New guidelines for the
management of pain in newborn infants, developed by the International
Consensus Group for Neonatal Pain, were published today in the Archives of
Pediatrics and Adolescent Medicine, a journal of the American Medical
Association. According to the guidelines, pain in newborn babies is most
often unrecognized and undertreated, causing unnecessary suffering.
"The research evaluated by this Consensus Group has revealed that the
earlier and more frequently a newborn baby is subjected to pain, the greater
is the potential harm," points out International Evidence-Based Group
Chairman, K.J.S. Anand, MD, from the Arkansas Children's Hospital, Little
Rock. "Neonates who experience repeated pain in the hospital such as frequent
heel-sticks or intramuscular injections may be more fearful of pain than their
peers during later childhood. We wanted to help take the 'hurt out of the
hospital' for these babies."
The Neonatal Consensus Group recommends that pediatricians adopt
preemptive comfort measures, such as the appropriate use of analgesia, as a
part of a practical pain management program. Some preemptive methods include
oral sucrose, morphine, and EMLA(R) CREAM, (lidocaine 2.5% and prilocaine
2.5%). EMLA, a topical anesthetic cream that can be used in pediatric
patients as young as full-term neonates is able to penetrate skin and provides
effective local anesthesia, allowing for pain-free needle insertions and minor
superficial surgery. EMLA should not be used in neonates with a gestational
age less than 37 weeks or in infants under the age of 12 months receiving
treatment with methemoglobin inducing agents.
According to the consensus panel, there is resistance to preventing or
managing pain in newborn babies due to fear over the adverse effects
associated with analgesics, especially morphine and similar opioid analgesics.
All newborns undergo routine invasive procedures the first days and weeks
after birth. Research has shown that very young babies -- some of whom are
very sick -- can undergo numerous medical procedures within the intensive care
unit. For example, one study showed that neonates in intensive care undergo as
many as three invasive procedures per one hour, while another study showed
that, on average, only three percent of such procedures are currently
performed with appropriate analgesics.1, 2, 3 Because babies cannot talk or
respond like adults, it is difficult for healthcare professionals to
understand the type and/or degree of pain the baby is experiencing. This lack
of understanding often leads to inadequate assessment, prevention, and
management of pain in neonates.
Pediatric Pain Guidelines
New recommendations propose the use of safe and effective approaches for
preventing and relieving pain and its adverse consequences. Three treatment
approaches highlighted in the guidelines are as follows:
- Pharmacological -- using anesthetics such as EMLA, morphine and other
opioids and acetaminophen. Specific dosing for EMLA can be found in
- Principles for Pain Relief --
The International Consensus Group for Neonatal Pain is made up of
pediatric pain experts including 25 physicians and nurses from 12 countries.
Highlights from the group's eight principles for pain relief in neonates
- If a procedure is painful in adults, it should be considered painful in
newborn infants, even if they are preterm.
- Adequate treatment of pain may be associated with decreased clinical
complications and decreased mortality.
- The appropriate use of environmental, behavioral, and pharmacological
interventions can prevent, reduce, or eliminate neonatal pain in many
"Our recommendations are mainly applicable in established neonatal
intensive care units that provide advanced medical and nursing care for
critically ill babies. However, we are working toward adapting them for the
management of neonatal pain in other clinical settings," says Dr. Anand. "In
addition, we hope that our work will stimulate further research by clearly
outlining the areas where current evidence is not available with regard to
specific therapeutic approaches."
The International Consensus Group for Neonatal pain is supported by an
unrestricted educational grant from AstraZeneca.
EMLA is indicated as a topical anesthetic for use on normal intact skin
for local analgesia and on genital mucous membranes for superficial minor
surgery and as pretreatment for infiltration anesthesia.
EMLA is not recommended in any clinical situation in which penetration or
migration beyond the tympanic membrane into the middle ear is possible because
of the ototoxic effects observed in animal studies. It is contraindicated in
patients with a known history of sensitivity to local anesthetics of the amide
type or to any other component of the product.
EMLA Cream is approved for use in full-term neonates (> or = 37 weeks
gestation). Maximum application time should not exceed 1 hour in infants less
than 3 months old or < 5kg. EMLA should not be used in those rare patients
with congenital or idiopathic methemoglobinemia and in infants under the age
of 12 months who are receiving treatment with methemoglobinemia-inducing
agents. In patients treated with EMLA Cream, local effects observed were
generally mild and transient, resolving spontaneously within 1 or 2 hours.
Local effects observed in the trials included: paleness (pallor or blanching)
37%, redness (erythema) 30%, alterations in temperature sensations 7%, and
EMLA is available only by prescription and is manufactured and marketed by
Click this link for the full prescribing information for EMLA Cream
- 1. Porter FL, Anand KJS. Epidemiology of pain in neonates. Research and
Clinical Forums 1998;20(4):9-16
- 2. Barker DP, Rutter N. Exposure to invasive procedures in neonatal
intensive care unit admissions. Archives of Disease in Childhood Fetal
and Neonatal Edition 1995;72(1):F47-8.
- 3. Johnston CCC, Collinge JM, Henderson SJ, Anand KJS. A cross-sectional
survey of pain and pharmacological analgesia in Canadian neonatal
intensive care units. Clinical Journal of Pain 1997;13(4):308-12.