Pain Management in the NICU Lecture Pack

Neonates admitted to the Neonatal Intensive Care Unit (NICU) undergo numerous painful procedures each day, with fewer than one-third receiving analgesia. This is alarming as neonates who are critically ill and in pain are susceptible to developing life-threatening complications, since they cannot maintain homeostasis in a state of stress. Additionally, the cumulative effects of these painful experiences, has significant negative consequences to the neurodevelopment of these vulnerable neonates.

Pain assessment is fundamental to effective pain management although there is currently no universally accepted scale for pain assessment in neonates, and more evidence is required to determine the reliability and validity of existing pain assessment tools. Additionally, health clinicians do not know if the physiological and behavioural indicators of pain they observe are specific to pain, or a manifestation of the neonates medical condition, disease process, agitation, distress, fear, stress or even sadness. This issue is compounded when the expressive capacity of critically ill neonates is compromised by the administration of heavy sedation and muscle-relaxants. This presentation explores some of the complexities of pain assessment in neonates followed by practical advice for the health clinician, including a look at the modified Pain Assessment Tool (mPAT) and how it can help improve neonatal pain assessment in the clinical setting.

There is abundant high-quality evidence demonstrating analgesic effects of breastfeeding, skin-skin care and sweet solutions (sucrose and glucose) for newborn infants during short lasting acute painful procedures. There is also growing and concerning evidence about long lasting adverse effects of painful procedures. Yet, studies continue to show that painful procedures are routinely performed on newborns with no pain management. This presentation will include an overview of the three recommended newborn procedural pain management strategies and the knowledge to action (KTA) gap concerning utilization of evidence in practice. Barriers and facilitators to using the three strategies in diverse clinical settings will be discussed and knowledge translation strategies being used to address KTA gaps in pain management in newborns will be presented.

As part of their lifesaving care, infants born very preterm (8 to 16 weeks too early) undergo repeated invasive procedures for what can be weeks to months on end. There is accumulating evidence demonstrating the negative long-term effects of repeated neonatal pain on the developing brain and neurodevelopmental outcomes of children born very preterm. The presentation will outline why infants born ≤32 weeks gestational age, are particularly vulnerable to repeated exposure to invasive procedures. I will highlight the latest literature exploring the long-term effects of neonatal pain on the brain and neurodevelopmental outcomes of both children born very preterm and animal models of prematurity. Furthermore, I will discuss evidence-based pain prevention and intervention strategies applied during neonatal intensive care. It is imperative that we continue to find ways to reduce the negative long-term effects of pain within this vulnerable population of infants born very-preterm.

Pain in infancy has negative long-term consequences and its prevention is a clinical priority, but adequate pain treatment requires mechanistic understanding of the structural and functional development of human pain-related brain circuitry. Recent scientific and technological advances provide insights into how noxious information is transmitted to the infant brain, providing a platform to ask how intrinsic brain network connectivity and the environment affect pain-related brain activity, behaviour and ultimately pain perception in the developing infant nervous system.

As infants cannot describe their pain, we are reliant on alternative methods to measure their pain experience. My goal is to understand the mechanisms that drive and modulate pain perception in early human development. In this talk, I will discuss a series of mechanistic studies in human infants that aim to better understand the development of human pain. I will address fundamental questions regarding the functional development of pain-related brain activity and behavior, and will discuss whether inherent individual differences in how the infant brain behaves at rest drives differences in pain vulnerability. Finally, I will describe how these mechanistic insights can be used to test new analgesic treatment options and improve the treatment of infant pain.

Managing pain and discomfort in the neonatal patient is complex in many ways. Immature metabolic processes can lead to unpredictable effects that may lead to either negative effects and/or unsuccessful control of pain. As we have learned more about these metabolic pathways and how these medications are utilized, more evidence now exists that determine when one medication may be preferred over another depending on the clinical situation. Looking into the future of drug dosing, we may soon be able to determine a neonate's pharmacogenomic profile in order to provide true personalized medicine.

This presentation will help the learner understand the complexities of these challenges and provide them with the information and the tools to provide state-of-the-art medical care.