Thursday, 22 September 2011

PAIN MANAGEMENT IN NEONATAL INTENSIVE CARE UNIT

Pain Management in Neonatal Intensive Care Unit


            People often times fear to hear the words intensive care unit when a family member or close friend is admitted in the hospital most especially parents. Neonatal Intensive Care Unit is one of the branches of intensive care unit wherein it specialises in taking care of newborn ill and premature babies. The usual first impressions of parents and family members is often shock due to the fact that the room is filled with small and ill babies all hooked up in machines with wires and tubes. In addition, the feeling of shock couple with fear is intensified because most of the parents of these babies did not expect that their child will be in the intensive care, thus most of them are not prepared for the sights inside the neonatal intensive care unit. Furthermore, it is an additional burden for the mother who is just recovering from the intense situation she has just been subjected.


            Care in the neonatal intensive care unit is often overlooked by a number of health care professionals. According to  (2001) recent studies have revealed that the patients in the neonatal intensive care are not receiving the proper pain treatment in comparison to adult and paediatric patients. According to  (2001) there are dfifferences in the pain management between patients in the paediatric intensive care unit and neonatal intensive care unit wherein 66% of paediatric intensive care unit patients receive analgesia compare to 26% of patients in the neonatal intensive care. In addition, in the study of  (2000) wherein neonatal intensive care units in United States and Canada were observed and it revealed that neonates that underwent various painful operations and procedures did not receive comfort or pain measures.


            Health care professionals, aside from members of the family play a significant role in the neonatal care of patients that are in the neonatal intensive care unit. Health care professionals are the front-runners in the management of pain among neonatal intensive care patients, as well as, the family members. Management of neonatal intensive care unit patients is a difficult and delicate task and needs professional, enough and proper knowledge to determine the specific needs of the patient.


The usual painful procedures that infants in the NICU are subjected are the heel prick sampling, endotracheal suction and intravenous cannula insertion and in order to reduce the pain decreasing the number of procedures and altering them together with adequate analgesia could aid in relieving the stress that the infants feel.


There are a number of negative effects if neonatal pain is not treated appropriately. According to  and  (2005) the repetitive pain and separations from mother due to being admitted in the neonatal intensive care unit could lead to permanent changes in the spinal cord, peripheral, neuroendocrine function, neurological development and supraspinal pain processing.


As mentioned earlier, in comparison to adults and children, the neonates are more sensitive and vulnerable to pain. Neonates have the highest probability of long-term effects due to painful procedures used in the intensive care. According to  (2001) the management of pain must be regarded as a significant constituent of the health care given to neonates regardless of the severity of pain. In addition,  discussed that the sources of pain must be determined and routine assessments of neonatal pain should prescribe the avoidance of procedures that induce recurrent pains and use specific behavioural, environmental, and pharmacological interventions.


Although health care professional are already aware and have the appropriate knowledge regarding pain management in infants, the pain related to procedures performed outside the operating room have the possibility of not being managed properly. In the survey conducted by , ,  and  (1997) nurses and doctors believe that infants feel the same pain just like children and adults and they believe that comfort measures and pharmacological interventions must be utilised frequently. 


As mentioned earlier, the health care professionals play an important role in the pain management for infants that are in the neonatal care. The prevention of pain in infants in the NICU must be the goal of health care professionals, particularly the nurses because repetitive pains have a negative consequence for neonates in the long run. According to  (2006) the neonates are at risk of developing neurodevelopmental impairments because of preterm births and are most likely to be subjected in painful procedures in the NICU. And due to the fact that the safest and most efficient methods of preventing pains among neonates in the NICU are not yet known, balancing efficient pain relief and avoidance of adverse outcomes from medications is a major challenge for health care professionals.


Pain assessment is also important in the neonatal intensive care because it determines the intensity of pain an infant feels during certain procedures. It will also aid in determining the procedures wherein lesser pains are felt by the infants. In addition, through pain assessment interventions can be made for painful procedures. In the study of , , ,  and  (2004) the premature infant pain profile (PIPP) and crying requires oxygen, increased vital signs, expression and sleepless (CRIES) are measures that could provide the health care workers on the intensity and level of pain felt by the neonates in the NICU.


Aside from pain assessment a standardised strategy on pain management could also be helpful in the pain management of infants in the neonatal intensive care unit. According to , ,  and  (1998) the following outcomes were observed on infants in the NICU after standardisation of the pain management strategies; reduced length of stay in the NICU, reduced time to extubation, the management of fluid intake is better, and the side effects of narcotics were reduced.  (2001) stated that whatever assessment procedures and tools utilised, the physicians and the nurses, as well as the parents, must have a continuous multidisciplinary training in determining the pain in neonates must be provided.


 and  (2001) stated that the neonates often are subjected to painful procedures during routine care like suctioning and insertion of needles. Aside from the painful procedures, disruptions such as diaper changes and physical evaluation could be stressful to infants. According to ,  and  (2003) the most efficient way in decreasing the procedural pain is to reduce the painful procedures performed on the neonates. Strategies could include removing the unnecessary laboratory procedure and minimising repetitive procedures if the first attempts failed.


Pain has disruptive effects on infants that are in the neonatal intensive care unit. ,  and  (2000) discussed that the most efficient strategy to reduce the pain among infants in the NICU is to impose rigorous standards on the frequency of painful procedures such as heel lances and endotracheal suctioning, and must only be performed by the most experience professional on unstable and critically ill patients. In addition, pharmacologic and nonpharmacologic strategies are also important to the management and prevention of pain among neonates in the NICU and must only be utilised for complementary use in each infant. A number of studies have pointed out that the efficacy and safety of pharmacologic and nonpharmacologic strategies have decreased pain caused by certain procedures.


There are numerous non-pharmacological strategies that could prevent pain and give relief to neonates in the NICU. It includes the utilisation of oral sucrose, developmental care and breastfeeding. According to ,  and  (2004) the non-pharmacological procedures could be useful among preterm and term infants in decreasing the pain from a heel stick, subcutaneous injections, and venipuncture. In addition, according to , , , ,  and  (2003) oral sucrose removes the electroencephalographic changes related to painful procedures in NICU. However, the long term-term safety has not yet been established for multiple dosages of oral sucrose for neonates undergoing painful procedures in the NICU (, , and , 2002).


According to  (2001) topical anaesthetics could be an efficient medication for procedures such as intravenous catheter insertion and lumbar puncture for infants. The topical agents must be utilised for an adequate lengths of time prior to the procedure to be effective.


Neonates in the NICU undergo mechanical ventilation and the infants are subjected to minor painful procedures. In order to manage the pain medication and sedatives are used for the patients. In the study of ,  and  (2004) intravenous morphine were utilised in order to decrease the poor neurologic outcome and the study revealed that morphine have decreased the pain felt by the neonates, on the other hand it did not alter the possibility of severe intraventricular haemorrhage and cystic periventricular leukomalacia.


Most of the neonates in the NICU have undergone major surgery and pain is one of the consequences of that.  Pain is an important aspect among neonates in NICU, because according to  if appropriate pain management is given the neonate will have improved clinical outcomes such as a decrease in mortality.


Intercostal Drains- insertion of a chest drain is a painful procedure that some neonates have undergone and will undergo. The recommendations of health care professionals are the skin site must be infiltrated with an anesthetic prior to incision because it has lasting effects on responses to pain and must be done in routine unless if the procedure threatens the life of the patient (,  2006). Infiltrating the skin must be slow in order to reduce the pain (, , and , 1998). Non-pharmacological procedures could also be utilised to reduce the pain during insertion of chest drains.


Chest-Drain Removal- removing the chest drain is likewise painful. In the study of , , and  (2004) the use of methohexital for removing the chest-tubes in infants has shown reduction and control of pain without compromising the respiratory functions of the neonates.


Intubation- just like any other surgical procedure intubation is also painful. In reducing the occurrence of severe hypoxia during intubation opiods could be utilised because it reduces the pain while the neonates are undergoing intubation ( and , 1998).    


Retinal Examination and Surgery for Retinopathy of Prematurity- retinal examination is painful procedure premature neonates undergo and it cannot be easily relieved by topical agents and oral sucrose. In the study of ( ,  and , 2003) continuous intravenous infusion of remifantil could efficiently decrease the pain from retinal examinations.


            Pain management for neonates in the NICU is not an easy task for any health care professional. The health care professionals must be trained to assess the intensity of pain felt be the neonates using various multidimensional tools and procedures. The assessment of pain must be done continuously and routinely in order to determine if there were changes. Each NICU must have its own pain scales to help the health care workers create provisions to relieve the pain felt by neonates in the NICU.


            The following procedures could be utilised in order to manage the pain of neonatal patients in the NICU:



  • The care given to the neonates in the NICU must integrate principles that minimises the pain and disruptions as much as possible.

  • For minor procedures such as heel pick, non-pharmacologic methods in reducing pain must be utilised.

  • Topical agents could also be utilised to decrease the paint related to catheter insertion and lumbar puncture.

  • Health care facilities that operate neonates must have rules of conduct for the management of pain of neonates in the NICU.

  • Adequate anaesthesia must be given in order to prevent pains and stress.

  • Pain assessment must be done continuously using a scale created for prolonged pain in neonates.


In addition, according to (2007) there are three types of intervention wherein the healthcare professionals could relieve the pain in neonates and its adverse effects in the future and these are:



  • Environment intervention- wherein the light and noise surrounding the neonate is reduced which allows adequate time for the baby to rest between medical procedures.

  • Behavioural intervention- wrapping the baby in cloth and using pacifiers dipped in sugar could also be helpful in alleviating the pain of the neonates in the NICU.

  • Pharmacological intervention- the proper use of anaesthetics could also help neonates relieve from pain. 


The feelings of parents are often times overlooked during painful procedures to infants in the NICU. According to ,  and  (2005) the parents perceived that the medical procedures are the main source of the pain that the infants feel, in addition parents wanted more information regarding the procedures and wanted to be more involved in the care for the infants. Furthermore, it emotionally pained the parents seeing their babies undergo painful procedures at such a young age and they voiced out ways in which health care workers could assist and help them and their babies in coping up with the pain associated with neonatal intensive care.


            Aside from the parents the siblings of the neonates in the NICU are also affected. According to  (as cited by , 2001) parents may become to focused on the situation of the infant and usually leaves thei other children unnoticed.  discussed that Parent group is one of the ways in which parents and the siblings of the neonates could cope up with the situation. The following are ways in which siblings could be supported by their parents:



  • Encourage the siblings to open their feelings. Children usually observe the coping mechanisms of their parents and through that they learn the positive and negative responses to crisis. The personalities of the children must also be considered when developing ways to express their feelings.

  • The parents must assure their siblings that it is not their fault why the baby is sick. Children usually have the tendency to believe that their negative perception towards their baby brother or sister may have cause the illness of the baby.

  • The parents must be alert on the possible changes of behaviours of their children in attempt to cope up with the situation.

  •  The routine of the household must be maintained as much as possible because children feel more secure when the daily activities in the house are not relevantly altered. 

  • Visit the NICU with the siblings because it helps to reinforce the bond between the neonates and siblings.

  • The parents must share and explain the conditions of the baby because children usually hesitate to ask questions because they fear that they could cause sadness to their parents.

  • The parents must have undivided attention to each sibling and must share activities that the parents and the child usually do prior to the birth of the baby.


Pain is often associated in intensive care unit and neonates are not an exemption to that and just like adults and children they experience the same pain when undergoing procedures. Pain must be treated immediately and properly by health care professionals because untreated pain could lead to further complications in the long run which could lead to longer stays in the hospitals. Assessment of pain among neonates in the NICU is a very challenging task in order to resolve it the health care facilities must have a standard measurement and procedures in order to facilitate the management of pain of neonates in the NICU.   


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