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Back To Vidyya Experts Recommend Pain Management For Newborn Babies

Pain Specialists Call For Greater Use Of Analgesia In Newborn Infants, According To Consensus Statement Published In An American Medical Association (AMA) Journal

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 today's issue.

  • 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 include:

  • 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 clinical situations.

"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.

About EMLA

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 edema 6%.

EMLA is available only by prescription and is manufactured and marketed by AstraZeneca.

Click this link for the full prescribing information for EMLA Cream

  • References
  • 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.

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