This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatrics. Prevention and management of pain and stress in the neonate. American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics 2000 Feb;105(2):454-61.

All clinical reports and policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Acute pain

Management
Prevention

Pediatrics

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians

• To emphasize that despite increased awareness of the importance of pain prevention, neonates in the neonatal intensive care unit (NICU) continue to be exposed to numerous painful minor procedures daily as part of their routine care
• To present objective means of assessing neonatal pain by health care professionals
• To describe effective strategies to prevent and treat pain associated with routine minor procedures
• To review appropriate methods to prevent and treat pain associated with surgery and other major procedures

Neonates (preterm to 1 month of age)

1. Assessment of pain and stress using multidimensional tools
2. Care protocols that minimize painful disruptions
3. Combination of oral sucrose/glucose and other nonpharmacologic measures, including nonnutritive sucking, kangaroo care, facilitated tuck, swaddling, developmental care, for minor routine procedures
4. Topical anesthetics for venipuncture, lumbar puncture, and intravenous catheter insertion
5. Coordinated strategy for pain management in surgery, including sufficient anesthesia, routine assessment of pain, opioids as the basis for postoperative analgesia after major surgery (in the absence of regional anesthesia), and acetaminophen as an adjunct to opioids or regional anesthesia
6. Analgesia for chest-drain insertion including general nonpharmacologic measures, slow infiltration of the skin site with a local anesthetic before incision, systemic analgesia (e.g., fentanyl)
7. Analgesia for chest-drain removal including general nonpharmacologic measures and short-acting, rapid-onset systemic analgesics
8. Local anesthetic eye drops and oral sucrose for retinal examinations
9. Opiate-based pain relief for retinal surgery

Note: The following medications are considered but not recommended: routine use of continuous infusions of morphine, fentanyl, or midazolam in chronically ventilated preterm neonates; non-steroidal anti-inflammatory agents.

• Pain as measured by assessment tools
• Physiologic and behavioral indicators of pain
• Adverse effects of pharmacological interventions

Searches of Electronic Databases

Not stated

Not stated

Not stated

Not applicable

Review

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Assessment of Pain and Stress in the Neonate

1. Caregivers should be trained to assess neonates for pain using multidimensional tools. Refer to Table 1: Pain Assessment Tools in the original guideline document for description of most commonly used assessment tools, physiologic and behavioral indicators of pain for each tool, and other information.
2. Neonates should be assessed for pain routinely and before and after procedures.
3. The chosen pain scales should help guide caregivers in the provision of effective pain relief.

Reducing Pain from Bedside Care Procedures

1. Care protocols for neonates should incorporate a principle of minimizing the number of painful disruptions in care as much as possible.
2. Use of a combination of oral sucrose/glucose and other nonpharmacologic pain-reduction methods (nonnutritive sucking, kangaroo care, facilitated tuck, swaddling, developmental care) should be used for minor routine procedures.
3. Topical anesthetics can be used to reduce pain associated with venipuncture, lumbar puncture, and intravenous catheter insertion when time permits but are ineffective for heel-stick blood draws, and repeated use of topical anesthetics should be limited.
4. The routine use of continuous infusions of morphine, fentanyl, or midazolam in chronically ventilated preterm neonates is not recommended because of concern about short-term adverse effects and lack of long-term outcome data.

Reducing Pain from Surgery

1. Any health care facility providing surgery for neonates should have an established protocol for pain management. Such a protocol requires a coordinated, multidimensional strategy and should be a priority in perioperative management.
2. Sufficient anesthesia should be provided to prevent intraoperative pain and stress responses to decrease postoperative analgesic requirements.
3. Pain should be routinely assessed by using a scale designed for postoperative or prolonged pain in neonates.
4. Opioids should be the basis for postoperative analgesia after major surgery in the absence of regional anesthesia.
5. Postoperative analgesia should be used as long as pain-assessment scales document that it is required.
6. Acetaminophen can be used after surgery as an adjunct to regional anesthetics or opioids, but there are inadequate data on pharmacokinetics at gestational ages less than 28 weeks to permit calculation of appropriate dosages.

Reducing Pain from Other Major Procedures

1. Analgesia for chest-drain insertion comprises all of the following:
   1. General nonpharmacologic measures
   2. Slow infiltration of the skin site with a local anesthetic before incision unless there is life-threatening instability (if there was inadequate time to infiltrate before insertion of the chest tube, local skin infiltration after achieving stability may reduce later pain responses and later analgesic requirements)
   3. Systemic analgesia with a rapidly acting opiate such as fentanyl

2. Analgesia for chest-drain removal comprises the following:
   1. General nonpharmacologic measures
   2. Short-acting, rapid-onset systemic analgesic

3. Although there are insufficient data to make a specific recommendation, retinal examinations are painful, and pain-relief measures should be used. A reasonable approach would be to administer local anesthetic eye drops and oral sucrose.
4. Retinal surgery should be considered major surgery, and effective opiate-based pain relief should be provided.

None provided

The type of evidence supporting each recommendation is not specifically stated.

Prevention, reduction, or elimination of pain

• There is a risk of methemoglobinemia after use of topical lidocaine-prilocaine cream in certain situations.
• Because of the physiologic and metabolic immaturity of the neonate, doses of medications that are effective for the reduction of pain may be close to the doses that cause toxicity.
• Rectal acetaminophen should be used cautiously because of erratic absorption.

In the original statement, stress and chronic pain were briefly discussed in addition to acute pain. However, neither chronic pain nor stress has been specifically defined for the neonate, and only an intuitive understanding of these concepts is possible. Therefore, this updated statement deals primarily with acute pain prevention.

An implementation strategy was not provided.

Getting Better
Living with Illness
Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2000 Feb (revised 2006 Nov)

American Academy of Pediatrics - Medical Specialty Society
Canadian Paediatric Society - Medical Specialty Society

American Academy of Pediatrics

Committee on Fetus and Newborn
Section on Surgery

Committee on Fetus and Newborn, 2005-2006: Ann R. Stark, MD, Chairperson; David H. Adamkin, MD; * Daniel G. Batton, MD; Edward F. Bell, MD; Susan E. Denson, MD; William A. Engle, MD; Gilbert I. Martin, MD

Liaisons: *Keith J. Barrington, MD, Canadian Paediatric Society; Tonse N.K. Raju, MD, National Institutes of Health; Laura Riley, MD, American College of Obstetricians and Gynecologists; Kay M. Tomashek, MD, Centers for Disease Control and Prevention; *Carol Wallman, MSN, RNC, NNP, National Association of Neonatal Nurses

Staff: Jim Couto, MA

Section on Surgery, 2005-2006: Donna A. Caniano, MD, Chairperson; Michael D. Klein, MD; Richard R. Ricketts, MD; Brad W. Warner, MD; Keith P. Lally, MD; Kurt D. Newman, MD; Thomas R. Weber, MD; Richard G. Azizkhan, MD; Mary L. Brandt, MD; A. Alfred Chahine, MD; Frederick J. Rescorla, MD; Michael A. Skinner, MD; George W. Holcomb, III, MD; Frederick C. Ryckman, MD

Staff: Chelsea Kirk

* Lead author

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatrics. Prevention and management of pain and stress in the neonate. American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics 2000 Feb;105(2):454-61.

All clinical reports and policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

None available

None available

This summary was completed by ECRI on November 16, 2000. The information was verified by the guideline developer on January 8, 2001. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was completed by ECRI on January 10, 2007. The information was verified by the guideline developer on January 23, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.