Pain Control

Interventions in Preterm
Neonates

―Dr. Ankit Yadavendra,

MD Paediatrics resident, BHIMS, Mumbai
What is pain?
• a complex sensation triggered by actual or
potential tissue damage and influenced by
cognitive, behavioral, emotional, social, and
cultural factors
• linked with abnormal neurodevelopment
Which stimuli cause pain?
•the stimulus can be
1. thermal (heat or cold),
2. chemical (acid or alkali), or
3. mechanical (torsion, stretch, pinch, or prick)
• Nociception/Pain perception: the series of
electrochemical events following tissue
damage or injury, excluding any emotional
correlates of the noxious sensation
Physiology of pain
Nociceptors:
•present in mucous membranes, cornea,
subcutaneous tissue, bone and teeth, joints, and
muscle
•detect noxious or potentially noxious thermal,
chemical and mechanical stimuli
•transmit the noxious stimuli to the CNS via
nerve fibres
Nerve fibres transmitting pain:
•A-beta (moderately myelinated, fast conducting)
fibres carry impulses from pressure/position
sensors
•A-delta (moderately myelinated, fast conducting)
fibres carry impulses from pressure and
temperature sensors
•C-fibres (unmyelinated, slow conducting) carry
impulses from cutaneous and deep, low
threshold mechanoreceptors, chemoreceptors,
and thermoreceptors
• These fibres enter through dorsal root ganglion
and cross to the opposite side in lateral
spinothalamic tract, and synapse with
secondary neurons to terminate in the medulla,
midbrain, periaqueductal gray matter,
hypothalamus, thalamus, and cortex.
• Afferent impulses can be amplified in the
periphery or the spinal cord by inflammatory
mediators (bradykinin, cytokines,
catecholamines, substance P)
• They can be attenuated by competitive
stimulation of A-beta fibres, endogenous
opioids (endorphins, dynorphins, enkephalins),
serotonergic, noradrenergic, cholinergic and
GABA-ergic compounds
• Fetal stress responses to painful stimuli is seen
by 18 wGA
• Peripheral, spinal and supraspinal capacity for
afferent pain transmission occurs by 26 wGA
• Blood flow changes in contralateral
somatosensory cortex related to heel stick
injury as early as 25 wGA
• These changes are inversely proportional to
gestational age
Neonates show characteristic
•facial expressions,
•aversive body movements,
•alterations in cardiac activity,
•and changes in their cry
in response to painful stimuli
• Nociceptive nerve endings are fewer in number
than in adults, so tissue damage is more
• Descending inhibitory pathways develop later
than afferent excitatory pathways
Pain in preterms causes:
•increased heart rate
•increased blood pressure
•cardiac variability
•hypoxemia
•changes in autonomic tone
•increased venous pressure
•increased cerebral blood flow
•increased intracranial pressure
Inadequately treated repetitive pain in the
developing brain:
•accentuates neuronal apoptosis
•increase hyperreactive pain responses to
subsequent stimuli
•cause long-term behavioural changes
•Recurrent pain exposure:
1. reduces brain maturation (diffuse tensor
imaging and spectroscopy)
2. impaired postnatal growth
3. permanently higher cortisol levels
4. poor motor and cognitive development
• Neonatal males who were circumcised with
little or no analgesia showed significantly
increased pain responses when immunized
at 2, 4, and 6 months of age compared to
infant males who were not circumcised or
who received adequate analgesia.
• Newborns undergoing cardiac surgery for
patent ductus arteriosus (PDA) ligation who
receive less opioid analgesia experienced a
significantly greater stress response and
more postoperative morbidities compared to
infants receiving adequate opioid analgesia.
Pain assessment scales
Preterm and term neonates:
•Modified Neonatal Infant Pain Scale
1. Facial expression
2. Cry
3. Breathing pattern
4. Arms
5. Legs
6. State of arousal
7. Heart rate
8. Oxygen saturation
Children aged 4 mths to 3 years
•FLACC scale
1. Face
2. Legs
3. Activity
4. Cry
5. Consolability
Children aged 3 to 11 years
•FACES scale
Children aged >7 years
•Visual analog scale from 0 to 10
Children aged >11 years
•Numerical Analog Scale
•Verbal Descriptive Scale
Management of pain
4 step approach to painful conditions:
1. Mild pain: cognitive techniques and weak
analgesics (NSAIDs)
2. Moderate pain: oral weaker opioids or
combination of opioids and NSAIDs
3. Severe pain: parenteral opioids
4. Intractable pain: invasive interventions such as
nerve blocks and intraspinal anaesthetic
infusions
Nonpharmacologic techniques
•comfort measures (swaddling, pacifiers,
contralateral tactile stimulation for newborns)
•soothing sounds
•gentle handling and proper positioning
•rest periods between procedures
•reduced environmental stimuli
•heat and cold
•massage
•transcutaneous electrical nerve stimulation
•distraction
Environmental modifications:
1. Light should be shielded from an infant's eyes
2. Minimize sound levels to promote a restful
environment
3. Positioning infants comfortably
4. Facilitated tucking or “hand swaddling”
5. Skin-to-skin (STS) holding or kangaroo care
6. Others: multisensory stimulation, massage,
and music therapy
Nonpharmacologic interventions
1. Sweet-tasting solutions
2. Breastfeeding
3. Nonnutritive sucking
Summary of Procedures and
Recommendations for Pain
Relief
Heel stick
•Use nonpharmacologic measures + mechanical
lance,squeezing the heel is the most painful
phase
•Venipuncture is more efficient, less painful;local
anesthetics, acetaminophen, heelwarming do
not reduce heel stick pain
Venipuncture
•Nonpharmacologic measures, use topical local
anesthetics
•Requires less time & less resampling than heel
stick
Arterial puncture
•Nonpharmacologic measures, use topical and
subcutaneouslocal anesthetics
•More painful than venipuncture
IV cannulation
•Nonpharmacologic measures, use topical local
anesthetics
Central line placement
•Nonpharmacologic measures, use topical local
anesthetics,consider low-dose opioids or deep
sedation based on clinical factors
•Some centers prefer using general anesthesia
Gastric tube insertion
•Nonpharmacologic measures, consider local
anesthetic gel
•Perform rapidly, use lubricant, avoid injury
Umbilical catheterization
•Nonpharmacologic measures, IV
acetaminophen (10 mg/kg),avoid sutures to the
skin
•Cord tissue is not innervated, but avoid injury to
skin
Randomized control trial
• Objectives: to compare individual efficacy and
additive effects of pain control interventions in
preterm neonates
• Participants: 200 neonates (28-36 wGA)
• Method: heel-prick procedure for glucose
assessment and assessment of pain using
Premature Infant Pain Profile (PIPP) score on
recorded videos
•Intervention:

1. Kangaroo mother care with music therapy

2. Music therapy
3. Kangaroo mother care
4. Control (no additional intervention)
• All infants were given 2 ml EBM 2 min prior to
heel prick
• All interventions were provided 10 min prior to
heel prick
• Music (Indian classical flute) was given by
mobile devices at 2 feet distance, 35-45 dB
• PIPP scoring was done at 30 sec after heel
prick
•Statistical analysis: Analysis of variance
(ANOVA)
What is already known?
• Kangaroo mother care, music therapy and
expressed breastmilk are individually effective
interventions for pain control in preterm
neonates
What this study adds?
• Kangaroo mother care has an additive effect
when combined with expressed breastmilk and
music therapy, showing significantly better pain
control as compared to expressed breastmilk
alone
Premature Infant Pain Profile
• Gestational age
• Behavioral state
• Heart rate
• Oxygen saturation
• Brow bulge
• Eye squeeze
• Naso-labial furrow
Anaesthesia
• Infantile amnesia: we have no recallable
memories before 3-4 yrs
• Neonates can form implicit memories
• Plasticity: early pain experiences can lead to
exaggerated responses to later painful stimuli
or stress and impaired neurodevelopmental
outcome