Pain is a complex notion that is not always easy to manage. What are the current practices in newborns? We provide some answers.
Pain is a complex notion that is sometimes difficult to assess in newborn infants
The International Association for the study of pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” 1. It is a highly subjective notion, specific to individuals and depending on their own personal perceptions and experience. However, babies are unable to tell us the level of pain they are experiencing. They are dependent on others to assess and manage their pain on the basis of their behavioral and psychological reactions.
Up until the 1980s, many people considered that neonates could not feel pain. This misconception was subsequently shown to be incorrect. Quite the contrary, in fact, since the immature nervous system of neonates induces hypersensitivity to pain stimuli. Furthermore, at the end of gestation, a fetus possesses all the anatomical, hormonal and neurophysiological elements required to perceive pain.2
In addition, poorly managed pain during the neonatal period may have harmful effects in the mid or longer term. To avoid these, appropriate pain assessment in newborns is essential.
Pain management in newborns
As in children and adults, pain in newborns can be managed with non-medicinal and medicinal treatments. These two types of treatments are often complementary.
It is not easy to assess pain in babies because they cannot talk. The use of pain assessment scales like the Accumulated Pain Stressor Scale (APSS) can be useful and essential. The role of this scale is to quantify pain and assess the effectiveness - or otherwise - of established medicinal and non-medicinal treatments. 3
Non-medicinal treatments can take various forms. Examples include non-nutritive sucking, swaddling and heel warming and the “kangaroo mum” method, when premature babies are carried against their mum’s abdomen, with skin to skin contact. All these methods can help relieve pain in newborns without the use of drugs.
In addition to non-medicinal management, there are also medicinal treatments for newborns. Significant progress has been made in recent years, enabling various classes of drugs to be used depending on the individual case.
Morphine is often the first-line analgesic. This drug belongs to the opioid family, meaning that intensive monitoring of the neonate’s renal and respiratory functions is required.4 Since opioid tolerance has been proven in newborns, it is necessary to be particularly vigilant. Opioids can be administered in various ways, either intravenously (continuous or time-released) or by the oral or rectal routes.
There are numerous non-opioid analgesics. These include acetaminophen, nonsteroidal anti-inflammatories (NSAIDs), anesthetics (local and regional) and benzodiazepines. Benzodiazepines have a limited analgesic effect but are often used in infants to induce sedation and muscle relaxation, alongside other analgesic drugs.
Anesthetic treatments can also be used in pain management. Regional anesthesia is often used for babies undergoing circumcision. Epidural anesthesia can also be used to manage surgical pain. This substantially reduces the infant’s surgical stress response.5
A local anesthetic is useful to relieve pain caused by an invasive skin treatment, such as the insertion of an intravenous catheter, for example.
Neonatal pain management is very complex but has improved considerably in the past 40 years. Several drug classes can be used to manage pain, combined with non-medicinal methods to make them more effective.
Anand KJ, Carr DB. The neuroanatomy, neurophysiology, and neurochemistry of pain, stress, and analgesia in newborns and children. Pediatr Clin North Am. 1989 Aug;36(4):795-822. doi: 10.1016/s0031-3955(16)36722-0. PMID: 2569180.
Xu W, Walsh S, Cong XS. Development of Accumulated Pain/Stressor Scale (APSS) in NICUs: A National Survey. Pain Manag Nurs. 2016 Dec;17(6):354-362. doi: 10.1016/j.pmn.2016.08.004. Epub 2016 Oct 15. PMID: 27756592; PMCID: PMC5609453.