Facial expression is a sensitive indicator of pain in neonates

See here for pain assessment algorithm

Facial expression may be absent in some neonates who are neurologically impaired or pharmacologically paralysed and some babies respond to acute and ongoing pain by lying extremely still and showing no expression. 

 There may also be changes in physiological parameters:

• Increased or decreased heart rate
• Decreased SpO2
• Increased blood pressure

• Avoid unnecessary painful procedures
• In general venepuncture is less painful than heel prick with prolonged squeezing.
• Use indwelling lines for blood sampling if present
• If possible procedures should be carried out when the baby is in a state of quiet wakefulness.
• Try to batch samples so that different tests are carried out from one painful stimulus (e.g. morning bloods done when drug levels due)
• Aim to decrease the number of bedside disruptions by timing routine medical interventions (daily physical examination on the ward round with cares).

Pre-emptive analgesia before and during elective painful procedures should be given to all neonates which often includes a combination of non-pharmacologic and pharmacologic techniques.

Non-pharmacologic approaches (for use for minor procedures including heel prick, venepuncture and venous canulation):

• Oral sucrose (see sucrose guideline)
• Breastfeeding
• Kangaroo care
• Non-nutritive sucking
• Swaddling
• Facilitated tuck (maintaining arms and legs in a flexed position)

Topical anaesthetics:

Lidocaine should be infiltrated in the skin prior to procedures such as chest drain insertion.

Systemic analgesia:

Opioids are the most effective therapy for moderate to severe pain in patients of all ages.  They provide both analgesia and sedation, have a wide therapeutic window, and also attenuate physiologic stress responses.  The most commonly used is morphine sulphate.  Ventilated neonates should not routinely receive morphine sulphate infusions as this can lead to longer periods of ventilation and slower weaning of feeds.  Morphine sulphate should be considered in neonates who appear to be in pain due to an identified cause (NEC, post-operatively).  Although data are limited morphine analgesia may be beneficial in term infants following birth asphyxia, and is standard practice for any cooled infant.  MRI scans have been shown to demonstrate less brain injury in infants with HIE treated with opioids than those who did not receive opioid therapy.  It should also be noted that chest drain removal can be almost as painful as insertion, therefore consider a bolus of morphine prior to chest drain removal. It is standard practice for infants who are paralysed to be given morphine for sedation/pain relief.

Paracetamol can be considered in the management of mild to moderate procedural and post operative pain.  This is administered orally or rarely by other routes after discussion with a consultant. See paracetamol guideline for dosing.

Adjunctive treatments:

Midazolam is a short-acting benzodiazepine which provides sedation, anxiolysis, muscle relaxation and amnesia.  It does not provide analgesia and may even mask the clinical signs of pain in some neonates.  There are limited data that midazolam is associated with an increase in poor neurological outcome among preterm neonates.  It should be considered in neonates who continue to display distress due to an identifiable cause despite adequate pain control e.g. distress from pleural effusions.

Balance timely assessment of pain with possible side effects of such treatment for babies returning from surgery.  Often these babies require morphine sulphate infusions for 24 – 48 hours post operatively.  This should be weaned as quickly as possible providing the baby remains comfortable.

Babies should be handled as little as possible and disturbed only with good reason.  Where possible cares, blood sampling, examinations and other disruption should be clustered to reduce disturbances to the baby.

Adequate pain control is an important consideration in neonatal intensive care and clinicians must weigh up the short-term and long-term consequences of acute neonatal pain against the adverse effects of using analgesia.  Any baby not felt to be adequately assessed for pain and discomfort, or over or under treated for pain should be discussed with the consultant.

American Academy of Pediatrics, Prevention and management of pain in the neonate: An update, Pediatrics, 2006

Anand KJS., Prevention and treatment of neonatal pain, UpToDate, 2013

Ballantyne JC et al., Acute pain management in newborn infants, Pain Clinical Updates, 2011