Download pain management - Emory Department of Pediatrics

PAIN IN NEWBORNS
Eileen Murray, RN, BSN
Objectives
• Discuss and explain myths which have contributed to
under treatment of pain in neonates
• Understand the behavioral and physiologic effects of
pain
• Identify factors that influence patient responses to
pain
• Discuss assessment of neonatal pain
• Familiarize yourself with pain scales and their use
• Discuss treatment options for pain management in
neonates
“Pain is whatever the person says it
is and exists whenever he says it
does.”
Margo McCaffery
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described in terms
of such. Pain is subjective.”
International Association for the Study of Pain
If that was the person you loved
MOST in the world, laying
critically ill in that bed, what
would you want for them?
PAIN MANAGEMENT MYTHS
• Neonates do not feel pain.
• Infants are less sensitive to pain than adults
• Neonates have no memory of pain.
• Children will tell you when they are having pain.
• If a child can be distracted, he is not in pain.
• Neonates are not able to tolerate the
effects of analgesics.
• Narcotics can lead to addiction in children.
• Infants become accustomed to pain.
So, what are the facts?
• Newborn infants have functional nervous systems
which are capable of perceiving pain
• Physiologic means of assessing pain (VS) can be an
unreliable predictor of pain
• Infants often develop an increase in signs of
discomfort with repeated painful procedures
• Premature infants can have unpredictable responses
to painful stimuli
• Unmanaged pain in the neonatal period can cause
long term developmental complications
“Even if not expressed as conscious memory,
memories of pain may be recorded biologically
and alter brain development and subsequent
behavior”
-Journal of Paediatrics and Child Health 42
(2006)
The Effects of Pain
• Physiological Effects
 changes in vital signs,
pupils
• Behavioral Cues
 how the baby acts when
she is in pain
• Hormonal/Metabolic
Responses
 what happens chemically
Physiological Responses
• variations in HR
•
•
•
•
variations in BP
increased ICP
increased or decreased RR
decreased sats or increase in oxygen requirement
• change in color (pale, poor perfusion or red,
increased perfusion)
• increased or decreased muscle tone
Behavioral Cues
• crying
 can vary from high
pitched, tense to soft
moaning or whining
• facial expressions




grimacing
quivering of chin
squeezing eyes shut
furrowed brow
• difficult to soothe,
comfort or calm
• body movements
 limb withdrawal
 fist clenching
 hypertonicity or
hypotonicity
• state changes
 changes in sleep-wake
cycles
 changes in activity
levels-increased
fussiness or irritability
Hormonal/Metabolic Responses
• increase in epinephrine and norepinephrine,
growth hormone and endorphins
• decrease in insulin secretion
• increased secretion of cortisol, glucagon, and
aldosterone…which leads to
• increased serum glucose, lactate, & ketones
• can lead to lactic acidosis
Is your “stress response” secondary to the
surgery/procedure or the pain afterwards?
Hormonal/Metabolic Responses
Changes in hormone levels affect the
absorption of fat, protein, and glucose, which
subsequently affect
HEALING AND GROWTH!
PAIN CONTROL IS MORE THAN A MATTER OF
COMFORTCONTROLLING PAIN DECREASES COMPLICATIONS
Factors Affecting Pain Response
• Gestational age-as preterm infants develop,
their responses become more sustained and
interpretable
• Environmental factors-external noise,
temperature, light
• Intensity and duration of insult-repeated
painful procedures decrease infant’s ability to
react to pain but not their perception of it
• Behavioral state-less reactive when in sleep
states than wake states
Long Term Effects of Untreated Pain
• Newly studied area-until recently, babies were
not thought to “remember” pain
• Some experts believe that untreated pain in
the newborn period forces abnormal
pathways to form in the brain
• This aberrant brain activity results in impaired
social/cognitive skills and specific patterns of
self- destructive behavior
• Studied MRI’s of newborns-reactions to pain
transferred into similar electrical reactions
to any kind of stressful situation
What can we do?
Common sense tells us that not all crying babies
are in pain.
A chronically stressed baby in the NICU may not
react at all to pain.
Assessment of Pain in the Newborn
• Pain scales use behavioral cues such as quality
of cry, breathing pattern, facial expression, &
muscle tone, as well as changes in VS &
increase in oxygen requirement.
• Proponents maintain that use of scales
decreases nurse to nurse variability of pain
med administration
• Limitations include differentiating between
pain and agitation, difficulty assessing
premature infants’ behavior, and few scales
for use with intubated/sedated patients
FLACC Scale
• F-face (expression)
• L-legs (tone)
• A-activity
• C-cry
• C-consolability
score is tallied, similar to APGAR (0,1, or 2 for
each category)
greater than 4 is indicative of pain
behaviorally based
CRIES scale
• C-crying
• R-requires O2
• I-increased VS
• E-expression
• S-sleepless
Simple and easy to use-uses a scale of 1-10,
similar to APGAR scoring
score of 4 or greater requires intervention
objective and behavioral categories
NIPS (Neonatal Infant Pain Scale)
• Behavioral cues scale
• rates crying, facial expression, breathing
patterns, tone of arms and legs, and state of
arousal at one minute intervals
• should be used taking other physiologic
factors into account
PIPP (Premature Infant Pain Profile)
• Uses both behavioral and physiologic reactions
to pain
• Measures behavioral state, HR, sat, and 3
facial expressions which are indicative of pain
in preemies (brow bulge, eye squeeze, and
nasolabial furrow)
• Takes into account gestational age
(postconceptual)
Prevent or Minimize Pain
• Cluster blood draws or use
arterial line whenever
possible to minimize sticks
• Use smallest gauge needle
possible
• Use minimal amounts of
tape/use tape remover to
remove it
• Premedicate prior to painful
or invasive procedures
Pain Management
• Developmental support is the first step in
managing all levels of pain
 4 handed care-support infant in a flexed position
 parental involvement-give parents a chance to help
support their baby
 facilitate hand to mouth contact, offer pacifiersucking causes endorphins to be released
 swaddling, holding
 minimize external stimuli such as noise & light
Circumcisions
• ASPMN statement
• circumcisions are painful
• Unrelieved pain from circs can cause adverse
stress responses such as breath holding, apnea,
gagging, and vomiting
• neonates have the right to an anesthetic to
prevent the pain of the procedure
• suggest use of blocks or EMLA cream as well as
sucrose pacifier and developmental support to
assist these babies with coping
Management of Mild Pain
• developmental support
• parental involvement
• Acetaminophen-excellent choice for mild post
operative pain (hernias, etc) especially in opioid-naïve
patients
• ibuprofen - analgesic, non-narcotic NSAID; no studies
to assess safety in babies less than 3 months old
• EMLA cream to prevent pain with planned procedures
(circumcisions, etc.) recommended in babies >36 weeks
GA or > 2 weeks old (don’t use with Tylenol)
Don’t you love Sucrose?
• sucrose is the most studied
treatment to help babies deal
with mild or procedural pain
• shown to help with LP’s,
circumcisions, venipunctures,
and heelsticks
• sucrose and sucking each
cause the release of
endorphins-putting these 2
treatments together has
been proven to decrease pain
in newborns
Management of Moderate Pain
• developmental support
• parental involvement
• acetaminophen with codeine-analgesic, narcotic
only comes in PO form which limits its usability
• ketorolac (torodal) - analgesic, non-narcotic, NSAID;
time limited use, works best when given around the
clock for 48 hours post op in addition to other
analgesics
Management of Severe Pain
• developmental support
• parental involvement
• pharmacological management
 medications given on a prn basis result in
peaks and valleys of pain relief
 pain is better controlled if medication is given
prior to the climax of pain
 continuous drip or regularly scheduled doses
maintain a constant level of analgesia
Management of Severe Pain
• Morphine
 Intermittent 0.05 mg-0.2mg/kg/dose may
give q1-8 hours
 Continuous load with 100mcg/kg, then 1015 mcg/kg/hr
 can have significant respiratory side
effects
 observe for abdominal distension,
decreased bowel sounds, and urinary
retention
Management of Severe Pain
• Fentanyl
 Intermittent 1-4mcg/kg/dose may give q2-4
hours
 Continuous 1-5mcg/kg/hour
 good choice for cardiac patients due to
decreased CV side effects
 can cause chest wall rigidity in neonates
when given IVP
• Meperidine (demerol) - not recommended for
pediatrics 2° toxic CNS metabolites
Management of Severe Pain
• Methadone
 respiratory effects outlast analgesia at such
dosing levels
 drug of choice to support narcotic weaning
• Hydromorphone (dilaudid)
 analgesic, narcotic; not for patients with
significant respiratory distress
 the injectable form contains benzyl alcohol
which is not recommended for neonates
GOALS OF MANAGEMENT
• Decrease pain and suffering
• Promote family bonding
•
•
•
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Increase patient comfort
Promote normal coping mechanisms
Decrease patient risk from complications
Prevent negative long term developmental outcomes
HAPPY, HEALTHY BABIES!
HAPPY, HEALTHY KIDS!
You are the KEY!
Babies are unable to communicate their pain to
the untrained eye…
However, you have the tools to assess your
babies for pain and make it better!!