FROM PEDIATRICS

Repeated exposure to physical pain can have both short-term and long-term adverse effects in newborns, yet providers too inconsistently assess and adequately manage pain in neonates, the American Academy of Pediatrics said in an updated policy statement on preventing and managing procedural pain in these infants.

“Neonates are frequently subjected to painful procedures, with the most immature infants receiving the highest number of painful events,” wrote the AAP Committee on Fetus and Newborn and the AAP Section on Anesthesiology and Pain Medicine. Premature infants also are at the highest risk for long-term sequelae, the committees noted. “These sequelae include physiologic instability; altered brain development; and abnormal neurodevelopment, somatosensory, and stress response systems, which can persist into childhood” (Pediatrics. 2016 Jan 25. doi: 10.1542/peds.2015-4271).

The statement nicely summarizes current evidence on the evaluation and management of pain in neonates, as well as potential short-term and long-term negative effects, said Dr. Clay T. Jones, a neonatal hospitalist at Newton-Wellesley Hospital in Newton, Mass., who was not involved in drafting the statement.

“It is a nice testament to how far we’ve come since the days of performing major surgeries in newborns without the use of analgesic medications, but there is still considerable room for improvement,” Dr. Jones said in an interview. “Although we’ve learned a lot about pain in this population over the past few decades, the authors go to great lengths to make it clear that the optimal way to treat pain hasn’t been established yet, and that the evaluation of risk versus benefit in regards to management using pharmaceutical agents is ongoing.”

The statement described the challenges of effective pain management, including foremost the newborn’s inability to communicate and the dearth of information about effective pain assessments and management in this population.

“Contextual factors such as gestational age and behavioral state may play a significant role in pain assessment and are beginning to be included in some assessment tools,” the committees wrote. “New and emerging technologies to measure pain responses, such as near-infrared spectroscopy, amplitude-integrated electroencephalography, functional MRI, skin conductance, and heart rate variability assessment, are being investigated.”

In the meantime, however, all facilities caring for newborns should implement a pain prevention program that takes advantage of what pain management strategies do exist. In addition to reviewing these strategies, the statement recommended all providers implement and use pain assessment and management plans that include both pharmacologic and nonpharmacologic therapies for major procedures and routine minor interventions that might still cause pain.

“Where this report might have the largest impact is in the outpatient offices of pediatric medical providers and in newborn nurseries,” Dr. Jones said. “It is not uncommon for young infants to undergo painful medical procedures, such as heel sticks and circumcisions, without a systematic approach to pain evaluation and inconsistent efforts to prevent or reduce pain.”

Yet there is no excuse for this lack of a consistent approach, he said.

“Nonpharmaceutical interventions are safe, easy to implement, [and] inexpensive, and there is good evidence that they reduce physiologic surrogate markers for pain such as blood pressure, heart rate, and respiratory rate,” Dr. Jones said.

The statement’s first recommendation is that all institutions have written guidelines for a stepwise plan of pain prevention and treatment in newborns. This plan also should include use of currently available and validated neonatal assessment tools “before, during, and after painful procedures to monitor the effectiveness of pain relief interventions.”

Another recommendation urged pediatricians and other neonatal health care providers and family members to receive ongoing education about recognizing and assessing pain in newborns and then managing it as much as current knowledge and evidence allow. The committees called for more research into pain assessment tools and pain prevention and amelioration strategies, including pharmacologic options.

The nonpharmacologic strategies shown to be effective for reducing pain during short-term mild or moderately painful procedures include facilitated tucking, sensorial stimulation, nonnutritive sucking, and breastfeeding or providing expressed human milk.

“Anything we can do to ease pain will improve a baby’s quality of life,” said Dr. Nathan Boonstra of Blank Children’s Hospital pediatric clinic in Des Moines, Iowa, who was not involved in writing the statement.

“Pediatricians should always be judicious when deciding to draw blood, but when we need to, we should reflexively think about what can keep the procedure’s pain at a minimum,” he said in an interview. “Many of my patients’ mothers instinctively want to breastfeed to help their newborns through something painful, and their instinct serves them well.”

The policy statement mentioned oral sucrose and/or glucose solutions as effective analgesic options for mild to moderately painful procedures, but recommended these be prescribed and tracked as medication.

This strategy carries risks and other drawbacks, however, Dr. Thomas M Seman, a pediatrician in group practice in Danvers, Mass., said in an interview

“Having sucrose or glucose solutions in the office can be dangerous because of the risk of overuse and hyperglycemia as well as the cost of these items,” said Dr. Seman, who was not involved with drafting the AAP statement. His office policy primarily focuses on the parents holding their children and talking, singing, or humming to them during procedures, followed by feeding and/or acetaminophen, he said.

“The other medications used are prohibitive for a number of reasons,” said Dr. Seman, although he added that most of the procedures described in the statement are performed on premature infants in a NICU with only a few done in private practices.

For example, opioids such as fentanyl and morphine are most frequently used for persistent pain, yet the data on appropriate dosing and long-term effects in the newborn period are “woefully lacking and/or conflicting,” the statement noted. The evidence for benzodiazepines, often used for sedation in the neonatal intensive care, shows little additional analgesic benefit, but these agents can potentiate the risk of respiratory depression and hypotension associated with opioid use. Caution should particularly be exercised before using methadone, ketamine, propofol, and dexmedetomidine because so little is known about safe and effective dosing of these medications in neonates. They also carry various potential risks ranging from neurotoxicity to bradycardia, desaturations, and prolonged hypotension.

While NSAIDs are not recommended at this young age, oral or intravenous acetaminophen has sufficient preliminary safety and efficacy to be considered for postoperative pain relief, according to the statement.

The AAP did not report disclosures for committee members. Dr. Boonstra, Dr. Jones, and Dr. Seman had no relevant financial disclosures.

pdnews@frontlinemedcom.com

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