .
Chest tube insertion
Use a pacifier with sucrose .Consider subcutaneous infiltration of
lidocaineConsider IV opoid slow infusion “ morphine
sulphate or fentanyl citrate .The use of IV midazolam is not
recommended
Circumcision
Use an appropriate clamp “ Mogen clamp preffered over Gomco”
Apply EMLA to the proposed site.Place a dorsal penile nerve block, ring block,
or caudal block , using plain or buffered lidocaine .
Use a pacifier with sucrose .Consider acetaminophen for postoperative
pain .
Ongoing analgesia for routine NICU care and procedures
Use a pacifier with sucrose .Use swaddling containment, facilitated
tucking .Low dose continuous infusion of morphine or
fentanyl . If patient is ventilated.
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Future perspectives .
Use of regional analgesia techniqueSequential rotation of analgesicsBolus Vs continuous infusion opoidsUse of new opoids ( remifentanil)Addition of ultra low doses of opoid
antagonists ( naloxone)
Use of non competitive NMDA antagonists .
Important to know
Pain in newborn is often unrecognized and undertreated. Neonates do feel pain, and analgesia should be prescribed when indicated during their medical care .
If a procedure is painful in adults, it should consider painful in newborn even in preterm.
Compared with older age groups, newborns may experience a greater sensitivity to pain and are more susceptible to long term effects of pain
Adequate treatment of pain, may be associated with decreased clinical complications, and decreased mortality
The proper use of environmental, behavioral, and pharmacological interventions can prevent , reduce or eliminate neonatal pain in many clinical situations.
Sedation does not provide pain relef and may mask the neonate’s response to pain.
Health care professionals have the responsibility for assessment , prevention and management of pain in neonates .
Clinical units providing health care to newborns, should develop written guidelines and protocols for the management of neonatal pain
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