Neo Pain

Shelby Wilham NUGR 615

Neonatal Pain

index

References

Pain Scales

Pharm tx

non-pharm tx

Assessment

Physiology

Physiology

Do Neonates feel pain?

• Prior to 1980 it was believed that neonates did not experience pain
• believed infants could not form memories and therefore did not have pain
• Concerns about side effects of anesthesia led to procedures/surgeries to be practiced without analgesia until 1990s
• MRI brain scans of infants revealed same response to pain when exposed to a stimulus 1/4 as strong
• indicates neonates are more sensitive to pain than adults

Thalamus localizes the pain response

05

Signal Separates

Surrounding cells release pain signaling chemicals in response

Nocioceptor turns signal into an impulse

interaction with a painful stimuli occurs

04

01

02

03

How do we sense pain?

Development of nocioception Pathway

• The myelin sheath is an electrical insulator- it increases the speed of signals traveling between the peripheral and central nervous system
• Develops after 25 weeks GA and is completed by 37 weeks GA
• It was once believed that unmyelinated neurons were unable to transfer signals
• incomplete myelination CAN transfer signals but at a slower rate
• offset by shorter distance to neonatal brain

Role of Myelination and neonatal pain

• Ascending pathways transmit noxious stimuli by 24 weeks GA
• Descending inhibitory neurotransmitters, part of the descending pathway and central in the role of pain modulation, take longer to develop
• Pain modulation
• ability for neurotransmitters to enhance or inhibit painful stimuli during pathway of perception
• Until 48 weeks, the immaturity of the descending pathway exposes infants to greater sensitibity & intensity

Pain Pathways

Painful consequences?

• changes to the hypothalamic-pituitary- adrenal axis
• reduction in brain growth
• altered development of the thalamus, decreased parietal and frontal brain width
• change in functional connectivity in temporal lobes

Untreated Neonatal Pain is associated with the following:

• poor executive function
• channges in motor & visual abilities
• blunted behavioral responses
• increased phsiological response
• altered pain thresholds
• decreased size of cerebellum
• epigenetic changes

painful experiences are multi-faceted- they depend on the intensity of the painful stimuli and how it is processed and interpreted by the body. Pain assessment is complex and subjective in nature and self-evaluation of pain is first choice- however this is not an option in this population. therefore providers need to recognize indicators of pain in neonates to provide adequate treatment and prevent adverse outcomes

Assessment tools

Behavioral

Neurophysical

Physical

Signs & Symptoms of Neonatal Pain

Click image to see detailed information of each pain scale

• N-PASS- Neonatal Pain, Agitation, and Sedation Scale
• PIPP- Premature Infant Pain Profile
• PIPP-R- Premature infant Pain Profile Revised

Established pain scales

• NFCS- Neonatal Facial Coding System
• FLACC- Face, Legs, Activity, Cry, Consolability
• Comfort Neo
• NIPS= Neonatal Infant Pain Scale

Treatment

Nonpharmacologic treatments either block the nocioceptive transduction or activate descending inhibitory pathwaysCombining nonpharamacologic treatments offer the most effective analgesic effectsclick the picture to see different techniques and when they are most appropriate

Nonpharmacologic Treatment options

• Optimal approach to pain management remains unclear
• difficult pain assessment
• variability in metabolism of medications
• drug clearance rates
• unclear consequences regarding neurodevelopment
• Non-opioid analgesics, local anesthetics, and opioids are pharmacological treatments
• Use a stepwise

Pharmacologic treatments

• Paracetamol (acetaminophen)
• EMLA
• lidocaine/prilocaine

non-Opioids

Opioids

• Used in the treatment of moderate to severe pain. Challenge in perscribing due to concerns of neurodevelopmental effects and sensitivities and slower drug clearance rates.
• Most common opioids
• Morphine

• Fentanyl

References

American College of Obstetricians and Gynecologists. (n.d.). Facts are important: Gestational development and capacity for pain. https://www.acog.org/advocacy/facts-are-important/gestational-development-capacity-for-pain#refCampbell-Yeo, M., Eriksson, M., & Benoit, B. (2022). Assessment and management of pain in preterm infants: A practice update. Children, 9(2), 244. https://doi.org/10.3390/children9020244 Hatfield, L. (2014). Neonatal pain: What′s age got to do with it? Surgical Neurology International, 5(14), 479. https://doi.org/10.4103/2152-7806.144630 Marko, T., & Dickerson, M. (2016). Clinical handbook of neonatal pain management for nurses (1st ed.). Springer Publishing Company. Pacifici, G. (2015). Clinical pharmacology of fentanyl in preterm infants. a review. Pediatrics & Neonatology, 56(3), 143–148. https://doi.org/10.1016/j.pedneo.2014.06.002 Pacifici, G. (2016). Metabolism and pharmacokinetics of morphine in neonates: A review. Clinics, 71(8), 474–480. https://doi.org/10.6061/clinics/2016(08)11 Pacifici, G., & Allegaert, K. (2015). Clinical pharmacology of paracetamol in neonates: A review. Current Therapeutic Research, 77, 24–30. https://doi.org/10.1016/j.curtheres.2014.12.001 Perry, M., Tan, Z., Chen, J., Weidig, T., Xu, W., & Cong, X. S. (2018). Neonatal pain. Critical Care Nursing Clinics of North America, 30(4), 549–561. https://doi.org/10.1016/j.cnc.2018.07.013 Puchalski, M., & Hummel, P. (2002). The reality of neonatal pain. Advances in Neonatal Care, 2(5), 233–247. https://doi.org/10.1016/s1536-0903(02)80059-5 Shahid, S., Florez, I. D., & Mbuagbaw, L. (2019). Efficacy and safety of emla cream for pain control due to venipuncture in infants: A meta-analysis. Pediatrics, 143(1). https://doi.org/10.1542/peds.2018-1173

THANK YOU!

The ability to sense pain depends on the development of nocioceptors- nerve endings that respond to pain stimuli and release pain signaling chemicals. The nocioceptive pathway follows the following timeline (be sure to click interactive elements)

Pain Pathways

American College of Obstetricians and Gynecologists. (n.d.). Facts are important: Gestational development and capacity for pain. https://www.acog.org/advocacy/facts-are-important/gestational-development-capacity-for-pain#ref Puchalski, M., & Hummel, P. (2002). The reality of neonatal pain. Advances in Neonatal Care, 2(5), 233–247. https://doi.org/10.1016/s1536-0903(02)80059-5

References

Perry, M., Tan, Z., Chen, J., Weidig, T., Xu, W., & Cong, X. S. (2018). Neonatal pain. Critical Care Nursing Clinics of North America, 30(4), 549–561. https://doi.org/10.1016/j.cnc.2018.07.013 Puchalski, M., & Hummel, P. (2002). The reality of neonatal pain. Advances in Neonatal Care, 2(5), 233–247. https://doi.org/10.1016/s1536-0903(02)80059-5

References

Hatfield, L. (2014). Neonatal pain: What′s age got to do with it? Surgical Neurology International, 5(14), 479. https://doi.org/10.4103/2152-7806.144630 Marko, T., & Dickerson, M. (2016). Clinical handbook of neonatal pain management for nurses (1st ed.). Springer Publishing Company.

References

There are over 40 pain scales published and even more scales that are used in the clinical setting that may not have been validated or researched in the neonatal population. A good pain scale should have high specificity, reliability, validity, and responsiveness

Which Scale Should I Use?

Reference Campbell-Yeo, M., Eriksson, M., & Benoit, B. (2022). Assessment and management of pain in preterm infants: A practice update. Children, 9(2), 244. https://doi.org/10.3390/children9020244 Perry, M., Tan, Z., Chen, J., Weidig, T., Xu, W., & Cong, X. S. (2018). Neonatal pain. Critical Care Nursing Clinics of North America, 30(4), 549–561. https://doi.org/10.1016/j.cnc.2018.07.013

References

only medication recommended to treat fever in neonates. Higher doses induce PDA closureMechanism of action: activates descending serotonergic pathways and inhibits prostaglandin synthesis. Eliminated by renal route- clearance lower in neonates than children and adults

A Cochrane review found that analyzed 8 studies including 614 infants found that paracetamol when compared with water, cherry elixer, and EMLA did not reduce pain associated with heel lance or examinations. May have some opioid sparing effects for major pain/post-op & effective in minor to moderate pain conditions. Still frequently used for procedural pain despite current best evidence

Paracetamol

Dosage

Combo of 2.5% prilocaine & 2.5% lidocainetopical agent commonly used to reduce pain with lumbar puncture. Recent review of 29 studies found that toical anethetic alone did not provide sufficient pain relief. Recent evidence demonstrates the medication is ineffective at reducing pain with heel lance, venipunture, insertion of intravenous or intraarterial linesMechanism of action: works by stabilizing neuronal membrane preventing initiation and conduction of nerve impulses.Adverse effects are usually limited to local skin reaction but med may cause methaemoglobinemia especially in preterm infantsdose 0.5-1g

EMLA

Shahid, S., Florez, I. D., & Mbuagbaw, L. (2019). Efficacy and safety of emla cream for pain control due to venipuncture in infants: A meta-analysis. Pediatrics, 143(1). https://doi.org/10.1542/peds.2018-1173

Pacifici, G., & Allegaert, K. (2015). Clinical pharmacology of paracetamol in neonates: A review. Current Therapeutic Research, 77, 24–30. https://doi.org/10.1016/j.curtheres.2014.12.001

Campbell-Yeo, M., Eriksson, M., & Benoit, B. (2022). Assessment and management of pain in preterm infants: A practice update. Children, 9(2), 244. https://doi.org/10.3390/children9020244

References

Used in modermorphine has been associated with increased mortality, intraventricular hemorrhage or periventricular leukomalacia, hypotension, prolonged ventilation, feeding intolerance, decreased cerebellar volume and lower 18-month motor and cognitive scores when compared with lower morphine exposure.

Mechanism of action: agonist of both the µ and the k receptors; blocks transmission of nocioceptive signals

Morphine

Dosage

Mechanism of action: agonist of both the µ and the k receptors; 50-100x more potent than morphineCan cause chest wall rigidity, nausea, vomiting, itching, muscle rigidity, laryngospasm, neuro-excitataion, rarely seizure activitylack of studies and clinical pharmacology in this population despite use

Fentanyl

Dosage

Pacifici, G. (2016). Metabolism and pharmacokinetics of morphine in neonates: A review. Clinics, 71(8), 474–480. https://doi.org/10.6061/clinics/2016(08)11

Pacifici, G. (2016). Metabolism and pharmacokinetics of morphine in neonates: A review. Clinics, 71(8), 474–480. https://doi.org/10.6061/clinics/2016(08)11

Campbell-Yeo, M., Eriksson, M., & Benoit, B. (2022). Assessment and management of pain in preterm infants: A practice update. Children, 9(2), 244. https://doi.org/10.3390/children9020244

References