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A new consensus statement stresses that neonates experience pain too and should be treated accordingly
Is there pain associated with a venipuncture, venous or arterial catheter insertion, tracheal intubation or lumbar puncture? Almost all health professionals would answer with a resounding Yes. Yet, when these procedures are performed on neonates in the neonatal intensive care unit (NICU), it has not been uncommon to see no pain treatment given or, if pain treatment is given, it's limited to the initial procedure itself.
"Indeed, even in the late '80s, it was not uncommon for a baby to go into the operating room for open-heart surgery and get nothing but the anesthetic during the procedure," said Marcia Buck, clinical pharmacy specialist for pediatrics at the University of Virginia Children's Medical Center, Charlottesville, Va.
This seems almost unthinkable. What adult would tolerate this? But, critically ill and preterm neonates do not demonstrate vigorous responses to pain. So, unless pain is carefully assessed, it can be overlooked. To be certain it isn't overlooked, K. J. S. Anand, M.D., of Arkansas Children's Hospital, Little Rock, and the International Evidence-Based Group for Neonatal Pain have developed a "Consensus Statement for the Prevention and Management of Pain in the Newborn," published in the Archives of Pediatric and Adolescent Medicine in February.
"Anand's mission is to improve pain management," said Marita Nazarian, director of pharmacy at Arkansas Children's Hospital. "He's really changed our practice here quite a bit. I think we're more aggressive in treating pain. We're certainly looking for it consistently," she explained.
During the first few days and weeks after birth, all newborns undergo routine invasive medical procedures. However, healthy babies experience far fewer pro-cedures than neonates in the NICU. One study found that neonates in the in-tensive care unit undergo as many as three invasive procedures per hour. Another documented a baby born at 23 weeks gestation, with a birth weight of 560 gm, had 488 in-vasive procedures. That same study found that endotracheal suction, heel prick, and blood sampling make up more than 90% of the procedures in the NICU.
The consensus statement covers neonatal types of pain experienced, pain assessment, and management. It also offers specific suggestions to treat pain from certain procedures, by using environmental methods, behavioral methods such as sucrose and nonnutritive sucking, as well as drugs for preemptive analgesia and ongoing pain. Pain control is recommended for procedures ranging from subcutaneous and intramuscular injection to circumcision.
For example, suggestions for procedures such as percutaneous catheter insertion, arterial or venous cutdown, and central line placement include the following: applying EMLA (a lidocaine and prilocaine cream from AstraZeneca), subcutaneous infiltration of lidocaine, and perhaps a dose of an opioid. In addition, central line placement could be done using general anesthesia. Buck noted that at the University of Virginia Children's Medical Center, "EMLA is probably not used to its fullest advantage. We have a lot of experience with it now and are comforted by its safety profile now that it has been on the market so long." She thinks sometimes the time required to use it and the cost get in the way of frequent use.
In the NICU at Arkansas Children's Hospital, pain control is in part determined by an ongoing study. Neonates on ventilation are treated with extremely low-dose morphine or placebo in addition to the normal sedation drugs such as phenobarbital or lorazepam. When invasive procedures are performed, additional doses are used.
Although dosing a neonate can be tricky, Nazarian expects all doses to be carefully checked. "This is a pediatric hospital. Because the orders can be so difficult, we've insisted for many years that every order has to be evaluated and the dose checked."
Buck sees the new guidelines as fitting well with the Joint Commission on Accreditation of Healthcare Organization's interest in pain. "It's what JCAHO is looking for in pain management," she commented. "Seeing an ongoing plan, rather than one event, looking at the baby as a whole and long-term. We've come a long way in a relatively short period of time, but we still have a ways to go to catch up to our counterparts who deal with adults. They deal more holistically with the patient. They're much better at making pain a part of the overall treatment plan."
Kathy Hitchens. New guidelines advise pain management for neonates.