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Focusing on Infant Pain Relief
Reducing discomfort is part of providing healthcare but pain can be under−treated when it comes to premature infants. For newborns in the neonatal intensive care unit (NICU), diagnostic and therapeutic procedures, including spinal taps, intravenous line placement, blood sampling, chest and endotracheal tube placement and others are common, necessary, and life−saving interventions. They are also painful and when it comes to treating tiny infants, many procedures require multiple attempts to achieve success.
A recent study published in the July 9 edition of the Journal of the American Medical Association prospectively reviewed the practice of pain management in 430 newborn ICU patients in hospitals near Paris. Among other measures, they documented the frequency of painful procedures during a hospitalization, the total number of procedures per neonate, the numbers of repeat attempts at procedures, and the types of pain management used for different types of procedures.
They reported that of over 42,000 procedures performed on over 400 neonates, 79.2% were performed without specific pain reducing medications or techniques. Multiple factors influenced the degree of pain management offered newborns including how premature the infant was, whether parents were present, the time of day during which surgery was scheduled and even the number of days since admission.
Treatment of pain in the NICU is complicated by the inability of neonates to communicate their degree of pain, or the degree of their relief from treatment, as well concerns for potential medication side effects.
Hospitals often provide infants with non−medicinal pain relief such as pacifiers, sweet liquids, stroking and "kangaroo care" — carrying the baby strapped against a parent or other adult's body. Soothing changes in the environment are also used, including decreased exposure to light and noise.
When pain and sedative medications are used, they may be given topically, intravenously, and orally. Deciding what is a safe and effective dose is complex for small sick babies, with immature metabolisms, potential interactions with other medications, and underlying complex illnesses. Additionally, there is concern about the long−term effects of exposure to certain medications on the developing brain.
Studies have shown that the experience of pain also has long−term effects. Newborns who experienced repeated pain showed changes in neurologic development and changes in their immediate and future behavior. Some babies who have experienced repeated pain, develop hypersensitivity to non−painful tactile stimuli, including handling for routine care. This raises concerns about the long−term developmental consequences for behavior and temperament of early pain exposure.
Interest in appropriate pain management in the neonatal intensive care unit is focused both on immediate relief and reduction of the long−term neurodevelopmental consequences of pain. Much attention has been given to the progress in this area. The American Academy of Pediatrics has issued guidelines for the reduction of noxious procedures, and the management of pain in 2006. This recent JAMA study adds important data and direction to the literature supporting the need for heightened awareness and procedural changes to improve this critical issue in the care of the sick neonates.
July 15, 2008
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