Regional anesthesia in neonates and infants outside the immediate perioperative period: A systematic review of studies with efficacy and safety considerations

Regional Anesthesia for Neonates

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Evolving approaches in neonatal postoperative pain management

Neonates experience significant moderate and severe postoperative pain. Effective postoperative pain management in neonates is required to minimize acute and long-term effects of neonatal pain. Protecting the developing nervous system from persistent sensitization of pain pathways and developing primary hyperalgesia is essential. Opioids and acetaminophen are commonly analgesics used for pain control. Regional anesthesia provides adequate intraoperative and postoperative analgesia in neonates. It decreases exposure to opioids, reduces adverse drug effects, and facilitates early extubation. It suppresses the stress response and can prevent long-term behavioral responses to pain. The most common blocks performed in neonates are neuraxial blocks. Using ultrasound increased the number of peripheral nerve blocks performed in neonates. Recently, various peripheral nerve blocks (paravertebral, transverse abdominis plane, rectus sheath, quadratus lumborum, erector spinae plane blocks) were safely used. Many studies support analgesic efficacy but highlight neonates' unpredictability and variability of fascial blocks.