Routine neonatal care involves many procedures that range from minimally invasive skin breaks to major surgery. Caregivers should be rigorously trained on the selected tool to ensure consistent assessment before, during, and after painful procedures and during routine assessments, such as care during invasive mechanical ventilation.
Each neonatal unit should choose one tool that best suits the breadth of that unit’s practices. Further, the N-PASS can also be used to assess chronic pain/agitation during mechanical ventilation. All of these tools can discern painful from stressful stimuli and have very high intraclass correlations for pain assessment during venipuncture. Five established neonatal assessment tools are summarized in Table 1. These scales generally include physiologic, behavioral, and contextual components. Neonatal pain assessment tools are predominantly designed to assess procedural and postoperative pain or acute distress with handling. In the absence of tools that clearly assess the necessity and effect of nonpharmacologic and pharmacologic treatment, clinicians must rely on subjective behavioral responses and surrogate physiological markers. Unfortunately, methods of real-time, direct measure of nociception do not exist for neonates. Landmark work in the late 20th century brought awareness that nociception and associated physiological adverse effects occur even at the lowest limits of human viability.
Historically, considerable debate has surrounded conscious pain perception in the newborn, due to the nonverbal nature of neonates. NICU hospitalization may require a broad range of painful interventions, including skin breaks for laboratory testing, intravenous line placement, and invasive mechanical ventilation. This review summarizes available evidence addressing these areas of clinical controversy, offering practical approaches for clinicians and highlighting areas of urgent research need for investigators. Finally, the ideal approach to prevent agitation and shivering during therapeutic hypothermia requires careful consideration. In addition, clinicians must address drug tolerance and iatrogenic withdrawal in patients requiring long-term pharmacologic sedation and/or analgesia. The optimal approach to preterm and term neonates experiencing agitation during invasive mechanical ventilation remains unclear. Investigation of the short-term and long-term safety of newer analgesic and anesthetic agents presents on ongoing challenge. Provision of analgesia prior to major invasive procedures ranging from endotracheal intubation to surgery represents standard neonatal care. Nonpharmacologic comfort measures and sucrose should be utilized for procedural pain however, the optimal bundle of interventions remains undefined. In this context, the accurate assessment and diligent avoidance of pain are vital, although a consensus, standardized approach has yet to be achieved. Pain in neonatal life also has profound long-term developmental impacts. Increasing evidence suggests that pain is a central factor predicting brain dysmaturation, especially in babies born very preterm and in those with many early exposures to pain. Careful investigation, including basic science and clinical research, documented the unique susceptibility of preterm neonates to adverse metabolic, behavioral, and clinical responses to acute pain, sparking a revolution in pain science in neonatal intensive care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.Īs recently as 30 years ago, preterm neonates underwent major surgical procedures without perioperative or postoperative analgesia. Further research in all areas represents an urgent priority for optimal neonatal care. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers.
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