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Consensus Statement for the Prevention and Management of Pain in the Newborn

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Consensus Statement for the Prevention and Management of Pain in the Newborn ARTICLE Consensus Statement for the Prevention and Management of Pain in the Newborn K. J. S. Anand, MBBS, DPhil; and the International Evidence-Based Group for Neonatal Pain Objective: To develop evidence-based guidelines for pre- Results: Recognition of the sources of pain and routine as- venting or treating neonatal pain and its adverse conse- sessments of neonatal pain should dictate the avoidance of quences. Compared with older children and adults, neo- recurrent painful stimuli and the use of specific environ- nates are more sensitive to pain and vulnerable to its long- mental, behavioral, and pharmacological interventions. term effects. Despite the clinical importance of neonatal Individualized care plans and analgesic protocols for spe- pain, current medical practices continue to expose in- cific clinical situations, patients, and health care settings can fants to repetitive, acute, or prolonged pain. be developed from these guidelines. By clearly outlining ar- eas where evidence is not available, these guidelines may also Design: Experts representing several different coun- stimulate further research. To use the recommended thera- tries, professional disciplines, and practice settings peutic approaches, clinicians must be familiar with their ad- used systematic reviews, data synthesis, and open dis- verse effects and the potential for drug interactions. cussion to develop a consensus on clinical practices that were supported by published evidence or were Conclusion: Management of pain must be considered commonly used, the latter based on extrapolation of an important component of the health care provided to evidence from older age groups. A practical format all neonates, regardless of their gestational age or sever- was used to describe the analgesic management for ity of illness. specific invasive procedures and for ongoing pain in neonates. Arch Pediatr Adolesc Med. 2001;155:173-180 EWBORNS routinely ex- sponses to the pain caused by mild, mod- perience pain associ- erate, or highly invasive procedures, and the ated with invasive pro- magnitude of their responses increase with cedures such as blood postnatal age.6,7,13 Compared with older sampling, immuniza- children, neonates exhibit greater hor- Ntion, vitamin K injection, or circumci- monal, metabolic, and cardiovascular re- sion. The sick or preterm infant may ex- sponses to surgical operations, and may re- perience repetitive or prolonged pain quire relatively higher doses of anesthetics resulting from many diagnostic, surgical, and analgesics for adequate pain con- or therapeutic procedures.1-4 trol.5,14-17 The metabolism and clearance Multiple lines of evidence suggest an rates of most analgesic agents in preterm increased sensitivity to pain in neonates neonates are slower than in term neo- compared with older age groups.5,6 This nates, but increase rapidly with age.18,19 pain sensitivity is further accentuated in pre- Management of pain in the newborn term neonates, and may not be clinically is hampered by the lack of awareness evident.5-8 Critically ill and preterm neo- among health care professionals that the nates do not mount vigorous behavioral re- neonate is capable of experiencing pain, sponses to pain, and therefore require par- and by fears about the adverse effects as- ticularly detailed assessment.6-8 The pain sociated with analgesic use. Current evi- modulation systems that operate in older dence supports the general principles listed From the International children and adults do not appear to be fully in Table 1 for the routine management Evidence-Based Group 9-11 for Neonatal Pain, whose functional in newborns or may func- of neonates using safe and effective envi- members are listed in the tion only during maternal contact in healthy ronmental, behavioral, and pharmacologi- acknowledgments at the end newborns.12 Even the most immature pre- cal interventions for relieving pain and for of this article. term neonates mount increasing re- preventing its adverse consequences.20 (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, FEB 2001 WWW.ARCHPEDIATRICS.COM 173 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 1. General Principles for the Prevention METHODS and Management of Pain in Newborns 1. Pain in newborns is often unrecognized and undertreated. Neonates These guidelines were developed from 2 consensus de- do feel pain, and analgesia should be prescribed when indicated velopment meetings (in April 1998 and August 1999). during their medical care. A detailed search of the published literature on neona- 2. If a procedure is painful in adults, it should be considered painful in tal pain was conducted to identify the experts who were newborns, even if they are preterm. invited to these meetings. Databases searched were 3. Compared with older age groups, newborns may experience a MEDLINE, Embase, and PubMed using the following greater sensitivity to pain and are more susceptible to the long-term effects of painful stimulation. terms:pain,nociception,stress,infant-newborn,andinfant- 4. Adequate treatment of pain may be associated with decreased premature. Faculty members were selected by the chair- clinical complications and decreased mortality. man (K.J.S.A.) based on their expertise in specific top- 5. The appropriate use of environmental, behavioral, and ics related to neonatal pain, coupled with a concerted pharmacological interventions can prevent, reduce, or eliminate effort to include professionals trained in different dis- neonatal pain in many clinical situations. ciplines and representing different countries and dis- 6. Sedation does not provide pain relief and may mask the neonate’s tinct practice settings (eg, children’s hospitals, general response to pain. hospitals, office practices). The disciplines represented 7. Health care professionals have the responsibility for assessment, were pediatrics, neonatology, child psychology, anes- prevention, and management of pain in neonates. thesiology,neuroscience,endocrinology,neonatalnurs- 8. Clinical units providing health care to newborns should develop ing, pharmacy/pharmacology, rehabilitation medicine, written guidelines and protocols for the management of neonatal pain. critical care medicine, rheumatology/immunology, and others. At the time of these meetings, faculty members were affiliated to academic institutions in Australia, Bra- zil, Canada, Denmark, France, Germany, Israel, Italy, Poland, Sweden, Switzerland, the Netherlands, United Table 2. Painful Procedures Commonly Performed Kingdom, and the United States. in the Neonatal Intensive Care Unit Faculty members performed a systematic review of the published literature on their specific topic, criti- Diagnostic cally evaluated the quality of published data, and syn- Arterial puncture thesized these findings. Data from all relevant studies Bronchoscopy were presented at these meetings and were discussed Endoscopy by the experts present. Other faculty members were en- Heel lancing couraged to present additional data and ample time was Lumbar puncture allowed for detailed discussion. Guidelines were de- Retinopathy of prematurity examination Suprapubic bladder tap veloped after reaching a consensus on the clinical prac- Venipuncture tices that were prevalent in most countries. As such, Therapeutic these guidelines were based on a combination of pub- Bladder catheterization lished evidence (from randomized controlled trials, sys- Central line insertion/removal tematic reviews, or meta-analyses of trials) and its criti- Chest tube insertion/removal cal evaluation by the faculty members. Between Chest physiotherapy September 1999 and April 2000, 3 separate draft ver- Dressing change sions of this statement were circulated and modified Gavage tube insertion by all members of the participating faculty. Approval Intramuscular injection of all faculty members was obtained for the final ver- Peripheral venous catheterization sion of the consensus statement, which is organized Mechanical ventilation around broad general principles (Table 1) and evidence- Postural drainage based guidelines for neonatal pain management. The Removal of adhesive tape pharmacological interventions recommended in these Suture removal guidelines are not the exclusive products of the phar- Tracheal intubation/extubation maceutical company that funded these meetings, and Tracheal suctioning the representatives of this company have had no in- Ventricular tap put in the format or content of these guidelines. Surgical Circumcision Other surgical procedures RESULTS EVIDENCE-BASED GUIDELINES FOR THE eter insertion, chest tube placement, tracheal intuba- MANAGEMENT OF NEONATAL PAIN tion or suctioning, lumbar puncture, and subcutaneous or intramuscular injections (see Table 2 for additional Recognition of the Sources of Pain procedures).1-4 Other sources of pain may include areas of inflammation and hyperalgesia around previous tis- Some of the painful procedures commonly performed on sue injury, postoperative pain, localized infection or in- neonates in the neonatal intensive care unit (NICU) in- flammation, and skin burns or abrasions caused by trans- clude heel lancing, venipuncture, venous or arterial cath- cutaneous probes, monitoring leads, or topical agents. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, FEB 2001 WWW.ARCHPEDIATRICS.COM 174 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 3. Commonly Used Methods for Assessment
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