Opioid analgesia for infants in the neonatal intensive care unit

Biomarkers for assessing pain and pain relief in the neonatal intensive care unit

Newborns admitted to the neonatal intensive care unit (NICU) regularly undergo painful procedures and may face various painful conditions such as postoperative pain. Optimal management of pain in these vulnerable preterm and term born neonates is crucial to ensure their comfort and prevent negative consequences of neonatal pain. This entails accurate and timely identification of pain, non-pharmacological pain treatment and if needed administration of analgesic therapy, evaluation of treatment effectiveness, and monitoring of adverse effects. Despite the widely recognized importance of pain management, pain assessment in neonates has thus far proven to be a challenge. As self-report, the gold standard for pain assessment, is not possible in neonates, other methods are needed. Several observational pain scales have been developed, but these often rely on snapshot and largely subjective observations and may fail to capture pain in certain conditions. Incorporation of biomarkers alongside observational pain scores holds promise in enhancing pain assessment and, by extension, optimizing pain treatment and neonatal outcomes. This review explores the possibilities of integrating biomarkers in pain assessment in the NICU.

Opioids for newborn infants receiving mechanical ventilation

BACKGROUND

Mechanical ventilation is a potentially painful and discomforting intervention that is widely used in neonatal intensive care. Newborn infants demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes.

OBJECTIVES

To determine the benefits and harms of opioid analgesics for neonates (term or preterm) receiving mechanical ventilation compared to placebo or no drug, other opioids, or other analgesics or sedatives.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 9), in the Cochrane Library; MEDLINE via PubMed (1966 to 29 September 2020); Embase (1980 to 29 September 2020); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 29 September 2020). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing opioids to placebo or no drug, to other opioids, or to other analgesics or sedatives in newborn infants on mechanical ventilation. We excluded cross-over trials. We included term (≥ 37 weeks' gestational age) and preterm (< 37 weeks' gestational age) newborn infants on mechanical ventilation. We included any duration of drug treatment and any dosage given continuously or as bolus; we excluded studies that gave opioids to ventilated infants for procedures.

DATA COLLECTION AND ANALYSIS

For each of the included trials, we independently extracted data (e.g. number of participants, birth weight, gestational age, types of opioids) using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 23 studies (enrolling 2023 infants) published between 1992 and 2019. Fifteen studies (1632 infants) compared the use of morphine or fentanyl versus placebo or no intervention. Four studies included both term and preterm infants, and one study only term infants; all other studies included only preterm infants, with five studies including only very preterm infants. We are uncertain whether opioids have an effect on the Premature Infant Pain Profile (PIPP) Scale in the first 12 hours after infusion (MD -5.74, 95% confidence interval (CI) -6.88 to -4.59; 50 participants, 2 studies) and between 12 and 48 hours after infusion (MD -0.98, 95% CI -1.35 to -0.61; 963 participants, 3 studies) because of limitations in study design, high heterogeneity (inconsistency), and imprecision of estimates (very low-certainty evidence - GRADE). The use of morphine or fentanyl probably has little or no effect in reducing duration of mechanical ventilation (MD 0.23 days, 95% CI -0.38 to 0.83; 1259 participants, 7 studies; moderate-certainty evidence because of unclear risk of bias in most studies) and neonatal mortality (RR 1.12, 95% CI 0.80 to 1.55; 1189 participants, 5 studies; moderate-certainty evidence because of imprecision of estimates). We are uncertain whether opioids have an effect on neurodevelopmental outcomes at 18 to 24 months (RR 2.00, 95% CI 0.39 to 10.29; 78 participants, 1 study; very low-certainty evidence because of serious imprecision of the estimates and indirectness). Limited data were available for the other comparisons (i.e. two studies (54 infants) on morphine versus midazolam, three (222 infants) on morphine versus fentanyl, and one each on morphine versus diamorphine (88 infants), morphine versus remifentanil (20 infants), fentanyl versus sufentanil (20 infants), and fentanyl versus remifentanil (24 infants)). For these comparisons, no meta-analysis was conducted because outcomes were reported by one study.

AUTHORS' CONCLUSIONS

We are uncertain whether opioids have an effect on pain and neurodevelopmental outcomes at 18 to 24 months; the use of morphine or fentanyl probably has little or no effect in reducing the duration of mechanical ventilation and neonatal mortality. Data on the other comparisons planned in this review (opioids versus analgesics; opioids versus other opioids) are extremely limited and do not allow any conclusions. In the absence of firm evidence to support a routine policy, opioids should be used selectively - based on clinical judgement and evaluation of pain indicators - although pain measurement in newborns has limitations.

A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants

Pain is a major problem in sick newborn infants, especially for those needing intensive care. Pharmacological pain relief is the most commonly used, but might be ineffective and has side effects, including long-term neurodevelopmental sequelae. The effectiveness and safety of alternative analgesic methods are ambiguous. The objective was to review the effectiveness and safety of non-pharmacological methods of pain relief in newborn infants and to identify those that are the most effective. PubMed and Google Scholar were searched using the terms: “infant”, “premature”, “pain”, “acupuncture”, “skin-to-skin contact”, “sucrose”, “massage”, “musical therapy” and ‘breastfeeding’. We included 24 studies assessing different methods of non-pharmacological analgesic techniques. Most resulted in some degree of analgesia but many were ineffective and some were even detrimental. Sucrose, for example, was often ineffective but was more effective than music therapy, massage, breast milk (for extremely premature infants) or non-invasive electrical stimulation acupuncture. There were also conflicting results for acupuncture, skin-to-skin care and musical therapy. Most non-pharmacological methods of analgesia provide a modicum of relief for preterm infants, but none are completely effective and there is no clearly superior method. Study is also required to assess potential long-term consequences of any of these methods.

Efficacy and safety of continuous infusion of fentanyl for pain control in preterm newborns on mechanical ventilation

OBJECTIVE

To evaluate the analgesic superiority and the safety equivalence of continuous fentanyl infusions versus fentanyl boluses in preterm infants on mechanical ventilation.

STUDY DESIGN

In this multicenter, double-blind, randomized controlled trial, mechanically ventilated newborns (≤ 32(+6) weeks gestational age) were randomized to fentanyl (continuous infusion of fentanyl plus open-label boluses of fentanyl) or placebo (continuous infusion of placebo plus open-label boluses of fentanyl). The primary endpoint was analgesic efficacy, as evaluated by the Echelle Douleur Inconfort Nouveau-Né (EDIN) and Premature Infant Pain Profile scales. Safety variables were evaluated as well.

RESULTS

Sixty-four infants were allocated to the fentanyl group, and 67 were allocated to the placebo group. The need for open-label boluses of fentanyl was similar in the 2 groups (P = .949). EDIN scores were comparable in the 2 groups; 65 of 961 (6.8%) EDIN scores were >6 in the fentanyl group and 91 of 857 (10.6%) in the placebo group (P = .003). The median Premature Infant Pain Profile score was clinically and statistically higher in the placebo group compared with the fentanyl group on days 1, 2, and 3 of treatment (P < .05). Mechanical ventilation at age 1 week was required in 27 of 64 infants in the fentanyl group (42.2%), compared with 17 of 67 infants in the placebo group (25.4%) (P = .042). The first cycle of mechanical ventilation was longer and the first meconium passage occurred later in the fentanyl group (P = .019 and .027, respectively).

CONCLUSION

In very preterm infants on mechanical ventilation, continuous fentanyl infusion plus open-label boluses of fentanyl does not reduce prolonged pain, but does reduce acute pain and increase side effects compared with open-label boluses of fentanyl alone.

Analgesic and sedative drugs in newborns requiring respiratory support

Infants receiving respiratory assistance may feel pain due to underlying disease or ventilation itself. Pain control during neonatal respiratory care reduces morbidity. This article summarizes the main scientific evidence about the use of drugs during ventilatory assistance, and provides some practical suggestions on pain management in neonates with respiratory support.

Pain management, morphine administration, and outcomes in preterm infants: a review of the literature

Infants in the Neonatal Intensive Care Unit may experience a myriad of painful procedures and stressful experiences. Pain management for infants requiring mechanical ventilation is complex and challenging especially in the preterm population. Many infants may not receive analgesia, primarily due to the unknown long-term neurodevelopmental effects of morphine exposure on the developing brain. Currently, there is no consensus on how to treat pain related to mechanical ventilation due to conflicting scientific evidence lacks clarity and certainty about the role of morphine in pain in preterm infants. The Advance Practice Neonatal Nurse must make the best use of available information about morphine analgesia for the preterm infant, and use it to guide policy and practice for infants. The Advance Practice Neonatal Nurse must use his/her clinical expertise to judicially balance the risks and benefits of morphine analgesia, when used, and tailor the treatment plan to each infant's specific needs.

Anesthetic technique and postoperative outcome in preterm infants undergoing PDA closure

OBJECTIVE

To describe the various anesthetic techniques used for surgical closure of PDA in premature infants at the Montreal Children's Hospital and assess their impact on postoperative outcome.

STUDY DESIGN

The charts of all preterms who underwent PDA ligation during a 21-month period were reviewed for preoperative status, intraoperative anesthetic management and postoperative outcome. We determined the associations between independent variables and two postoperative outcome variables: unstable postoperative respiratory course (UPRC) and hypotension.

RESULT

The mean weight at surgery of the 33 infants was 1.031±0.29 kg. All infants, but one, received intraoperative opioids. Eight patients presented UPRC. Mean fentanyl doses were 5.3±2.6 mcg kg(-1) for patients with UPRC vs 22.6±16.6 mcg kg(-1) for patients without UPRC (P=0.004). Applying the receiver-operator characteristic curve (ROC), 10.5 mcg kg(-1) of fentanyl was established as the dose that discriminated and identified patients who experienced UPRC. The postnatal and postmenstrual age of the patient, birthweight, current weight, ventilator settings preoperatively, previous courses of indomethacin, sex and preoperative creatinine, were not correlated with the dose of fentanyl equivalent used. Logistic regression did not show a relationship between any of the previously mentioned factors and receiving a fentanyl equivalent of >10.5 mcg kg(-1). The only factor associated with the total fentanyl equivalent dose (as a continuous variable) or receiving <10.5 mcg kg(-1) (as a dichotomous variable) was the identity of the anesthetist involved, P<0.001.

CONCLUSION

We conclude that the use of at least 10.5 mcg kg(-1) of fentanyl equivalent as a component of the anesthetic regimen for surgical closure of a PDA in premature infants, avoids an unstable postoperative respiratory course.

Fentanyl transdermal analgesia during pregnancy and lactation

This report describes an infant who was born to a mother with chronic pain treated with fentanyl 100 microg/h transdermal patch throughout her pregnancy and during lactation. On day of life 27, when the baby was feeding and gaining weight on maternal milk, samples of the baby's blood and maternal milk were sent for analysis. The mother's milk fentanyl level was 6.4 ng/ mL. The infant's blood fentanyl level was undetectable. This preliminary report suggests that fentanyl transdermal patch treatment might be a viable option for managing chronic pain during lactation.

Pharmacological analgesia in neonates undergoing cardiac surgery

The objectives of this study were to verify the frequency of pharmacological analgesia and the occurrence of postoperative pain in neonates undergoing cardiac surgery. METHODS: This is a cross-sectional study and data were collected from 30 medical charts of neonates who underwent cardiac surgery in a private hospital in the city of São Paulo. RESULTS: The majority (96.6%) of neonates received analgesia: 18 (60.0%) received continuous analgesics, five (16.7%) received intermittent drugs, and six (20.0%) received a combination of continuous and intermittent analgesics. Fentanyl citrate was continuously administered to 24 (80.0%) neonates. Intermittent dipyrone and morphine was administered to ten (33.3%) and one (3.3%) neonates, respectively. Pain registers were observed in 17 (56.7%) medical charts and the occurrence of pain among neonates who received analgesics was 53.4%. CONCLUSION: There was no efficacy in pharmacological postoperative pain control in the neonates included in this study.

Early awakening and extubation with remifentanil in ventilated premature neonates

BACKGROUND

Morphine is one of the most commonly used drugs for sedation and analgesia during mechanical ventilation, but its pharmacological profile has limitations, such as prolonged duration of action, especially in premature neonates. Because of its very short context-sensitive half-time, remifentanil has rapid onset and quickly decreases in plasma concentration after interrupting administration. The aim of the present study was to compare a continuous infusion of remifentanil and morphine during mechanical ventilation of premature neonates with respiratory distress syndrome (RDS).

METHODS

Twenty premature neonates (28-34 weeks) with RDS were randomized in a prospective double-blinded study to receive either a continuous infusion of morphine (n = 10) or remifentanil (n = 10) for mechanical ventilation. The length of time to awaken and extubate the neonate after interrupting opioid administration was recorded. We also recorded stress (COMFORT scale), pain response [Neonatal Infant Pain Scale (NIPS)], hemodynamic and ventilatory variables as well as adverse effects secondary to infusion of the specific opioid.

RESULTS

After terminating infusion, the length of time required to awaken and extubate the neonates was 18.9- and 12.1-fold longer, respectively, in the morphine group than in the remifentanil group. Both groups produced good quality sedation and analgesia as evaluated by the NIPS and COMFORT scores. No major side effects were observed.

CONCLUSIONS

Our results show an interesting potential for the use of remifentanil in premature neonates. Remifentanil allowed an adequate level of sedation and analgesia as well as rapid recovery after discontinuation. However, further properly designed clinical trials are needed before it can be generally recommended.

Opioids for neonates receiving mechanical ventilation

BACKGROUND

Mechanical ventilation is a potentially painful and discomforting intervention widely used in neonatal intensive care units. Newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation.

SEARCH STRATEGY

Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007); MEDLINE (1966 to June 2007); EMBASE (1974 to June 2007); and CINAHL (1982 to 2007). Previous reviews and lists of relevant articles were cross-referenced.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, in which case a random effects model was used.

MAIN RESULTS

Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short-term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.

Pharmacokinetics of piritramide in newborns, infants and young children in intensive care units

Piritramide is indicated for treatment of postoperative pain and analgosedation in the intensive care unit (ICU) setting. In an open prospective study the pharmacokinetics of piritramide were investigated in four groups: newborns (NB, age: 1-28 days) (n=8), infants 1 (IF1, age: 2-4 months) (n=7), infants 2 (IF2, age: 5-12 months) (n=14) and young children (YC, age: 2-4 years) (n=10). The recommended paediatric dose range for therapy of postoperative pain is 50-200 microg/kg. Piritramide was administered intravenously as a single dose by bolus injection of 50 microg/kg. Blood samples were collected at 0, 15, 45, 90 min and 3, 6, 9, 12 h after application, and urine samples were collected before application and during the following intervals: 1-2, 2-6, 6-12 h. Piritramide was measured in blood and urine by HPLC-ESI-MS. The following pharmacokinetic parameters: maximum plasma concentration (C(max)), distribution half-life (t 1/2 alpha), elimination half-life (t 1/2 beta), total clearance (Cl(t)) and median volume of distribution at equilibrium (Vd(ss)) were calculated using a non-compartment and a two-compartment model for the disposition of piritramide (TOPFIT and NONMEM-pharmacokinetic analysis). Newborns (NB) showed the highest maximum plasma concentrations (median+/-SD) C(max) (79+/-240 microg/l) compared to the other three groups (IF1 36+/-367, IF2 12+/-81 and YC 16+/-9 microg/l) without statistical significance. The median elimination half-lives (t 1/2 beta) were 702+/-720 min in NB, 157+/-102 min in IF1, 160+/-68 min in IF2 and 166+/-143 min in YC. For t 1/2 beta the difference between NB and the other three groups (IF1, IF2 and YC) was statistically significant (Mann-Whitney-U, P<0.05). Cl(t) was 15.9+/-16.7, 46.6+/-76.9, 235.5+/-454.1 and 338+/-168.1 ml/min in NB, IF1, IF2 and YC respectively. The total clearance increased exponentially with an elimination half-life of 702 min from 15.9 ml/min in NB to 46.6 ml/min in IF2. Differences between the NB/IF1 groups and IF2/YC groups were significantly significant (NB vs. IF2, NB vs. YC, IF1 vs. IF2 and IF1 vs. YC). Vd(ss) was 2.0+/-4.93, 1.7+/-2.5, 7.0+/-5.2 and 6.7+/-2.2 l/kg in NB, IF1, IF2 and YC respectively. In comparison to group IF1 the Vd(ss) was significantly larger in groups IF2 and YC (Mann-Whitney U, P<0.05). Newborns showed a high initial concentration and a distinct prolongation of the elimination half-life of piritramide compared to infants, young children and adults. Therefore, dosage needed to treat postoperative pain should be reduced, and the repetitive doses should be geared to the analgesic effects. In infants and young children the elimination of piritramide is increased compared to adults; therefore the duration of the effects of piritramide will be shortened, and dose intervals ought to be reduced. Subsequent clinical trials for detailed dose adjustment of piritramide in paediatric patients comparing pharmacokinetics and effectiveness are needed.

Judgments of pain in the neonatal intensive care setting: a survey of direct care staffs' perceptions of pain in infants at risk for neurological impairment

OBJECTIVE

To determine whether healthcare professionals believe the pain of infants at risk for neurologic impairment differs from that of typical infants.

SETTING

Neonatal intensive care units at 2 tertiary pediatric centers in Canada.

PARTICIPANTS

Ninety-nine healthcare professionals who practice in the neonatal intensive care unit (51 nurses, 19 physicians, 18 respiratory therapists, 11 other). MAJOR MEASURES: Participants completed the Pain Opinion Questionnaire. It elicits beliefs regarding the similarity of the pain experienced by infants at mild, moderate, and severe risk for neurologic impairment relative to those without risk for neurologic impairment along 5 pain facets (ie, sensation, emotional reaction, behavioral reaction, communication, incidence).

RESULTS

Pain Opinion Questionnaire scores varied by level of risk of neurologic impairment (mild, moderate, severe) and pain facet. Respondents believed infants with risk were overall less likely to experience pain similar to infants without risk as the level of risk increased [F(2,97) = 66.0, P < 0.001] and were more likely to have a reduced pain experience relative to infants without risk as the level of risk increased [F(2,97) = 62.2, P < 0.001]. Pain Opinion Questionnaire scores did not vary due to profession, experience, gender, or age.

CONCLUSION

Professionals expressed the belief that neurologically impaired infants' pain experience is reduced, relative to infants without impairment, as their level of risk for neurologic impairment increases. This belief did not vary due to professional experience or personal factors. Future studies should investigate the source of these beliefs and their impact on the pain management provided to infants with risk for neurologic impairment.

The pharmacological treatment of neonatal pain

Optimal analgesia remains a major challenge for all involved in the care of (critically) ill newborns. The rapid changes in liver metabolism involving maturation of liver enzymes and renal clearance of drugs render (extreme) very low birth weight infants different from newborns of later postconceptional age with regards to the use of opioids such as morphine and fentanyl. Acute and/or procedural pain has been investigated fairly recently in randomized controlled trials and there are now guidelines. The long-term effects of opioid use in this particular age group of vulnerable babies await further evaluation.

Opioids for neonates receiving mechanical ventilation

BACKGROUND

Mechanical ventilation is a potentially painful intervention widely used in neonatal intensive care units. Since newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes, the use of drugs which reduce pain might be very important.

OBJECTIVES

To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation.

SEARCH STRATEGY

Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004); MEDLINE (1966 to June 2004); EMBASE (1974 to June 2004); and CINAHL (1982 to 2003). Previous reviews and lists of relevant articles were cross-referenced.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, when a random effects model was used.

MAIN RESULTS

Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.

Healthcare professionals' perceptions of pain in infants at risk for neurological impairment

BACKGROUND

To determine whether healthcare professionals perceive the pain of infants differently due to their understanding of that infant's level of risk for neurological impairment.

METHOD

Neonatal Intensive Care Units (NICU's) at two tertiary pediatric centers. Ninety-five healthcare professionals who practice in the NICU (50 nurses, 19 physicians, 17 respiratory therapists, 9 other) participated. They rated the pain (0-10 scale and 0-6 Faces Pain Scale), distress (0-10), effectiveness of cuddling to relieve pain (0-10) and time to calm without intervention (seconds) for nine video clips of neonates receiving a heel stick. Prior to each rating, they were provided with descriptions that suggested the infant had mild, moderate or severe risk for neurological impairment. Ratings were examined as a function of the level of risk described.

RESULTS

Professionals' ratings of pain, distress, and time to calm did not vary significantly with level of risk, but ratings of the effectiveness of cuddling were significantly lower as risk increased [F (2,93) = 4.4, p = .02]. No differences in ratings were found due to participants' age, gender or site of study. Physicians' ratings were significantly lower than nurses' across ratings.

CONCLUSION

Professionals provided with visual information regarding an infants' pain during a procedure did not display the belief that infants' level of risk for neurological impairment affected their pain experience. Professionals' estimates of the effectiveness of a nonpharmacological intervention did differ due to level of risk.

Assessment and management of pain in infants

Infants, including newborn babies, experience pain similarly and probably more intensely than older children and adults. They are also at risk of adverse long term effects on behaviour and development, through inadequate attention towards pain relief in early life. However, the issue of analgesia in young babies has been largely neglected in most clinical settings, despite subjecting them to painful diagnostic and therapeutic procedures. Several therapeutic and preventive strategies, including systemic and local pharmacological and non-pharmacological interventions, are reported to be effective in relieving pain in infants. A judicious application of these interventions, backed by awareness and sensitivity to pain perception, on the part of the caregivers is likely to yield the best results. This article is a review of the mechanisms of pain perception, objective assessment, and management strategies of pain in infants.

Assessment and management of acute pain in high-risk neonates

Neonates in the neonatal intensive care unit experience hundreds of painful procedures at a time of rapid neurological development. Although the immediate responses to pain may be protective, the potential long-term effects of early and under-treated pain are concerning. As pain assessment is the first step in the provision of appropriate and timely pain management, attention should be directed to the quantification of pain in terms of its location, severity, intensity and duration. Over the past decade, numerous pain measures have been developed for preterm and term neonates, however, most of them have been developed for research purposes and have not been tested in the clinical setting. In order to effectively implement pain measures in the clinical setting, the psychometric properties of reliability, validity, feasibility and clinical utility must be established. This review paper will highlight the importance of neonatal pain assessment and examine the psychometric properties of various measures of neonatal pain. Pharmacological and non-pharmacological interventions to manage acute pain in high-risk neonates will be addressed and future research topics will be proposed.