Prevention and Management of Pain and Stress in the Neonate

This statement is intended for health care professionals caring for neonates (preterm to 1 month of age). The objectives of this statement are to: 1. Increase awareness that neonates experience pain; 2. Provide a physiological basis for neonatal pain and stress assessment and management by health care professionals; 3. Make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes; and 4. Recommend effective and safe interventions that relieve pain and stress. ABBREVIATION. Sao2, oxygen saturation. The International Association for the Study of Pain has defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”1 The interpretation of pain is subjective. Each person forms an internal construct of pain through encountered injury. Several experts suggest that the neonate’s expression of pain does not fit within the strict definition of the International Association for the Study of Pain because of the requirement for self-report.2–4 This lack of ability to report pain contributes to the failure of health care professionals to recognize and treat pain aggressively during infancy and early childhood.5 Because neonates cannot verbalize their pain, they depend on others to recognize, assess, and manage their pain. Therefore, health care professionals can diagnose neonatal pain only by recognizing the neonate’s associated behavioral and physiological responses.6 Stress is defined as “a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation.”7 These responses can be specific to the stressor or can be generalized and nonspecific. Pain is always stressful, but stress is not necessarily painful; both require assessment, evaluation, and treatment. The signs of pain and stress must be distinguished from signs of life-threatening conditions, such as hypoxemia or carbon dioxide retention, that require other forms of intervention.8 Studies indicate a lack of awareness among health care professionals of pain perception, assessment, and management in neonates.9–11 When analgesics were used in infants, they often were administered based only on the perceptions of health care professionals or family members. Fear of adverse reactions and toxic effects often contributed to the inadequate use of analgesics. In addition, health care professionals often focused on treatment of pain rather than a systematic approach to reduce or prevent pain.12,13 More recent surveys have demonstrated increased awareness among health care professionals of pain in neonates and infants and its assessment and management.14–16 Several textbooks on pain in neonates and infants have been published,17–19 and measures for assessing pain have been developed and validated.20–24 However, despite the advances in pain assessment and management, prevention and treatment of unnecessary pain attributable to anticipated noxious stimuli remain limited.25–27 Several important concepts must be recognized to provide adequate pain management for the preterm and term neonate: • Neuroanatomical components and neuroendocrine systems are sufficiently developed to allow transmission of painful stimuli in the neonate.28–32 • Exposure to prolonged or severe pain may increase neonatal morbidity.33–36 • Infants who have experienced pain during the neonatal period respond differently to subsequent painful events.37–41 • Severity of pain and effects of analgesia can be assessed in the neonate.20–24,42–46 • Neonates are not easily comforted when analgesia is needed.8 • A lack of behavioral responses (including crying and movement) does not necessarily indicate a lack of pain.47