Literature Review
Neonates are exposed to an assortment of stimuli that generate pain on a daily basis including mechanical ventilation, repeated heel sticks for blood draws, acute medical illnesses, postoperative issues, and even invasive procedures. It has been found that acutely ill neonates in the NICU are subject to between 50 and 132 bedside procedures that can cause pain in a single 24-hour period (Witt, 2016). Nurses, in their nature, strive to make comfort their primary focus. The nurse must strive to alleviate the pain and discomfort of their patients regardless of the ability of the patient to communicate that pain. Sadly, even though there is an abundance of research on pain responses in neonatal populations, this population still falls victim to underestimated and undertreated pain, whether it is related to slowness of changing attitudes, inadequate knowledge, limited assessment tools, or a failure to recognize the response to pain.
One misconception that has been widely proven incorrect is that neonates are unable to feel pain because of their immature central nervous system (Johnston, 2011). Pain management in the neonate has experienced remarkable changes over the past couple of decades. These changes stemmed out from the attempts of health professionals to refute misconceptions regarding pain among neonates.Pain Management in Infants Paper Formerly, the belief was that neonates have limited responses to stimuli, because of the undeveloped nervous system. However, research has demonstrated that the premature nervous system makes neonates more likely to feel pain. Some believe that the neonate may experience hypersensitivity to pain compared to the adult in pain (Smith, 2011). Researchers also suggest that untreated pain among neonate can have long-lasting developmental impacts. These current developments indicate that neonatal pain management must be effective and safe to prevent the negative consequence of untreated pain. Also, reducing pain can improve both short-term and long-term outcomes. These outcomes could be then later used as evidence to guide neonate clinical practice. This paper discusses evidence-based practice in neonate pain management.
Assessing Pain Response in Neonates
Physiological Alterations in Response to Pain
Several known indicators may be measured to assess physiological responses to pain, including heart rate, blood pressure, respiratory rate, blood oxygenation, palmar sweating, vagal tone and intracranial pressure (Johnston, 2011). Other physiological symptoms of pain may include dilation of pupils, changes in skin and body temperature, increased muscle tone, sweating, and increased defecation and urination. While these methods of assessment may shed some light on the pain response, it is essential to look at all the body systems and how they are affected to understand the pain response truly. The nurse should also be mindful that each infant’s response to pain will have variations and may exhibit more or less response based on gestational age and individual factors. It is also important to note that while pain may include these responses, they can also be caused by other factors.
Behavioral Response to Pain
Pain can also be noted through facial expression, body posture, movements, and vigilance. There has been substantial evidence reported in research studies that have linked facial expression of neonates to specific emotions. Longer crying time is also attributed to pain, but these responses need to be observed in context, and the situation as infant crying may signal different needs. Changes in sleep patterns can also be used by the nurse to identify pain among neonate patients.Pain Management in Infants Paper
In a study that assessed facial expression in neonates who underwent heal lance determined that evaluation of pain while assessing eye squeeze, nasolabial furrow, the opening of the mouth, and brow bulging are significant cues that indicate pain in healthy neonates (Rushforth & Levene, 1994). The research revealed ninety-seven percent of term infants and eighty-four percent of preterm infants demonstrated an increase in these behaviors as a response to the heel lance. This assessment should be considered a vital tool because its use could dramatically affect the amount of pain reduction available to the infant when the cues are identified. Equally significant is that this method can be implemented at the bedside and with proper education, will diminish disagreements in differing pain scores from one healthcare provider to the next.
Hormonal/Metabolic Response to Pain
In addition to physical and behavioral responses to pain, there are now resources available that allow the healthcare provider to measure chemical changes as a response to pain in the neonate. Increases in epinephrine and norepinephrine, growth hormone, and endorphins have been noted. This was achieved by measuring levels before, during and after heal lance. Studies have also concluded that insulin secretion is decreased during pain. Furthermore, cortisol, glucagon, and aldosterone levels were increased with noxious stimuli. This finding translates to increased serum glucose, lactate, and ketones, which could then progress the infant to lactic acidosis.
These hormonal changes noted in the neonate can affect their absorption of essential nutrients like fats, proteins, and glucose. Insufficient absorption then has a direct correlation with their healing process and progress, as well as, their growth and development.Pain Management in Infants Paper It has become evident that pain management is so much more than merely keeping the neonate comfortable. When the healthcare team can control their pain, it leads to a decrease in complications.
Assessment: Pain Scales
Self-help reports are the most common instrument for pain assessment, but these tools only apply to patients who can communicate. Since neonates cannot talk, self-help report is not applicable, and the nurse must assess pain using a combination objective signs and subjective observation that are then scored or scaled. However, accurately determining the level of pain among neonates is extremely difficult. Assessment is very complicated given that there are more than 50 different pain scales that are currently in use (Johnson, Ranger & Anand, 2017). These pain scales and pain assessment tools rely on a combination of behavioral observation (such as body posture, tone, and facial expression) and Physiological parameters that include blood pressure, oxygen saturation and heart rate. There are cases when behavioral measures and physiological measures do not correlate. The former may reveal pain specifically while the latter reflects generalized physiologic stress. It has been found that different responses are pPain Management in Infants Paper
revalent in neonates. Among the most widely used pain assessment scales for neonates include the following: Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Neonatal Infant Pain Scale (NIPS), CRIES, and Pain Assessment in Neonates Scale (PAIN).
The Children’s Hospital of Eastern Ontario Pain Scale is a behavioral scale that is widely used to evaluate postoperative pain in children and may also be beneficial in monitor the usefulness of interventions that have been implemented by healthcare providers. It can assist in evaluating effects for reducing the pain and discomfort and is typically applied to children from birth to four years old (Rudd & Kocisko, 2014). This scale bases its assessment of pain on crying, facial expression, verbal cues, assessment of the torso, response to touch and movement of legs. The minimum score is four with a maximum score of 13 (Rudd & Kocisko, 2014). This scale also outlines definitions of each choice in the six parameters, providing further understanding and clarification to decrease variability in rater scores.
The Neonatal Infant Pain Scale is a six-item scale that was developed based on a survey of 43 neonatal nurses who were asked to identify behaviors associated with pain in patients they cared for in the NICU. The six categories identified were facial expressions, crying, breathing pattern, arm movement, leg movement, and infant arousal states. The total score range is 0-7. This scale was used to score 38 term infants’ pain two minutes before, during needle insertion, and three minutes after the procedure in order to test its validity for assessing pain in infants (Lawrence, et al., 1993). These researchers determined the NIPS was a successful tool and its use became common to determine the need for pain management in neonates.Pain Management in Infants Paper
The CRIES scale is another simple validated tool that allows assessment of pain through physiological and behavioral function. It was developed at the University of Missouri at Columbia as a method to evaluate pain in the postoperative period. This tool assesses crying, need for oxygen therapy, increased vital signs, facial expression, and infant sleep state by assigning a value of 0-2 to each category. This scale was an improvement on the NIPS scale because it provided a greater range of score. However, the assessment of the blood pressure is seen as a procedure that could be painful to the neonate, likely resulting in unnecessary distress and could have an effect on the observes scoring (Bildner & Krechel, 1996).
The Pain Assessment in Neonates Scale was developed in response to a study seeking to improve the effectiveness of rating neonatal pain by combining the NIPS and CRIES scales and addressing the downfalls that the researchers experienced with the two. A group of researchers, seeking to validate pain scales within their organization, designed a study to compare the results of the NIPS and CRIES on the NICU floor and a Step-Down Unit (SDU). The nurses that were involved with this research survey stated worries that the NIPS gave more weight to body movements by assigning it two categories while the rest of the behavioral cues were assigned to as single category (Hudson-Barr, et al. 2002).Pain Management in Infants Paper Additionally, it is common for neonates to be swaddled for comfort creating a dilemma. Do the nurses disturb the baby to assess movement or assume that if they are not moving then they are not in pain. On the other hand, the CRIES assessment requires checking blood pressure which is considered a painful procedure that could cause stress to the infant (Hudson-Barr, et al. 2002). The PAIN scale combined extremity movements into one category, eliminating the uneven weight of bodily movements, and eliminated blood pressure from the assessment creating less distress on the infant.
Long-Term Effects of Unmanaged or Poorly Managed Pain
Neonates experience a multitude of procedures that can cause them to experience pain. Studies have shown that neonates undergo about 750 procedures during their hospital stay (Fitzgerald, 2009). Since infants cannot communicate their pain, it is likely that it will go unnoticed. Untreated pain can have adverse long-term effects on the development of the child. When the pain goes unmanaged, this results in prolonged suppression of the immune system, placing the patient at an increased risk for multiple complications (Pasero & McCaffery, 2011). The brain of neonates is still developing, and untreated pain causes changing levels of neural activity. The central nervous system responds to the pain and may create neural pathways. This persistent sensitization of pain can alter the healthy development of the brain or can have damaging effects on the entire central nervous system.Pain Management in Infants Paper
Neonatal surgery is linked to changes in future pain response. Neonates that undergo circumcision without analgesia were found to have enhanced behavioral response to immunization several months later. Following neonatal circumcision without analgesia, the behavioral response to immunization many months later is also enhanced (Tadio, 2008). Children that were exposed to neonatal intensive care as infants were found to have persistent changes in sensory processing (Hermann & Holdmeister, 2006) and the degree of change was more intense among children who have undergone surgery as a neonate. Animal studies found that injury during the neonatal stage may occur because enhancement is a somatosensory response and this could be true among humans.
Pharmacological Pain management
Opioids are effective pain management medication, but there are dosage requirements which are much lower among neonate than among children and infants.Pain Management in Infants Paper Opioids are given based on body weight, and since neonates have the lowest body weight, there is a decreased clearance in neonates. In procedures that require surgery, however, opioids are used as part of pain management. Recent studies have shown that opioids are safe. Protocols vary and may include intermittent bolus doses, continuous infusions, or nurse-controlled analgesia (Lago, 2013). Respiratory depression is one of the side effects of opioids, and the fear of side effects is a contributing factor to the inadequate use of opioids in neonates.
Paracetamol is also given to neonates, usually in combination with other drugs, as a form of pain management. Its analgesic efficacy is influenced by dose, route of administration, and type of pain stimulus. It may be administered orally and intravenously. Paracetamol may benefit neonates because it can lead to reduced general anesthetic and opioid requirements. There is also evidence that paracetamol use can lead to a reduction in the need for postoperative mechanical ventilation. It is also advisable to neonates that are susceptible to respiratory complications (Walker, 2014). Additionally, it has also meager complication rates.Pain Management in Infants Paper
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