Literature Review
Neonates are exposed to an assortment of stimuli that generate pain on a daily basis including mechanical ventilation, repeated heel sticks for blood draws, acute medical illnesses, postoperative issues, and even invasive procedures. It has been found that acutely ill neonates in the NICU are subject to between 50 and 132 bedside procedures that can cause pain in a single 24-hour period (Witt, 2016). Nurses, in their nature, strive to make comfort their primary focus. The nurse must strive to alleviate the pain and discomfort of their patients regardless of the ability of the patient to communicate that pain. Sadly, even though there is an abundance of research on pain responses in neonatal populations, this population still falls victim to underestimated and undertreated pain, whether it is related to slowness of changing attitudes, inadequate knowledge, limited assessment tools, or a failure to recognize the response to pain.
One misconception that has been widely proven incorrect is that neonates are unable to feel pain because of their immature central nervous system (Johnston, 2011). Pain management in the neonate has experienced remarkable changes over the past couple of decades. These changes stemmed out from the attempts of health professionals to refute misconceptions regarding pain among neonates. Formerly, the belief was that neonates have limited responses to stimuli, because of the undeveloped nervous system. However, research has demonstrated that the premature nervous system makes neonates more likely to feel pain. Some believe that the neonate may experience hypersensitivity to pain compared to the adult in pain (Smith, 2011). Researchers also suggest that untreated pain among neonate can have long-lasting developmental impacts. These current developments indicate that neonatal pain management must be effective and safe to prevent the negative consequence of untreated pain. Also, reducing pain can improve both short-term and long-term outcomes. These outcomes could be then later used as evidence to guide neonate clinical practice. This paper discusses evidence-based practice in neonate pain management.
Assessing Pain Response in Neonates
Physiological Alterations in Response to Pain
Several known indicators may be measured to assess physiological responses to pain, including heart rate, blood pressure, respiratory rate, blood oxygenation, palmar sweating, vagal tone and intracranial pressure (Johnston, 2011). Other physiological symptoms of pain may include dilation of pupils, changes in skin and body temperature, increased muscle tone, sweating, and increased defecation and urination. While these methods of assessment may shed some light on the pain response, it is essential to look at all the body systems and how they are affected to understand the pain response truly. The nurse should also be mindful that each infant’s response to pain will have variations and may exhibit more or less response based on gestational age and individual factors. It is also important to note that while pain may include these responses, they can also be caused by other factors.
Behavioral Response to Pain
Pain can also be noted through facial expression, body posture, movements, and vigilance. There has been substantial evidence reported in research studies that have linked facial expression of neonates to specific emotions. Longer crying time is also attributed to pain, but these responses need to be observed in context, and the situation as infant crying may signal different needs. Changes in sleep patterns can also be used by the nurse to identify pain among neonate patients.
In a study that assessed facial expression in neonates who underwent heal lance determined that evaluation of pain while assessing eye squeeze, nasolabial furrow, the opening of the mouth, and brow bulging are significant cues that indicate pain in healthy neonates (Rushforth & Levene, 1994). The research revealed ninety-seven percent of term infants and eighty-four percent of preterm infants demonstrated an increase in these behaviors as a response to the heel lance. This assessment should be considered a vital tool because its use could dramatically affect the amount of pain reduction available to the infant when the cues are identified. Equally significant is that this method can be implemented at the bedside and with proper education, will diminish disagreements in differing pain scores from one healthcare provider to the next.
Hormonal/Metabolic Response to Pain
In addition to physical and behavioral responses to pain, there are now resources available that allow the healthcare provider to measure chemical changes as a response to pain in the neonate. Increases in epinephrine and norepinephrine, growth hormone, and endorphins have been noted. This was achieved by measuring levels before, during and after heal lance. Studies have also concluded that insulin secretion is decreased during pain. Furthermore, cortisol, glucagon, and aldosterone levels were increased with noxious stimuli. This finding translates to increased serum glucose, lactate, and ketones, which could then progress the infant to lactic acidosis.
These hormonal changes noted in the neonate can affect their absorption of essential nutrients like fats, proteins, and glucose. Insufficient absorption then has a direct correlation with their healing process and progress, as well as, their growth and development. It has become evident that pain management is so much more than merely keeping the neonate comfortable. When the healthcare team can control their pain, it leads to a decrease in complications.
Assessment: Pain Scales
Self-help reports are the most common instrument for pain assessment, but these tools only apply to patients who can communicate. Since neonates cannot talk, self-help report is not applicable, and the nurse must assess pain using a combination objective signs and subjective observation that are then scored or scaled. However, accurately determining the level of pain among neonates is extremely difficult. Assessment is very complicated given that there are more than 50 different pain scales that are currently in use (Johnson, Ranger & Anand, 2017). These pain scales and pain assessment tools rely on a combination of behavioral observation (such as body posture, tone, and facial expression) and Physiological parameters that include blood pressure, oxygen saturation and heart rate. There are cases when behavioral measures and physiological measures do not correlate. The former may reveal pain specifically while the latter reflects generalized physiologic stress. It has been found
that different responses are p
revalent in neonates. Among the most widely used pain assessment scales for neonates include the following: Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Neonatal Infant Pain Scale (NIPS), CRIES, and Pain Assessment in Neonates Scale (PAIN).
The Children’s Hospital of Eastern Ontario Pain Scale is a behavioral scale that is widely used to evaluate postoperative pain in children and may also be beneficial in monitor the usefulness of interventions that have been implemented by healthcare providers. It can assist in evaluating effects for reducing the pain and discomfort and is typically applied to children from birth to four years old (Rudd & Kocisko, 2014). This scale bases its assessment of pain on crying, facial expression, verbal cues, assessment of the torso, response to touch and movement of legs. The minimum score is four with a maximum score of 13 (Rudd & Kocisko, 2014). This scale also outlines definitions of each choice in the six parameters, providing further understanding and clarification to decrease variability in rater scores.
The Neonatal Infant Pain Scale is a six-item scale that was developed based on a survey of 43 neonatal nurses who were asked to identify behaviors associated with pain in patients they cared for in the NICU. The six categories identified were facial expressions, crying, breathing pattern, arm movement, leg movement, and infant arousal states. The total score range is 0-7. This scale was used to score 38 term infants’ pain two minutes before, during needle insertion, and three minutes after the procedure in order to test its validity for assessing pain in infants (Lawrence, et al., 1993). These researchers determined the NIPS was a successful tool and its use became common to determine the need for pain management in neonates.
The CRIES scale is another simple validated tool that allows assessment of pain through physiological and behavioral function. It was developed at the University of Missouri at Columbia as a method to evaluate pain in the postoperative period. This tool assesses crying, need for oxygen therapy, increased vital signs, facial expression, and infant sleep state by assigning a value of 0-2 to each category. This scale was an improvement on the NIPS scale because it provided a greater range of score. However, the assessment of the blood pressure is seen as a procedure that could be painful to the neonate, likely resulting in unnecessary distress and could have an effect on the observes scoring (Bildner & Krechel, 1996).
The Pain Assessment in Neonates Scale was developed in response to a study seeking to improve the effectiveness of rating neonatal pain by combining the NIPS and CRIES scales and addressing the downfalls that the researchers experienced with the two. A group of researchers, seeking to validate pain scales within their organization, designed a study to compare the results of the NIPS and CRIES on the NICU floor and a Step-Down Unit (SDU). The nurses that were involved with this research survey stated worries that the NIPS gave more weight to body movements by assigning it two categories while the rest of the behavioral cues were assigned to as single category (Hudson-Barr, et al. 2002). Additionally, it is common for neonates to be swaddled for comfort creating a dilemma. Do the nurses disturb the baby to assess movement or assume that if they are not moving then they are not in pain. On the other hand, the CRIES assessment requires checking blood pressure which is considered a painful procedure that could cause stress to the infant (Hudson-Barr, et al. 2002). The PAIN scale combined extremity movements into one category, eliminating the uneven weight of bodily movements, and eliminated blood pressure from the assessment creating less distress on the infant.
Long-Term Effects of Unmanaged or Poorly Managed Pain
Neonates experience a multitude of procedures that can cause them to experience pain. Studies have shown that neonates undergo about 750 procedures during their hospital stay (Fitzgerald, 2009). Since infants cannot communicate their pain, it is likely that it will go unnoticed. Untreated pain can have adverse long-term effects on the development of the child. When the pain goes unmanaged, this results in prolonged suppression of the immune system, placing the patient at an increased risk for multiple complications (Pasero & McCaffery, 2011). The brain of neonates is still developing, and untreated pain causes changing levels of neural activity. The central nervous system responds to the pain and may create neural pathways. This persistent sensitization of pain can alter the healthy development of the brain or can have damaging effects on the entire central nervous system.
Neonatal surgery is linked to changes in future pain response. Neonates that undergo circumcision without analgesia were found to have enhanced behavioral response to immunization several months later. Following neonatal circumcision without analgesia, the behavioral response to immunization many months later is also enhanced (Tadio, 2008). Children that were exposed to neonatal intensive care as infants were found to have persistent changes in sensory processing (Hermann & Holdmeister, 2006) and the degree of change was more intense among children who have undergone surgery as a neonate. Animal studies found that injury during the neonatal stage may occur because enhancement is a somatosensory response and this could be true among humans.
Pharmacological Pain management
Opioids are effective pain management medication, but there are dosage requirements which are much lower among neonate than among children and infants. Opioids are given based on body weight, and since neonates have the lowest body weight, there is a decreased clearance in neonates. In procedures that require surgery, however, opioids are used as part of pain management. Recent studies have shown that opioids are safe. Protocols vary and may include intermittent bolus doses, continuous infusions, or nurse-controlled analgesia (Lago, 2013). Respiratory depression is one of the side effects of opioids, and the fear of side effects is a contributing factor to the inadequate use of opioids in neonates.
Paracetamol is also given to neonates, usually in combination with other drugs, as a form of pain management. Its analgesic efficacy is influenced by dose, route of administration, and type of pain stimulus. It may be administered orally and intravenously. Paracetamol may benefit neonates because it can lead to reduced general anesthetic and opioid requirements. There is also evidence that paracetamol use can lead to a reduction in the need for postoperative mechanical ventilation. It is also advisable to neonates that are susceptible to respiratory complications (Walker, 2014). Additionally, it has also meager complication rates.
Acetaminophen and NSAIDs inhibit prostaglandin formation and have minimal risk of causing respiratory depression. They are not used as sole agents for severe or moderate pain but are instead used to assist opioid analgesia, which can then lead to a reduction of the dose of opioids. The use of this combination limits the adverse effects of opioid use. The commonly used IV NSAID for analgesia in neonates is Ketorolac, which has been found to be safe and effective, though evidence of safety is mostly anecdotal and retrospective. Acetaminophen is found to be an attractive agent for pain management in neonates, but dosing should be based on gestational age, and strict attention to dosing must be provided to prevent toxicity. Acetaminophen is used as an adjunct to opioid analgesia to reduce the adverse effects of opioids. One adverse effect of NSAID is bleeding, and if provided to neonates there should be close observation for clinical signs of bleeding. Future clinical trials are needed for NSAID use.
Non-Pharmacological Forms of Pain Management
Non-pharmacologic method for
pain management includes
oral sucrose or glucose, breast or bottle feeding, skin-to-skin care Kangaroo Care (also known as skin to skin care). Growing interest has developed in this area of pain management due to the significant amount of painful procedures neonates are subjected to due to their status as preterm. Because there are many adverse effects associated with pharmacological interventions, there is a desire to step outside of that realm and explore new methods to decrease painful stimuli in the neonate. Nonpharmacological methods are extremely desirable to the healthcare community because they have proven to be effective and work in two different ways. These methods are believed to block nociceptive transmission, activate descending inhibitory pathways, and activate the attention and arousal systems that modulate pain. Indirectly, they reduce the amount of total noxious stimuli.
Oral sucrose is administered to infants because it causes the body to released natural opioids through an unknown mechanism (Walker 2014). Stevens (2012) conducted a systematic review of the oral sucrose method among neonate population and found that it significantly reduced the pain associated with procedures. Neonate patients who receive sucrose exhibited a significant decreased in behavioral and physiologic indicators of pain. It also showed improvement in various validated pain scores. In clinical experiments, vital signs were found to be more stable when compared to a placebo. Oral sucrose is safe and has limited side effects. The recommended dosage ranges from 12 to 120 mg (24 % sucrose solution or 20–30 % glucose solution). Sucrose therapy, however, is not recommended to infants after three months of age because its efficacy is reduced.
Breastfeeding or Breastmilk
Breastfeeding is an alternative to sucrose use for pain therapy of the neonate. Breastfeeding was found to have an advantage for one-time painful procedures (Shah, 2006). Breastfeeding the neonate after a one-time painful procedure such as heel stick procedure or venipuncture demonstrated a decrease in the variability of physiologic response associated with pain (Witt, 2016). It showed a reduced duration of total crying time, a lower increase in heart rate, and decreased scores in standardized pain assessment tools such as the neonatal infant pain scale (NIPS), and neonatal facial coding system (NFCS) (Witt, 2016). Another study conducted in Taiwan revealed that the use of breastmilk or sucrose in combination with tucking showed a significant decrease in pain recovery after heel stick compared to no intervention at all (Peng, et al., 2018). This evidence further points to the effectiveness of using multiple non-pharmacological interventions to relieve pain.
Other Non-Pharmacological Therapy
Kangaroo care or Skin to Skin contact, positioning, and non-nutritive sucking are categorized as environmental interventions, and they have been known to have useful pain reduction properties, notably when used in combination with sweet solutions and breastfeeding (Witt, 2016). Kangaroo care is allowing direct physical contact with a parent and is named for the way that animal’s provide when caring for their young. It is also known as skin to skin care. Kangaroo care is found to be effective in reducing pain as indicated by both stable physiologic parameters and lower scores in pain assessment tools (Johnston, Campbell-Yeo, Fernandez, Inglis Streiner & Zee 2014).
Careful positioning is also found to be effective in reducing pain. Examples are swaddling a neonate, also known as facilitated tucking. This method involves manually flexing the patient’s arms and the legs and wrapping them snuggly in a blanket (Witt, 2016). The goal is to foster self-soothing behaviors. Non-Nutritive Sucking such as pacifier is also found to be effective in reducing pain among preterm and term infants (Riddell, Racine & Turcotte 2011). It decreases crying time and lowers the variability in heart rate when compared to no intervention, swaddling alone, or rocking alone (Riddell, Racine & Turcotte 2011).
Simple implementations like reducing light levels and noise levels aids in reducing stress, promoting sleep while developing their circadian rhythm, and increases weight gain. It is essential to understand that these environmental methods can reduce the pain associated with procedures independently or in conjunction with multiple pain reduction techniques, none of them require a doctor’s order and can be implemented by the nurse unless contraindicated (Witt, 2016).
Role of the Nurse
The critical role of the nurse is to have knowledge of the mechanism of pain in neonates. It is vital that nurses believe that neonates do feel pain. This is important as the misconception about neonate pain is still prevalent in the medical community. If the nurse considered the neonate as capable of experiencing pain, they could quickly identify behavioral cues. The nurse should be adept in the use of standardized pain assessment scales specific to neonates in order to assist in her understanding of pain, and to confirm her observation during the assessment of pain. Some scales involve evaluation of crying time, but crying can mean many things and not only pain. It can mean that the infant is just hungry or uncomfortable. In many cases, neonates are intubated and pharmacologically sedated and thereby are incapable of crying. The nurse should know how to evaluate the applicability of the pain assessment tool especially if one of the parameters is crying (Martinez, Grassi, & Marques, 2011). Crying can be a useful tool in the assessment of pain, but it must be analyzed in the context of which it is happening with the neonate.
Other behavioral parameters of assessment tools that need nursing skills are facial expression. It requires keen observation and the nurse’s instinct to analyze facial expression as a manifestation of pain. Still, it is imperative to remember that the quality and intensity of the pain cannot be determined by facial expressions alone. Also, a nurse cannot solely rely on their experiences due to the multitude of different responses that each child may exhibit. This can lead to the nurse over or under-diagnosing pain if only their experience is guiding them in their assessment.
The nurse must know the consequence of untreated pain. This will serve as a motivation to constantly assess the newborn for pain. While the pharmacological intervention can be administered by the attending physician and the role of the nurse is monitoring, the non-pharmacological interventions, on the other hand, are typically only implemented by the nurse. This means that the nurse should be familiar with non-pharmacological interventions that can aid the neonate in feeling more comfortable and reduce pain. Skin to Skin requires the caregiver to be educated. The caregiver must understand that this method can assist in pain reduction and should regularly be employed. Skills and knowledge about proper positioning are also vital to the nurse role in neonatal pain management. The nurse must also know the negative consequence of non-pharmacological intervention and include this information in their patient education program. Non-nutritive sucking such as using a pacifier, for example, may lead to early weaning. This method if not applied correctly can have more detrimental effects. As mentioned beforehand, nurses do not prescribe medication, and their role is to monitor (unless there already exists clinical protocols). Knowledge of the prescribed medicines helps in discussing with other healthcare professionals the possible strategies for the better management of the pain, without adverse consequences for the neonate health.
Whatever the method employed by the multi-professional team for pain relief, the nurse must always remember that the humanization of the care should be the primary focus of nursing care activities. The nurse must seek to minimize the trauma on neonates that
is caused by the proces
s of hospitalization and subjection to multiple painful procedures. Aside from recognizing the ability of neonate to feel pain, the nurse must see to it that she has a genuine awareness of the importance of her role in assisting the neonatal patient in relieving its pain. She must continue to assess the neonate’s pain based on scientific advances in the area and not just on personal beliefs.
The nurse must know her role as a childbirth educator. They must know what parents, whose infants may undergo painful procedures, need to know. The inclusion of pain as a possible risk when considering treatment in procedures is essential since most healthcare providers overlook this (Witt, 2016).
The nurse as the educator should promote minimizing pain experiences and increasing comfort measures for neonates under their care (Page, 2004). Parents of the neonate must also be educated on the substantial benefits of infant soothing and skin to skin contact to assist the infant in their ability to handle these daily stressors while encouraging parents to amplify their use of human contact with the infant (Page, 2004). It is the nurses responsibility to be a well-informed nurse who can then transfer their knowledge to the parent who can both take an active role in the prevention, management, and treatment of the adverse effects of infant pain (Page, 2004).
Recommendations
Many researchers suggest a standard policy related to the education for staff should be established and focus on further improvement in the understanding and management of neonatal pain. More research should be undertaken to increased high-quality evidence in neonatal pain management. Availability of data regarding the effects of medication from clinical and laboratory studies is vital. This will help the multi-professional team understand age- and injury-specific dosing.
Efforts should be made to increased validation and use of neonatal pain assessment tools because they rely on observer assessment of behavioral and physiological responses which at times is influenced by nursing knowledge and other factors that may compromise their validity. Clinical guidelines on neonatal pain management should be available to nurses and should be regularly updated. The guidelines should be revised according to the latest empirical evidence. The guidelines will ensure effectiveness in and consistent pain assessment and pain management. The hospital must have pain assessment tools in place and the corresponding procedure and guidelines to follow after conducting pain assessment, which may include documentation, interpreting scores, and frequency of pain assessment.
Along with education of pain measurement in neonates, implementations should be in place to prevent neonatal pain as well. Possible solutions include; combining procedures and clustering care; decrease noises and bright lights; ensure the infant’s sleep-wake cycle is respected; using smallest gauge needle possible for the procedure and minimizing the amount of tape used; consideration for placement of a peripheral or central line to reduce number of painful sticks for long-term care. By implementing these interventions and incorporating some of the nonpharmacological techniques discussed, the neonate will receive better care and be subjected to less stress, thereby increasing the effectiveness of their pain management.
The nurse should advocate for an integrated approach with targeted practice interventions, education and use of validated assessment tools. Factors that may also be included in the integration of methods include local protocols for pain medication administration as well as regular audit and feedback. This will ensure translation into improved outcomes for neonate pain management.
Conclusion
Based on the discussion in this paper, the management of neonate pain starts with the recognition of the fact that neonates feel pain and understanding that they are exposed to a variety of medical procedures that cause pain during the duration of their hospital stay. The management of pain involves both pharmacological and non-pharmacological intervention to maximize positive results of pain management.
Provisions of effective pain medication are best accomplished by a combination of non-pharmacologic and pharmacologic techniques. Dosing should be guided by an age-appropriate pain assessment scale. Opioid medications are the most effective in the post-surgery management, and acetaminophen and NSAIDs are used in adjunct to opioid to reduce the adverse side effects of opioids. Opioids remain the choice of pain medication in surgery, but there are several options such as regional anesthesia. The regional anesthesia method does require appropriate experience and training though.
The proper use of pain assessment tools is an important role the nurse assumes in pain management. The assessment results will be the basis on the decision for medication and non-medication intervention. The assessment tools do have flaws, meaning the nurse should also rely on her experience and instinct to properly evaluate pain in neonates. Kangaroo care and oral sucrose can also help reduce the pain, and they are useful in combination with pain medications. Future research is still needed to better quantify the adverse effects of untreated pain on neonatal patients. Clinical trials that compare various approaches should also be conducted.