Dr. Lokanath Reddy

International Association for Study of

Pain(IASP)

An unpleasant sensory and emotional

experience associated with actual or

potential tissue damage, or described in

terms of such damage (note that the inability

to communicate verbally or nonverbally does

not negate the possibility that an individual

is experiencing pain and is in need of

appropriate pain relieving treatment)

YES

Pain system is intact and functional in both

preterm and term neonates.

Acute pain is processed in the somatosensory

cortex which suggests “conscious perception”

Behavioral responses to pain are complex and

you can observe “self expression.” Effective

mechanisms of hyperalgesia, allodynia and

referred pain occur in both preterm and term

neonates.

Flexion and adduction of affected limb

Distinct facial expressions

Specific features of a pain “cry” that has

unique spectrographic characteristics to

distinguish it from other types of cry(pain cry

vs hunger cry)

8 weeks -1st cutaneous sensory receptors –perioral area

20 weeks – Sensory receptors present in all cutaneous and mucosal surfaces

6 weeks - Synapses between peripheral sensory afferents and dorsal horn neurons will appear

20 weeks – Thalamocortical connections will form that allow painful stimuli to reach the somatosensory cortex.

A current theory of pain postulates that pain perception occurs at the level of “thalamus”

NO

Developmentally regulated processes and

behavioral reflexes suggest that pain

threshold increases progressively during

late gestation and postnatal period.

Preterm neonates have much greater

sensitivity to pain than term neonates and

they manifest prolonged hyperalgesia after

tissue injury.

Acute pain: Heel sticks, venipunctures, tracheal suctioning,lumbar puncture, circumcision.

Prolonged/chronic pain: NEC, meningitis, mechanical ventilation, birth trauma, chest tubes.

Post-operative pain: Hernia repair, ligation of PDA, VP shunts, abscess drainage etc.

Routine care : Diaper change, daily weights, removing adhesive tapes, burns from transcutaneous probes and cold light, rectal stimulation.

YES, but in a different manner.

Although children may not directly recall painful experiences from their NICU stay, they may demonstrate altered behavioral states from painful experiences that were not well managed.

Pain will lead to long term and permanent alterations in brain development depending on type, duration and severity of pain, the neurological maturity at which pain occurs and the use of analgesia.

Pathophysiology: Tissue damage profound and long lasting dendritic sprouting of sensory nerve terminals hyper-innervation that continues in childhood and adolescents.

Repeated heel sticks Abnormal gait in

childhood

Perioral and nasal suctioning Oral aversion

syndrome

Gastric suctioning Irritable bowel syndrome

Surgical sites increased pain sensitivity

Nerve injury in neonates does not lead to

neuropathic pain as in adults

PRIMARY HYPERALGESIA: Neonates exposed to acute short term pain at the areas where injury occurred

SECONDARY HYPERALGESIA: Hyperalgesia at remote areas from the site of injury.

Primary and Secondary hyperalgesia – several months

Visceral Hyperalgesia – several months to years

Signs of ADHD, impulsivity and socialisationproblems during early school years.

Chronic pain syndromes in adult life.

Similar to term babies have heightened pain reactivity to painful procedures like heel stick.

Conversely, cumulative pain since birth was significantly correlated with dampened reactivity to heel stick and lower cortisollevels to stress at 32 weeks, less pain reactivity at 4 months, faster recovery at 8 months, decreased everyday pain behavior at 18 months, increased somatization at 4.5 years and increased affective responses to depicted pain at 8-10 years.

Acute procedural pain/post operative pain

Intensity – Many pain scales

PIPP(Premature Infant Pain Profile) (27 wks – term)

NIPS(Neonatal Infant Pain Scale) (28-38 wks)

NPASS(Neonatal Pain, Agitation and Sedation Scale)

CRIES score (32-60 wks)

Character, location, duration and rhythm

cannot be measured

Chronic pain – No scales to assess.

Scale Variables Type of pain

PIPP (Premature Infant

Pain Profile)

(27 wks – term)

HR, SpO2, Facial expression, takes

state and GA into account

Procedural,

Postoperative (minor)

NIPS(Neonatal Infant Pain

Scale) (28-38 wks)

Facial expression, crying,

breathing pattern, arm and leg

movements, state of arousal

Procedural

NFCS (Neonatal Facial

Coding System)

Facial actions Procedural

N-PASS (Neonatal pain,

Agitation, and Sedation

Scale)

Crying, irritability, behavioral

state, facial expression, extremity

tone, vital signs

Postoperative,

Procedural,

Ventilated

CRIES (Cry, Requires O2,

Increased vital signs,

Expression, Sleeplessness)

Cry, Requires O2, Increased vital

signs, Expression, Sleeplessness

Postopetive

COMFORT Scale (0-3 yr

old)

Movement, Calmness, facial

tension, alertness, RR, HR, BP

Postoperative, critical

care, sedated,

Relaxed – restful face/neutral

expression

score - 0

Grimace – Tight facial muscles

furrowed brow, chin & jaw

Score - 1

No Cry –Quiet, not crying – 0

Whimper – Mild moaning, intermittent – 1

Vigorous cry – Loud cry, shrill, continuous - 2

Relaxed – Usual pattern for that baby - 0

Change in breathing – Indrawing , irregular,

fast than usual, gagging, breath holding - 1

Relaxed – No muscular rigidity, occasional

random movements – 0

Flexed/Extended – Tense straight arms/legs,

rigid, rapid flexion/extension - 1

Sleeping/awake – Quiet, peaceful sleeping,

occasional random legs/arm movements – 0

Fussy – Alert restless and trashing - 1

Neonatal infant pain scale = SUM(points for

the 6 parameters)

Interpretation:

• minimum score: 0

• maximum score: 7

Pain Level Intervention

0-2 = mild to no pain None

3-4 = mild to

moderate pain

Non-pharmacological intervention

with a reassessment in 30 minutes

>4 = severe pain Non-pharmacological intervention

and possibly a pharmacological

intervention with reassessment in

30 minutes

PIPP (Premature Infant Pain Profile)

(27 wks – term)

Indicators:

(1) gestational age

(2) behavioral state before painful stimulus

(3) change in heart rate during painful stimulus

(4) change in oxygen saturation during painful

stimulus

(5) brow bulge during painful stimulus

(6) eye squeeze during painful stimulus

(7) nasolabial furrow during painful stimulus

Scoring instructions:

(1) Score gestational age before examining infant.

(2) Score the behavioral state before the potentially painful event by observing the infant for 15 seconds .

(3) Record the baseline heart rate and oxygen saturation.

(4) Observe the infant for 30 seconds immediately following the painful event. Score physiologic and facial changes seen during this time and record immediately

premature infant pain profile = SUM(points

for all 7 indicators)

Interpretation:

minimum score: 0

maximum score: 21

The higher the score the greater the pain

behavior.

Prevention is better than cure

Procedure Prevention/Management

Removing adhesive tapes Use ether, pull slowly

Burns from transcutaneous

probes and cold light.

Frequent change of probes

every 2 hrly. Careful use of cold

light.

Diaper change, daily weights Minimal handling

Rectal stimulation Xylocaine jelly

Heel sticks, venipunctures Sucrose 0.5ml 2 min before

Tracheal suctioning Sedation

Lumbar puncture EMLA patch, local anestetic

NEC, meningitis, mechanical

ventilation, chest tubes,

postoperative

Sedation

Non pharmacological interventions

facilitated tucking (holding the infant’s

extremities close to the body, promoting

flexion), swaddling, nesting, use of

nonnutritive sucking

minimal handling protocols

lowering noise levels in the NICU

avoiding exposure to bright lights

promoting of day/night light cycles.