Shouldn't we reconsider procedural techniques to prevent neonatal pain?

Neonatal pain management: still in search for the Holy Grail

Inadequate pain management but also inappropriate use of analgesics in early infancy has negative effects on neurodevelopmental outcome. As a consequence, neonatal pain management is still in search for the Holy Grail. At best, effective pain management is based on prevention, assessment, and treatment followed by a re-assessment of the pain to determine if additional treatment is still necessary. Unfortunately, epidemiological observations suggest that neonates are undergoing painful procedures very frequently, unveiling the need for effective preventive, non-pharmacological strategies. In addition, assessment is still based on validated, multimodal, but subjective pain assessment tools. Finally, in neonatal intensive care units, there is a shift in clinical practices (e.g., shorter intubation and ventilation), and this necessitates the development and validation of new pharmacological treatment modalities. To illustrate this, a shift in the use of opioids to paracetamol has occurred and short-acting agents (remifentanil, propofol) are more commonly administered to neonates. In addition to these new modalities and as part of a more advanced approach of the developmental pharmacology of analgesics, pharmacogenetics also emerged as a tool for precision medicine in neonates. To assure further improvement of neonatal pain management the integration of pharmacogenetics with the usual covariates like weight, age and/or disease characteristics is needed.

Randomized crossover trial of endotracheal tube suctioning systems use in newborns

BACKGROUND

Maintaining endotracheal tube patency is critical for neonates receiving mechanical ventilation. Endotracheal tube suctioning removes accumulated secretions preventing potential adverse events, however is also potentially hazardous to the patient.

OBJECTIVE

To compare respiratory rate, arterial blood oxygen saturation, heart rate and pain in newborns undergoing endotracheal tube suctioning with closed (CS) and open (OS) systems.

METHODS

Randomized crossover trial with 13 newborns from two Brazilian hospitals. The respiratory rate, arterial blood oxygen saturation, heart rate and pain (Premature Infant Pain Profile) were analysed: immediately before (T1), during (T2), immediately after (T3), 10 min after (T4) and 30 min (T5) after endotracheal suctioning.

RESULTS

The majority (11/85·0%) of the newborns were premature and 45% weighed less than 1000 g. No statistically significant difference was identified according to the use of CS or OS to all the parameters investigated. The main results demonstrated that in T2 arterial blood oxygen saturation was higher with CS (CS 93·0%; OS 89 · 0%; p = 0·561). In T3 there was an increase in respiratory rate average only with the use of OS (T1 50·0; T3 56·0). The pain score in T2 and heart rate in T3 were higher with OS without significant differences (p = 0·114; p = 0·479, respectively).

CONCLUSION

There was no significant difference in the studied clinical parameters or presence and intensity of pain according to the two investigated techniques of endotracheal tube suctioning.

RELEVANCE TO CLINICAL PRACTICE

This research can provide support for clinical practice regarding endotracheal tube suctioning of newborns describing that the use of closed systems was similar to the open system regarding pain presence and intensity, as well as, in the clinical effects analysed, in accordance with other studies produced in this field.

Pharmacological treatment of neonatal pain: in search of a new equipoise

Inadequate management of pain in early human life contributes to impaired neurodevelopmental outcome and alters pain thresholds, pain or stress-related behavior and physiological responses. However, there are also emerging animal experimental data on the impact of exposure to analgo-sedatives on the incidence and extent of neuro-apoptosis. Since this association has also been suggested in humans, the pharmacological treatment of neonatal pain is in search of a new equipoise since these 'conflicting' observations are the main drivers to further reconsider our current treatment regimens. This review focuses on new data concerning clinical pharmacology of morphine, followed by data on more recently introduced opioids like remifentanil and tramadol, locoregional anesthesia and minimally invasive techniques in neonates, and finally with data on intravenous paracetamol. Since the available data are still incomplete, priorities for both clinical management and future research will be proposed.

Pain management in newborns: from prevention to treatment

All neonates in the Neonatal Intensive Care Unit (NICU) or during the first days of life undergo painful and stressful procedures. Epidemiologic studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. Pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Prevention is the first step of pain management, and practical guidelines should be used in the NICU. Assessment must be done with adequate tools that take into account the infant's pathology and gestational age. Distinguishing between acute and prolonged pain is important for both assessment and treatment. The most common drugs that have been studied for the treatment of pain and stress are opioids, hypnosedatives, and NMDA receptor antagonists. Morphine and fentanyl are most frequently used for acute or prolonged pain in the NICU. They have potent analgesic effects and few immediate or long-term adverse effects. Midazolam is a commonly used hypnosedative, but its adverse effects limit its use. Drugs such as propofol and ketamine have been used for acute painful procedures; however, further research is needed to assess their long-term effects. Use of non-pharmacologic pain management techniques has increased in recent years. These methods are easy, inexpensive, and effective in helping newborns recover from painful procedures. Sweet solutions and non-nutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and facilitated tucking are the most commonly employed and evaluated non-pharmacologic methods. Hospitals should promote and improve parent involvement in pain management. In-service education and well organized hospital teams are crucial for successful implementation of pain protocols in newborns.

Clinical practice: analgesia in neonates

Effective management of pain remains an important indicator of the quality of care provided to neonates. Since the review of McIntosh in this journal over a decade ago, an extensive number of papers on assessment, prevention, and treatment of pain have been reported. In addition, preclinical insights into neurodevelopmental aspects of pain processing and the neuro-apoptotic effects of analgesics and sedatives were unveiled. Based on the newly collected evidence, the practice of "one-drug, one dose and one treatment fits all" became obsolete, necessitating a more individualized analgesia, based on non-pharmacological and pharmacological therapies and preventive strategies for effective management of neonatal pain. The progress made is impressive, but the current major challenge is to implement the available knowledge in clinical care. Future research should therefore focus on the evaluation of the effectiveness of non-opioid and moderately potent opioids compared to morphine and should also describe the methods to facilitate effective implementation. Finally, there is an extensive field of procedural techniques that need to be evaluated on their pain related response.