Painful Procedures Often Performed Without Pain Medication On Newborns In ICUs

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Main Category: Pregnancy / Obstetrics
Also Included In: Pediatrics / Children's Health;  Pain / Anesthetics
Article Date: 02 Jul 2008 - 0:00 PDT

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Newborns in intensive care undergo many procedures that are associated with pain and stress, and many of these procedures are performed without medication or therapy to relieve the pain, according to a study released on July 7, 2008 in JAMA.

According to the authors of this study, this could instigate developmental issues. "Repeated invasive procedures occur routinely in neonates [a baby, from birth to four weeks] who require intensive care, causing pain at a time when it is developmentally unexpected. Neonates are more sensitive to pain than older infants, children, and adults, and this hypersensitivity is exacerbated in preterm neonates. Multiple lines of evidence suggest that repeated and prolonged pain exposure alters their subsequent pain processing, long-term development, and behavior. It is essential, therefore, to prevent or treat pain in neonates," they write. "Effective strategies to improve pain management in neonates require a better understanding of the epidemiology and management of procedural pain."

To study the frequency of these stressful procedures and the corresponding use of analgesic or other pain relief, Ricardo Carbajal, M.D., Ph.D., of the Hopital d'enfants Armand Trousseau, Paris, and colleagues gathered data on neonatal pain. To do this, direct bedside observations were made in intensive care units (ICUs) in the Paris area. Taken between September 2005 and January 2006, data was collected regarding all painful and stressful procedures in the first fourteen days of admission, as well as the corresponding medications (if any) used to relieve pain. The average gestational period of the subjectswas 33 weeks, and the average length of ICU stay was 8.4 days.

In this period, 60,969 procedures were performed on the subjects. Of these, 69.6% (42,413) were considered painful and 30.4% (18,556) were considered stressful. Some examples of painful procedures include: nasal and tracheal aspiration, heel stick, and adhesive removal. As a group, the neonates received and average of 141 procedures, with a daily average of 16. Of these, a median 75 painful procedures were performed on each neonate, with an average of 10 painful procedures per day.

When examining analgesic use, pain relievers were used in a median 20% of the painful procedures performed in the study period. When the nature of these pain relievers is examined, 2.1% of the painful procedures were performed with pharmacological therapy, while 18.2% were with nonpharmacological-only therapy. 0.4% used both, and 79.2% were performed without any indicated in the procedure.

After further analysis, several factors contributed to a greater use of specific preprocedural analgesia, including: prematurity, parental presence in procedures, daytime surgeries (between 7 a.m. and 6 p.m.) and the day of hospitalization (between 2 and 14 days). Some factors that decreased the changes of pain reliever use included: mechanical ventilation, noninvasive ventilation, and the administration of nonspecific but concurrent analgesia.

The authors write that this is an issue that requires attention in the field of neonatal health. "Advances in neonatal care in recent decades with increased survival of immature and sick neonates have led to an increased number of invasive procedures that may cause pain in these vulnerable neonates. The prevention of pain in critically ill neonates is not only an ethical obligation, but it also averts immediate and long-term adverse consequences," they day. "Strategies to reduce the number of procedures in neonates are needed urgently. The American Academy of Pediatrics recently emphasized the need to incorporate a principle of minimizing the number of painful disruptions in neonatal care protocols. Such strategies would aim at bundling interventions, eliminating unnecessary laboratory or radiographic procedures, using transcutaneous measurements when possible, and minimizing the number of procedures performed after failed attempts."

They conclude with a statistic highlighting this need: "The knowledge that some vulnerable neonates underwent 153 tracheal aspirations or 95 heel sticks in a two-week period should elicit a thoughtful and relevant analysis on the necessity and the risk-benefit ratio of our clinical practices."

Epidemiology and Treatment of Painful Procedures in Neonates in Intensive Care Units
Ricardo Carbajal; André Rousset; Claude Danan; Sarah Coquery; Paul Nolent; Sarah Ducrocq; Carole Saizou; Alexandre Lapillonne; Michèle Granier; Philippe Durand; Richard Lenclen; Anne Coursol; Philippe Hubert; Laure de Saint Blanquat; Pierre-Yves Boëlle; Daniel Annequin; Patricia Cimerman; K. J. S. Anand; Gérard Bréart
JAMA. 2008;300(1):60-70.
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Written by Anna Sophia McKenney
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