Acute Pain: Evaluation and Management. The tool uses the behaviors that nurses have described as being indicative of infant pain or distress. It is composed of six 6 indicators, and each behavioral indicator is scored with 0 or 1 except "cry", which has three possible descriptors and is scored with a 0, 1 or 2. A score greater than 3 indicates pain. Infants should be observed for one minute in order to fully assess each indicator.
Prevention and management of pain in the neonate: an update. J Romantic orgasm Gynecol Neonatal Nurs. Half of the neonatal nurses who participated Neonatal infant pain scale nips a survey considered indicators as important measures for pain assessment Exclusion of the first 23 postoperative hour registers can be explained by possible residual effects of anesthetic agents used during the surgery. NIPS is a multidimensional and practical instrument, based on specific parameters related to pain 21which was developed for assessing acute pain in Nenoatal during invasive procedures. Ultimately, further research is needed regarding efficacy, safety profiles, and satisfaction scoring to better achieve these goals. Pain and its effects in the human neonate and fetus. In addition to differences in pain scales, there are myriad of other factors that may influence perception Neonatal infant pain scale nips evaluation of pain.
Condo hard hotel rock. Introduction
Tier 1: Non-pharmacologic Therapies The first tier is aimed at employing non-pharmacologic therapies, which Neonatal infant pain scale nips oral sucrose or glucose, breast or bottle feeding, skin-to-skin care aka Kangaroo Careswaddling or facilitated tucking, non-nutritive sucking, and sensorial saturation. Opioid withdrawal in neonates after continuous morphine or fentanyl during extracorporeal membrane oxygenation. Fentanyl provides rapid analgesia and has been well established as effective for pain reduction in tracheal intubation, chest tube insertion, incision and drainage, and postoperative procedural pain [ 67 ]. Type of pain Notes PIPP premature infant pain profile Heart rate, oxygen saturation, facial actions Procedural, postoperative Reliable, valid, clinical utility is well established NIPS neonatal infant pain score Facial expression, crying, breathing patterns, arm and leg movements, arousal Procedural Reliable, valid NFCS neonatal facial coding system Facial actions Procedural Reliable, valid, clinical utility is well established, high degree of sensitivity to analgesia N-PASS neonatal pain, agitation and sedation scale Crying, irritability, facial expression, extremity tone, vital signs Procedural, postoperative, mechanically ventilated patients Reliable, valid. Pediatr Res. Anesth Analg. Thirty-eight infants contributed to the 90 procedures videotaped for the study. A model for Stoned teens and age changes in the pharmacokinetics of paracetamol in neonates, infants and children. Although many formulations of topical anesthetic are available, EMLA has been well established as effective in the neonatal population for reducing pain associated with minor procedures. Management of acute pain in children. As noted in Fig. A systematic review of lidocaine-prilocaine cream EMLA in the treatment of acute pain in neonates. The use of sucrose in neonates, when compared to breast milk or pacifier use, has also been Neonatal infant pain scale nips with a reduction in behavioral indicators of pain, such as crying and grimacing during painful procedures [ 35 ].
Newborn infants experience acute pain with various medical procedures.
- Newborn infants experience acute pain with various medical procedures.
- The objectives of this study were to 1 develop a behavioral assessment tool for the measurement of pain in the preterm and full-term neonate; 2 establish the construct and concurrent validity, interrater reliability, and internal consistency of the tool; and 3 examine the relationship between the pain scores and infant characteristics.
I RN, M. Corresponding Author. Retrospective data collection. Specific pain assessment scale was used in Pain assessment was done from one to thirteen times, Keywords: Infant, newborn; Pain measurement; Neonatal nursing. The prevalence of congenital heart disease is 8 to 10 out of every 1, live births and the majority of the defects can be surgically corrected 1.
Pain is a common postoperative event as a result of tissue damage and also of organs and tissue manipulation during surgery. Besides these, other factors can contribute to pain occurrence in the postoperative period, such as invasive devices that are necessary for monitorization and life support, e.
Pain is a complex, subjective and multilayered phenomenon, defined by the International Association for the Study of Pain IASP as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" 4.
Pain perception and the requirement for adequate analgesia are not related to the inability to communicate verbally or non verbally 5.
Pain control is fundamental in postoperative care 6 , since it contributes to minimizing the chances of postoperative hemodynamic and metabolic complications, future affective and behavioral changes.
It also protects neonates from the long-term harmful consequences of pain. Few Brazilian publications are available concerning postoperative pain in neonates.
The importance of frequent health team training on provide postoperative analgesia is emphasized. Pain assessment is essential for effective pain control and can be done by using pain indicators, which are described as physiological, behavioral and hormonal, and also by using specific pain scales.
The objective of this study was to identify pain assessment methods used by nursing staff in neonates who underwent cardiac surgery; to verify the frequency of pain assessment and to identify the prevalence of postoperative pain in neonates who underwent cardiac surgery.
This is a reference center for neonatal surgical heart treatment. Data were collected from medical charts of neonates surgically treated between July and December Institutional forms analyzed for data collection were: Clinical history, Surgery description, Vitals signs registers, Nursing notes and Pain management notes. Eligibility criteria were: gestational age e" 35 weeks at birth and surviving through the first 48 hours of postoperative. Medical charts of neonates with malformations besides the cardiac disease were excluded.
Only registers for the 24 th to 47 th complete postoperative hours were analyzed. Exclusion of the first 23 postoperative hour registers can be explained by possible residual effects of anesthetic agents used during the surgery. The following variables were studied:. Behavioral indicators of pain were considered as follows: crying, including non vocalized crying, facial expression, agitation, excessive limb movements, thoracic rigidity and muscle tension Physiological indicators of pain were: increases in heart rate, blood pressure, intracranial pressure, intrathoracic pressure, change in respiratory pattern, decreased arterial oxygen saturation and vagal tonus Epi-Info Version 6.
In compliance with Resolution n. Forty two neonates underwent cardiac surgery and 30 met the eligibility criteria. Mean gestational age at birth was The majority of the neonates underwent surgical procedures in the first week of life 21 or Fourteen different types of surgical procedures were performed and 23 Table 1 shows pain assessment methods used by the nursing staff. Behavioral and physiological indicators of pain were registered in 15 Agitation and crying were commonly registered as pain indicators, revealing that the nursing team frequently relates these alterations to pain.
Table 3 shows pain assessment methods used in neonates considering the occurrence of pain. Seventeen Absence of pain achieved by using NIPS was registered in seven One episode of pain was registered in nine The median of pain episodes was 1.
With regard to pain assessment, in November , a standard pain evaluation was introduced at the institution where data were collected and NIPS was the standard tool at the NICU. This might explain the absence of pain assessment registers in Pain assessment was largely performed by using NIPS. However, behavioral and physiological indicators of pain were also commonly used and continued to be used by the nursing staff, despite the standardization of pain assessment through NIPS. Behavioral and physiological alterations are considered important pain indicators by health care professionals.
Half of the neonatal nurses who participated in a survey considered indicators as important measures for pain assessment In a Brazilian teaching hospital, all of the nurses considered crying, grumbling and facial contraction as signs of pain in neonates; they also considered changes in vital signs and body movements as pain indicators: Information about the nature and intensity of pain can be obtained by grimacing analysis Although behavioral and physiological changes are described in scientific literature as important measures of pain assessment its use during postoperative period might be better investigated.
Some postoperative responses or complications, such as changes in heart rate, arrhythmias, increased blood pressure, hypoxemia and electrolytic disorders , can lead to behavioral and physiological changes which are similar to indicators of pain.
Vasoactive drugs can also result in physiological changes similar to physiological indicators of pain. Another important limitation on the use of pain indicators is the presence of a tracheal tube, which makes it difficult to assess grimacing and crying. Due to these reasons, behavioral and physiological indicators of pain can not be considered as the best choice for pain assessment in neonates who underwent cardiac surgery.
The use of reliable, validated and multidimensional tools for pain assessment in neonates during the postoperative period is possibly better than using behavioral and physiological parameters 6, Despite the large number of tools for neonatal pain assessment available in scientific literature, none of them can be considered an ideal instrument, nor can they be used in different situations, e.
NIPS is a multidimensional and practical instrument, based on specific parameters related to pain 21 , which was developed for assessing acute pain in neonates during invasive procedures.
A limited number of postoperative pain assessment studies in neonates is available However, the large variety of instruments used in each of these studies, e. The use of a standard neonatal pain assessment tool demonstrates concern with improvement in pain management quality and effectiveness at the institution where data were collected. But this process requires continuous evaluation in terms of the utility of the tool, nursing staff training and recycling, which allows for the appropriate and uniform use of the adopted standard pain scale.
There is still no agreement related to postoperative pain assessment frequency. Pain assessment may be performed in every manipulation or care delivery, which can result in discomfort before and after any painful or invasive procedure, concomitant to vital signs assessment, when there is some suspicion of pain and also at established intervals from four to eight hours 2, One to three-hour intervals reinforce the possibility of pain assessment in association with vital signs assessment.
Pain is a common phenomenon in the postoperative period, and its absence is probably related to the effectiveness of analgesic therapy Pain absence was only diagnosed using NIPS. As a multidimensional and specific tool for neonatal pain assessment, NIPS may provide better evidence of the absence of pain when compared to behavioral and physiological indicators of pain.
However, further investigation is needed to confirm the utility and validity of NIPS to diagnose the absence of postoperative pain in neonates. Although the administration of analgesics and sedatives was not the aim of this study, it is important to mention that Despite this fact, neonates still suffered pain.
Prevalence of pain was The major limitation of this study is data collection from medical charts. Absence of or imprecise registers can compromise the accuracy and veracity of data. However, presenting the profile of postoperative pain management in neonates at a specific institution stimulates reflections on pain assessment programs at other Brazilian institutions, permits assessment of the whole pain management process program in neonates who underwent cardiac surgery at the institution where the data were collected.
Greater scientific knowledge on postoperative pain management in neonates is needed. Using pain assessment tools in clinical practice and, consequently, defining effectiveness of these instruments can be considered as important measures for the implementation of pain management strategies in the postoperative period. Thus, well designed and well conducted clinical trials can provide this information.
Further studies are fundamental to provide evidence on the best instruments for neonatal postoperative pain assessment, and also to establish the ideal frequency and intervals for pain assessment in neonatal patients. In: Knobel E. Pediatria e neonatologia. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. Opioids for neonates receiving mechanical ventilation [Cochrane Review].
Cochrane Database Syst Rev. Merskey H. Summary proceedings from the neonatal pain-control group. Prevention and management of pain in the neonate: an update.
Erratum in: Pediatrics. Rev Bras Anestesiol. Pain and its effects in the human neonate and fetus. N Engl Med. Jorgensen KM. Pain assessment and management in the newborn infant. J Perianesth Nurs. Beacham PS. Behavioral and physiological indicators of procedural and postoperative pain in high-risk infants. J Obstet Gynecol Neonatal Nurs. The development of a tool to assess neonatal pain.
How can clinicians reduce the number of painful events? Neonatal Netw. It should also be noted that needle free formulations of lidocaine injections J-Tip have not been adequately studied in newborns [ 64 ]. If a patient is undergoing a single painful procedure, an alternative to use of sucrose or glucose or no intervention, is the use of breastfeeding or breast milk. Other sedative medications including anxiolytics such as midazolam, dexmedetomidine, and inhaled nitrous oxide have potential applications for use for painful procedures.
Neonatal infant pain scale nips. Introduction
Newborn infants experience acute pain with various medical procedures. Evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes. Multiple validated scoring systems exist to assess pain in a neonate; however, there is no standardized or universal approach for pain management.
Healthcare facilities should establish a neonatal pain control program. The first step is to minimize the total number of painful iatrogenic events when possible. This systematic approach should decrease acute neonatal pain, poor outcomes, and provider and parent dissatisfaction.
They also experience long-term effects, including negative effects on neurologic and behavioral development. This is because the experience of pain occurs during a critical time of neurologic maturation [ 2 ]. In fact, preterm infants have demonstrated an exaggerated acute response to pain and worse behavioral and sensory long-term outcomes when compared to term neonates [ 3 , 4 ]. So, why does it remain controversial? Assessing pain in a neonate is difficult as they are non-verbal and though multiple validated pain scoring systems exist; there is no standardized or universal approach to assessing neonatal pain.
Additionally, there appears to be a lack of understanding of how neonates perceive pain and the resulting adverse sequelae that occur when pain remains untreated [ 2 ].
Thus, the use of pain control for neonates undergoing procedures is limited and inadequate [ 5 , 6 ]. Further, until recently, there have been limited data on analgesia effectiveness and safety profiles. In , the American Academy of Pediatrics and the Canadian Pediatric Society published a policy stating that each healthcare facility should establish a neonatal pain control program aimed at routine assessment of pain, reduction in the number of painful procedures, and also reduction and prevention of acute pain from invasive procedures [ 7 ].
In , an Italian panel of expert neonatologists, Lago et al. Neonates interface with clinicians outside of the NICU and thus potentially experience painful procedures within other venues as well.
This includes the newborn nursery, outpatient clinics, the emergency department and the pediatric ward of the hospital. However, there have not yet been guidelines addressing pain assessment or management within these arenas. This review will explore the methods for assessing pain, the importance of establishing a universal approach for assessing pain as well as providing a tiered approach to managing pain in the neonate. Our goal is to improve pain scores patient satisfaction , parental satisfaction, and provider satisfaction in all venues in which neonates are evaluated and treated.
Pain assessment in the non-verbal child and neonate can be a very challenging task in an already subjective process. There are pain scales used to assess pain; however, there are variations in the methods and scales used, and there is not a universal method to assess pain in this population. In addition to differences in pain scales, there are myriad of other factors that may influence perception and evaluation of pain.
It is difficult, for example, to assess the impact of the often foreign and stressful nature of being in an emergency department or in an exam room. Another potentially powerful factor may be the dynamics of the parent—child relationship and the degree of stress the parent experiences when their child needs a painful procedure, which may be perceived by the child and lead to increased anxiety for the patient.
The Joint Commission standards for hospitalized patients make pain assessments mandatory for all patients [ 13 ]. The standard numeric 0—10 pain scale may be useful in verbal children; however, there are scales that have been validated for use in children as young as three for pain reporting [ 14 — 17 ]. In addition to assessing pain by physiologic parameters in the neonatal population, there are multiple validated pain scales utilized by NICUs to assess pain.
The premature infant pain profile PIPP is a validated pain scoring system for preterm neonates [ 2 , 17 ]. For infants, non-verbal young children, and in patients with cognitive impairment, the face, legs, activity, crying, and consolability FLACC scale or the revised FLACC scale can be used [ 23 — 30 ]. Summary of neonatal pain scales [ 1 ]. It is important to note that there are no validated or widely studied scales to assess pain outside of the hospital setting.
Neonatal pain is best managed using a multi-directional approach which can be conceptualized in a tiered manner see Fig. The foundational basis for optimizing pain management in the neonatal population is aimed at reducing the total number of painful events [ 31 ]. This has been well established as a fundamental intervention employed in the NICU, where painful procedures are performed regularly. How can clinicians reduce the number of painful events?
As noted in Fig. Further, clinicians should reduce the number of bedside interruptions and daily examinations, if possible. Additionally, clinicians can anticipate the need for future studies and, with thoughtful planning, can coordinate studies to minimize the frequency of blood draws [ 7 ].
Another way to reduce painful procedures is to use non-invasive monitoring when clinically relevant and when resources are available.
These include near infrared spectroscopy NIRS monitoring, oxygen saturation monitoring, and obtaining bilirubin levels via transcutaneous bilirubinometer [ 1 ].
The first tier is aimed at employing non-pharmacologic therapies, which include oral sucrose or glucose, breast or bottle feeding, skin-to-skin care aka Kangaroo Care , swaddling or facilitated tucking, non-nutritive sucking, and sensorial saturation. How do sugars affect pain? The proposed hypothesis is that glucose and its alternative forms, such as sucrose causes endogenous opioid release, through an unknown mechanism [ 32 — 34 ].
In a systematic review, Stevens et al. While the reported outcomes varied among the studies included in this meta-analysis, patients receiving sucrose were found to have significant reductions in behavioral and physiologic indicators of pain, as well as improvements on several different validated pain scores [ 35 ]. Specifically, measures of physiologic response, such as changes in heart rate, oxygen saturation, and vagal tone, were dampened when compared to placebo [ 35 ].
The use of sucrose in neonates, when compared to breast milk or pacifier use, has also been associated with a reduction in behavioral indicators of pain, such as crying and grimacing during painful procedures [ 35 ].
In a recent systematic review, Bueno demonstrated that there has been no significant difference between the effectiveness of sucrose as compared to glucose [ 36 ]. In studying their pharmacologic properties, glucose and sucrose have an ideal safety profile with limited side effects [ 36 ]. If a patient is undergoing a single painful procedure, an alternative to use of sucrose or glucose or no intervention, is the use of breastfeeding or breast milk.
Shah et al. Neonates who were breastfed during heelstick procedures and venipunctures showed a significant decrease in the variability of physiologic response as compared to swaddling, holding by mother, placebo, pacifier use, or oral sucrose [ 40 ].
The physiologic parameters measured demonstrated a lower increase in heart rate, reduced duration of total crying time and also reduced the time to first cry [ 40 ]. In regard to physiologic parameters, the outcomes were favorable, as there was less of an increase in heart rate and decreased duration of total crying time [ 40 ]. Shah also notes a reduction in NFCS scores, as compared to the placebo group. However, when evaluated in comparison to NIPS and DAN, both validated scoring systems, there was no significant reduction in pain scores with supplemental breast milk.
Is sucrose better? Non-Nutritive Sucking has also been evaluated in preterm and term infants and is effective at reducing pain [ 42 ]. Non-nutritive sucking has been shown to have lower variability in heart rate and decreased crying time duration when compared to swaddling alone, no intervention, or rocking alone [ 43 , 44 ]. Although these environmental measures reduce the pain associated with procedures, they are not as effective as when used in combination with other non-pharmacologic therapies.
The use of sucrose or glucose has the best effectiveness when used in combination with other non-pharmacologic therapies [ 36 , 45 ]. Glucose or sucrose when used in combination with non-nutritive sucking reduces pain in neonates [ 36 , 45 ]. Sensorial saturation, another method of pain reduction, involves multisensorial stimulation, including tactile, gustatory, auditory, and visual stimulation.
Sensorial saturation used in combination with oral sucrose or glucose has been shown to even further reduce pain associated with minor painful procedures i. Facilitated tucking is less effective than sucrose, however, when used in combination with sugary solutions has also demonstrated a synergistic effect [ 48 ].
Breastfeeding in combination with the use of glucose or sucrose has also demonstrated a reduction in pain compared to either individually [ 49 ]. Thus, when feasible and appropriate resources are available, for single minor painful procedures, clinicians should aim to use combination of environmental and non-pharmacologic methods to achieve optimal analgesia.
Following the tiered approach to neonatal pain management, as noted in Fig. Multiple formulations of topical anesthetics are available for use in the pediatric population, including lidocaine 2. Toxicity of these products can lead to multiple adverse effects, including methemoglobinemia and life-threatening arrhythmias, so caution should be used when choosing the appropriate topical anesthetic [ 51 , 53 ].
The FDA has also issued a black box warning against using over-the-counter topical anesthetics for teething pain [ 53 ]. Although many formulations of topical anesthetic are available, EMLA has been well established as effective in the neonatal population for reducing pain associated with minor procedures.
EMLA is a eutectic mixture of lidocaine 2. With circumcisions, EMLA decreased facial grimacing, the total duration of crying time, heart rate variability, and oxygen desaturations when compared to placebo [ 54 ]. EMLA should also be used for analgesia with lumbar punctures, as it reduced heart rate variability, facial grimacing, and oxygen desaturations when compared to placebo [ 52 ]. EMLA has demonstrated effective safety profile; however, rare but serious side effects, such as methemoglobinemia, can occur.
A common side effect of EMLA is transient skin irritation, which can occur with any of the topical anesthetics [ 51 , 52 ]. There are various formulations, which have different dosing and clearance patterns, particularly in neonates. Neonates have slower clearance as compared to older children, so clinicians should be aware to dose less frequently [ 56 ]. Acetaminophen in low doses is safe for use in neonates, but rare side effects should be noted including hepatic and renal toxicity [ 59 , 60 ].
Acetaminophen is also helpful when used in combination with morphine. Typically, use can begin for infants older than 6 months. Traditional local anesthetics have been well established as effective in providing analgesia associated with painful procedures. This represents Tier 4 in the approach to neonatal analgesia. Lidocaine injections can safely reduce pain associated with PICC line, arterial line, central venous line placement, lumbar puncture, and circumcision.
Again, as with EMLA, in higher doses, there is risk of arrhythmia and seizures when approaching toxic doses. Clinicians should avoid combination with epinephrine in neonates, to minimize the risk of arrhythmia and also tissue necrosis.
It should also be noted that needle free formulations of lidocaine injections J-Tip have not been adequately studied in newborns [ 64 ]. These systemic analgesics are typically reserved for moderately to severely painful procedures and should be adequately titrated accordingly. Such procedures include wound treatment, incision and drainage, lumbar puncture, tracheal intubation, chest tube insertion, and central line placement [ 1 ]. Much of the available evidence on the use of morphine and fentanyl in neonates has come from studies evaluating preterm infants within the NICU, who were typically mechanically ventilated.
Thus, one should be careful when extrapolating this data to apply to a wider patient population including term neonates who are not mechanically ventilated. However, as noted before both morphine and fentanyl are commonly used for procedural pain control. In regard to side effect profile, hypotension has been associated with use of morphine in preterm infants, which was not found in term infants [ 65 , 66 ].
Fentanyl provides rapid analgesia and has been well established as effective for pain reduction in tracheal intubation, chest tube insertion, incision and drainage, and postoperative procedural pain [ 67 ]. Fentanyl is an optimal choice in neonates because it has minimal hemodynamic effects, including less hypotension.
It also has less GI dysmotility and urinary retention when compared with morphine [ 68 — 71 ].