2011 pain in the neonate
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Neonatal Pain
Anne Martinez RNC-NIC
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With acknowledgment of Renee Hunt
ARNP, for sharing information on neonatal
pain.
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Objectives
Become familiar with pain assessment and management in
neonates.
Identify behavioral and physiologic signs of pain in the
neonate.
Discuss non-pharmacologic/pharmacologic management of
pain in neonates.
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Historical Perspective
Lawson case-patent ductus arteriosus
(PDA) surgery without anesthesia in mid
1980s
Edward case-ventriculoperitoneal (VP)
shunt performed using only curare. Baby
survived but screamed if anyone touchedhis head
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Definition of Pain
unpleasant sensory and emotional experience,
causing potential or actual tissue damage
acute pain-a constellation of unpleasant sensory,perceptual, emotional and mental experiences &
certain associated autonomic, psychological &
behavioral responses provoked by injury or acute
disease (the International Association for theStudy of Pain)
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Definition of pain
Acute pain-normal predicted physiologicresponse to adverse chemical, thermal, or
mechanical stimulus (KS State Board ofNursing, 2001)
Chronic pain-chronic pathologic processthat causes pain to continue or recur(KSBN)
Whatever a patient says it is (McCaffery)
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Detrimental Consequences
Increases in: plasma renin activity, epinephrine,norepinephrine, plasma cortisol, catecholamines,growth hormone, glucagon, and aldosterone
Decrease in: insulin secretion
May lead to:
severe hyperglycemia
metabolic acidosis (increased lactate, pyruvate, ketonebodies, & fatty acids)
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End Result of Pain
INCREASED MORBIDITY
INCREASED MORTALITY
(Anand & Hickey, 1986)
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Consequences of Pain
Even brief periods of severe pain early in
life may be responsible for prolonged
sensory disturbances
May cause altered pain responses
These alterations may persist into
adolescence and adulthood
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Pain is Subjective
Pain is defined by the person experiencing
the pain.
Pre-verbal Neonates are unable to verbalize
and describe pain.
Assessment must be guided by
physiological & behavioral cues.
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Frequency of Neonatal Pain
Approximately 9% of live births are admitted to aNICU annually
Painful procedures are required for treatment
Heelsticks
Arterial/venous punctures, IV/PICC/PAL
Intubation/suctioning
Lumbar puncturesChest tubes
Surgery
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Frequency of Neonatal Pain
Other sources of discomfort
bright lights
noise
frequent handling
REMEMBER-the most premature infantsrequire the highest number of procedures
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Historical Misconceptions
Nervous system too immature to perceive pain
Fear of addiction
Fear of side effects (hypotension, apnea,
decreased GI motility, liver/kidney damage)Belief that infants had no memory of pain
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Debunking the Myths
1. Nervous system of neonate too immature
to perceive pain
7 wks-sensory nerve endings in perioral
region
15 wks-sensory nerve endings on trunk
& proximal extremities
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20 wks-sensory nerve endings onmucous membranes & cutaneous
areas. Fetus experiences pain.
24 wks-thalamic track is complete
30 wks-myelination of brain stem andthalamic tract
37 wks-myelination of nociceptive tractcomplete
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Debunking the Myths
Recent research indicates newborns have
exaggerated cutaneous responses that last
longer compared to adults Neonates experience more pain to the same
stimulus than older children or adults
There is an increased density of peripheralnerves and immature descending pathway
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Debunking the Myth of Addiction
Addiction-neuro-behavioral syndrome that results inpsychological dependence for psychic effects
*no documented evidence of this syndrome in infants
Physical Dependence-expected result of continued opioiduse, may cause withdrawal symptoms if abruptly stopped
*gradually wean dose if opioids have been used for >5days
Tolerance-increased dosage needed to produce same effect
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Debunking the Myth that infants
have no memory of painRemember Baby Edwards (VP shunt)
Current research showing increased pain
responses to immunization injections inmales circumcised with NO analgesia
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Wind Up Phenomena
Altered excitability of CNS
After exposure to noxious stimulus,
multiple levels of spinal cord experiencealtered excitability. Activities such as
handling or diaper changes may then be
perceived as painful.
J i t C i i A dit ti
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Joint Commission on Accreditation
of Healthcare Organizations
(JCAHO) 2001 guidelines
1. Right to assessment/management of pain2. Record results, regular reassessments
3. Educate providers and determine competency
4. Establish policies and procedures
5. Educate patients/families
6. Collect data/monitor
appropriateness/effectiveness of pain mgt.
N ti l A i ti f N t l
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National Association of Neonatal
Nurses (NANN)-position statement
on pain management in infants1. Infants must be protected from adverse effects of
pain
2. Analgesia or sedation when appropriate
3. Ongoing assessment
4. Nurses must be proactive in pain management
5. Inform and educate and parents
6. Interdisciplinary collaboration
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American Academy of Pediatrics
1. Use an interdisciplinary approach
2. Personal values/beliefs of the health care
professional must not stand in the way orrecognition and treatment of pain in
children
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Agency for Health Care Policy &
Research
1. Prevention is better than treatment
2. Use reliable & valid measurement tools
3. Include physical and behavioral
assessment
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Recent Findings
Impulses can travel along unmyelinated
nerve tracts
Apoptosis-pruning of unnecessary cells
*in developing brains, an overstimulation of
nociceptive pathway can lead to
understimulation of another pathway(good touch or non-pain pathway)
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Recent Findings, cont.
Plasticity-concept that every experience of
the premature infant has the potential to
alter brain development*may lead to abnormal development &
behavior
*may enable infant to recover from braininsults
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Recent Findings, cont.
Allodynia-pain due to stimulus that
normally does not provoke pain
*touch & pain fibers are very close together,allowing the impulse to jump tracts
*handling or physical examinations may be
perceived as noxious stimulus
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Recent Findings, cont
Hyperalgesia-hypersensitivity to
painful stimuli
*Sensitivity persists after the stimulus removed
*May lead to new nerve endings in the injured
area (hyperinnervation) & cause increased pain
& hypersensitivity*Compounded by inadequate subcutaneous fat
to prevent thermal/pressure insults
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Innate Coping Mechanisms
Neonate has limited ability to block or cope
with pain
Primary coping method is sucking
Limited ability to block light-iris does not
constrict until 32 wk. gestation & eyelid is
very thin
Limited ability to block noise
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Short term Effects of Pain
Pain causes stress-triggers fight or flight
response
Release of glucocorticoids (cortisol,epinephrine, norepinephrine) that are
catabolic in nature-inhibiting cell division &
growth, protein synthesis & neuronalmyelination
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Short term Effects of Pain, cont.
Heart rate & blood pressure may be
increased
Intracranial blood volume & cerebral bloodflow may fluctuate leading to
intraventricular hemorrhage (IVH) and
periventricular leukomalacia (PVL)
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Long Term Effects of Pain
Increased sensory innervation
Altered pain behaviors in infancy
Increased pain thresholds
Hyperactivity/Attention deficit disorder
Decreased cognitive performance
Poor socialization, increased impulsivity
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Pain Assessment
Physiologic indicators- increased heart
rate and decreased oxygen saturation
Behavioral indicators-facial activity,(brow bulge, eye squeeze, nasolabial
furrow), crying, and body movements
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Additional Physiologic Signs
Increased Blood Pressure
Palmar Sweating
Pallor/flushing
Shallow Respirations
Diaphoresis
Dilated Pupils
These signs less reliable & harder to measure.
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Pain Assessment
Contextual factors modifying pain responses
Gestational age
Behavioral state
Severity of illness
Total number of painful procedures
Environmental stress
Sensitization after repeated stimulation Technician effects/procedural modifiers
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Premature Infant Pain Profile
Multidimensional or composite instrument
Altered responses due to prematurity are
factored into the calculation (very preterminfants can have maximum score of 21
compared to term infant score maximum of
18) Based on research data
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PIPP
Tested on babies from 24 to 40 weeks
gestation
Greater validity & reliability
Generally considered best instrument for
premature infants
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PIPP
Physiologic indicators-Heart Rate
-Oxygen Saturation
Behavioral variables-Brow Bulge
-Eye Squeeze
-Nasolabial Furrow
Contextual Factors-Gestational Age
-Behavioral State
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PIPP
Gestational age
0= >/= 36 wk
1= 32-35 6/7 wk
2= 28-31 6/7 wk
3=
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PIPP
Behavioral State
0= active awake state, eyes open, facial
movement1= quiet awake state, eyes open, no facial
movement
2= active/asleep, eyes closed, facial movements3= quiet/asleep, eyes closed, no facial movements
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PIPP
Maximum Heart Rate Increase
0= 0-4 BPM
1= 5-14 BPM
2= 15-24 BPM
3= >/=25 BPM
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PIPP
0xygen saturation decrease
0= 0-2.4%
1= 2.5-4.9%
2= 5-7.4%
3= >/=7.5%
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PIPP
Brow Bulge
0= none (0-9% of the time)
1= minimum (10-39% of the time)
2= moderate (40-69% of the time)
3= maximum (70 to 100% of the time)
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PIPP
Eye Squeeze
0= none (0-9%)
1= minimum (10-39%)
2= moderate (40-69%)
3=maximum (70-100%)
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PIPP
Nasolabial Furrow
0= none (0-9%)
1= minimum (10-39%)
2= moderate (40-69%)
3= maximum (70-100%)
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PIPP
Behavioral State scored immediately before
the event
Heart Rate, Saturation, Brow Bulge, EyeSqueeze, Nasolabial Furrow are scored in
the 30 seconds immediately following the
event
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PIPP
Scores of 7-12 =Mild Pain
Try nonpharmacologic measures
Scores > than 12=Moderate/Severe Pain
Consider Pharmacologic Intervention
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PIPP
New baseline heart rate & saturation
entered every Saturday night
Gestational age found on medical progressnote, Kardex, SBAR tool
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FLACC
Scores 0 to 2 for each category
Face
Legs
Activity
Cry
Consolability
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FLACC
Face
0=No particular expression, smile, eye contact,interest in surroundings
1=Occasional grimace/frown, withdrawn, worried,eyebrows lowered, eyes partially closed, mouthpursed
2=Frequent frown, clenched jaw, quivering chin,furrowed forehead, eyes closed, mouth open,nasolabial furrows
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FLACC
Legs
0=normal position, relaxed
1=uneasy, restless, tense, rigid, intermittent
flexion/extension of limbs
2=kicking, legs drawn up, hypertonicity,
exaggerated flexion/extension
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FLACC
Activity
0=lying quietly, moving freely
1=squirming, shifting, guarding
2=arched, rigid, or jerking, fixed position
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FLACC
Cry
0=no crying or moaning
1=moans, whimpers, occasional cry, sigh
2=crying steadily, screaming, sobs, grunts
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FLACC
Consolability-
0=calm, content, relaxed
1=reassured by occasional touching or
hugging
2=difficult to console or comfort
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FLACC
Designed for newborns to 3 years of age
Initiate FLACC at 38 weeks adjusted age
Consider pharmacologic intervention for
scores 5 or more
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Goals of pain management
Minimize intensity, duration, and
physiologic cost of pain
Maximize neonates ability to cope withand recover from the painful experience
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Nonpharmacologic approaches
Reduce total noxious stimuli
Containment/ swaddling
Non-nutritive sucking
Sucrose pacifier
Developmentally supportive care
Cautious clustering of care
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Sucrose
Theoretically works by releasing serotonin
to modulate transmission of noxious stimuli
Promotes activation of endogenous opioidsthat attenuate noxious stimuli at the dorsal
horn
Give 1-2 minutes before procedure Anterior tongue administration most
effective
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Sucrose
Research supports effectiveness in infants
Research has not determined the absolute
limit of safety in extremely prematureinfants
27 to 31 6/7 wk-1 to 2 dips per procedure(max in 24 hr. 8 dips)
>/=32 weeks- 1 to 4 dips per procedure(max in 24 hr 24 dips)
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Sucrose
Chart administration with number of dips
on MAR
Our 24 hour period starts at midnight
Example-At midnight baby given 2 dips so
chart 2/2 (second number is the total for the
day)
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Pharmacologic considerations
Analgesic use
Sedatives
Opioids
EMLA cream
Circumcision considerations
End of life pain
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Analgesics
Acetaminophen 20-25 mg/kg PO loading dose
12-15 mg/kg PO
32 to 37 weeks q 8 hr.
>37 weeks q 6 hr.
Cautious use in liver disease
Ibuprofen-not tested for analgesia in preterm/terminfants
Caution- may interfere with immune response
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Analgesics
Topical Proparacaine eye drops
Used for eye exams
Onset 20 seconds
Duration 15-20 minutes
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Pain control during eye exams
Review of literature and studies by Samra
and McGrath in June 2009 Advances in
Neonatal Care (NANN) There are clear guidelines for performing
eye exams
There are no standard protocols for painmanagement during exams
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Sedatives
Phenobarbital 5mg/kg IV or PO q 24 hr.
Midazolam (Versed)-Very cautious use in
prematures due to increased incidence ofIVH & other neurological adverse effects
according to the NO PAIN study
Chloral hydrate 20 to 50mg/kg orally- onoccasion may cause excitability
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Opioids
Fentanyl 1-4mcg/kg IV q 2 to 4 hr.
1-5mcg/kg/hr continuous infusion
Infuse over at least 15 min.
Observe for chest wall rigidity.
Compared to morphine, has less BPeffects, less histamine release, and
decreases pulmonary vascular resistance
Can be reversed with NarcanSome references suggest using the paralyzing
agent Pavulon to counteract chest wall rigidity
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Opioids
Morphine 0.05 to 0.2 mg/kg IV q 4 hr.
0.01 to 0.015mg/kg/hr (may have
loading dose ordered)
Can be given PO (onset & durationunpredictable)
Avoid rapid infusion-can decrease blood pressure andheart rate and cause bronchospasm.
Decreases GI motility Can be reversed with Narcan
Morphine is used for weaning from in utero drug exposure
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Opioids
Metabolism of Fentanyl & Morphine alteredby maturity of liver
May need higher doses of opioids due tohigher body water content
Hypotension more likely in hypovolemia
Wean opioids after prolonged use (5-7days)
Avoid Opiophobia!
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EMLA
Mixture of lidocaine/prilocaine
Approved for use in infants 37 wk. or more
Used for circumcision, venipuncture,arterial puncture, PICC placement
Apply 60 minutes before procedure
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Circumcision Pain
AAP states-procedural analgesia necessary
Subcutaneous Ring Block
Dorsal Penile Nerve Block
EMLA
Sucrose Pacifier
Acetaminophen
Physiologic Positioning
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Circumcision Pain
NEVER use Lidocaine with Epinephrine
due to compromise of blood supply and
potential for severe tissue damage Buffered Lidocaine stocked in Omnicell
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End of Life Pain
Opioids to prevent unnecessary pain
Palliative care orders include opioids and
other medications for patient comfort Consider ethical and humane care for dying
infants
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Conclusion
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