Gaining on Pain in the Neonatal ICU

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Susan Givens Bell, RNC, is working on a pain assessment scale to help care for neonates like baby Jeanette Dempsey. Photo by Mike Sexton, courtesy of All Children’s Hospital.

Kevin,* born at 36 weeks of gestation a few hours ago, is returning to the neonatal intensive care unit (NICU) after a stage 1 repair of gastroschisis, a full-thickness defect in the abdominal wall that permits extrusion of abdominal contents.¹ Portions of the small and large intestine and sometimes the stomach, liver, and other organs are trapped outside the body cavity. Gastroschisis is a surgical emergency because the exposed organs are susceptible to infection, trauma, and severe fluid loss. As the admitting nurse, I learn that Kevin received two analgesic anesthetics during the operation, plus IV fentanyl about 45 minutes ago. Although he’s intubated, I can see Kevin is beet red and crying. His legs are drawn up and stiff, and his arms are flailing. His heart rate is 186 and blood pressure is 100/76 mm Hg. Is Kevin in pain?

Elayna,* born weighing 740 grams, had surgery four days after delivery to repair a perforated bowel. She now lies flaccid in her bed, arms and legs outstretched in a froglike position. Her heart rate is 160, blood pressure is 40/32 mm Hg, and she’s slightly pale. Is Elayna in pain?

Pain Assessment Techniques

Recognizing pain in these two patients is as different as recognizing pain in a healthy individual and one who is severely developmentally delayed. Nursing teaches us that the patient’s report of pain is the most reliable, even in pediatrics. Behavioral demonstrations of pain are the next most reliable, while physiological parameters are the least reliable. Heart rate, respiratory rate, and blood pressure are not only altered during painful states — they change with fluid imbalance, sepsis, and respiratory and cardiac compromise, as well as other conditions. They can be helpful clues, although they’re not as reliable as crying, tenseness, or facial features associated with neonatal pain. The behaviors observed when babies are in pain are the infantile forms of self-report and should not be considered as mere surrogate measures of pain.²

Term infants have an arsenal of energy and neurological maturity. Kevin has normal lipid tissue to mount a significant response to pain. He demonstrates his pain by his behaviors (crying, stiff position), and physiological changes (vital signs, color). Pain response is more subtle in Elayna because she has no energy reserve to mount a significant behavioral or physiological response. She’s more likely to show little or no response. Although very-low-birth-weight infants normally have little muscle tone, a completely flaccid infant may very well be demonstrating a pain response. We must also use our common sense in the NICU. Should we expect someone to have pain two days after major abdominal surgery? Of course — and so we should be highly suspicious when behaviors aren’t within normal developmental parameters.

Fortunately, there are many neonatal pain assessment tools available to choose from. Abu-Saad and colleagues identify and describe 16 tools developed for neonates.³ Some of the common scales are CRIES,⁴ NIPS,⁵ and PIPP.⁶ The Premature Infant Pain Profile, or PIPP, enables users to account for the effects of prematurity on ability to mount a pain response. The Neonatal Infant Pain Scale, or NIPS, was tested on procedural pain in infants ranging from 29 weeks to 40 weeks of gestation; it uses a 0-to-7 scale. CRIES, short for Crying Requires increased oxygen administration, Increased vital signs, Expression, Sleeplessness, is a 10-point scale used with postoperative newborns. It makes sense to review a number of published tools and choose the one most likely to be successfully implemented in your unit.

The Neonatal Pain Assessment Score (NPAS) was developed by Susan Givens Bell, ARNP, MSN, staff nurse III in the NICU at All Children’s Hospital in St. Petersburg. NPAS is based on a 0-to-10 scale consistent with other pain scales used at All Children’s. Nurses rate six behavioral and four physiological parameters as 0, 0.5, or 1 and add the total score.

Bell is principal investigator in a study under way to establish NPAS’s validity and reliability. She and coinvestigators — all NICU staff nurses — rate pain on study subjects using NPAS and will compare scores to another neonatal pain assessment tool with known validity and reliability. The research team hopes to publish the results in 2002.

Managing Neonatal Pain

The treatment of neonatal pain depends upon its severity. Minor pain can usually be managed with acetaminophen. Nurses in the NICU at All Children’s consider minor pain as a pain score of 2 or less on NPAS. Moderate to severe pain is greater than 2 and is generally treated with morphine sulfate. If there’s no contraindication for acetaminophen, it’s also ordered since pain is best managed with a combination of therapies. Morphine may be administered as a bolus dose or continuous drip.

Neonatal pain is managed at All Children’s using several pain management algorithms developed by a multidisciplinary team of nurses, surgeons, anesthesiologists, and neonatologists. The algorithms are based on the current literature and provide guidelines for managing postoperative neonates who are intubated, those not intubated, and those receiving regional analgesia (epidural). A research project is under way to document the patient outcomes associated with these algorithms.

Finally, though most infants require only a few days of morphine or another opioid, the treatment for a few neonates extends beyond a week or two. These infants are at risk of physical dependence, and the opioids must be tapered off slowly. Withdrawal symptoms are opposite to those for opioid overdose — instead of being lethargic, infants will be irritable; instead of having constipation, they’ll have loose stools. Crying and sleeplessness are other symptoms that occur frequently.

Nurses use the Neonatal Abstinence Scale to quantify the severity of withdrawal symptoms.⁷ That scale should be used with every hands-on assessment to follow trends. Scores greater than 8 to 10 indicate major withdrawal symptoms, usually treated by returning to the previous opioid dose before the last tapering-off amount. The American Academy of Pediatrics suggests that opioid withdrawal is best treated with another opioid,⁸ and the group recommends using methadone during neonatal withdrawal. Nonopioids like phenobarbitol serve only to mask symptoms of withdrawal that aren’t being treated and don’t treat diarrhea and vomiting associated with opioid withdrawal.⁹ Robertson and colleagues provide an evidence-based approach to tapering off opioids using methadone.¹⁰

Comfort measures are the most important nursing care intervention, and since they’re entirely under nursing’s purview, they don’t require an order.

First, make sure the baby is in a comfortable position. Help the infant curl up as much as he or she desires — the fetal position is very comforting. Use blankets to create a nest for the baby. Help the infant get his or her hands up to the mouth. Look for rounded, flexed hips and shoulders. Use “facilitated tucking” to calm the child: Hold one hand on the head and the other over the diaper area when the infant is prone, or hold flexed knees gently toward the abdomen when supine.

Second, create an environment of minimal stimulation. Rest is one of the best remedies for recovering from an operation or illness — that means leaving the infant alone in a dark, quiet environment. Make sure that people lower their voices when near the bedside and that unnecessary lighting is off. Involve parents in calming activities, but let no one touch the baby between hands-on times. Other nonpharmacological interventions include alternative therapies like therapeutic touch and sucrose-coated pacifiers.

Making the Grade

Nurses working in a New York NICU felt that their pain management practices were good, and they were proud of how they managed postoperative pain.¹¹ After reviewing patient charts for quality improvement, they found some neonates never received analgesics postoperatively, even if there was an order. The nurses used this discovery to develop a pain management protocol based on current literature. The tenets of their protocol include using a standardized pain assessment tool, discussing pain management strategies and effectiveness every day during rounds, documenting the effectiveness of strategies on every shift, using continuous morphine or fentanyl for major operative procedures and giving a bolus before infusion begins, using round-the-clock boluses of medication for minor procedures, and rejecting PRN orders during the first postoperative days.

Implementing a similar protocol with these important principles could ensure that your NICU meets regulatory requirements, such as the new pain standards published by the Joint Commission on Accreditation of Healthcare Organizations.

Tips for Parents

What do parents of NICU patients want for their infants? Families are also in nurses’ care, though there’s little information about what’s important to them regarding neonatal pain management.

Nurses at All Children’s have joined in an international study, “Parent Views of Pain Management in the NICU.” London-based principal investigator Linda Franck, RN, PhD, RGN, RSCN, hopes to learn what aspects of pain and pain management are of concern to parents.

All Children’s coinvestigators invite parents of NICU infants to complete an anonymous paper survey after gaining informed consent. Results from this survey will help us to learn more about parental concerns and how we can improve care for both parents and the hospital’s most vulnerable patients.

* Name has been changed.

Denise Maguire, RNC, PhD, is a clinical nurse specialist at All Children’s Hospital, St. Petersburg.

References

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2. Anand KJS, Craig KD. New perspectives on the definition of pain. Pain. 1996;67(1):3-6.

3. Abu-Saad JJ, Bours GJJW, Stevens B, Hamers JPH. Assessment of pain in the neonate. Semin in Perinatol. 1998;22(5):402-416.

4. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatric Anaesthesia. 1995;5:53-61.

5. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Network. 1993;12(6):59-66.

6. Stevens B, Johnston C, Petryshen P, Taddio A. Premature infant pain profile: development and initial validation. Pain. 1996:12(1):13-22.

7. Finnegan LP. Neonatal abstinence. In: Nelson NM, ed. Current Therapy in Neonatal-Perinatal Medicine. Toronto, Ontario, Canada: BC Decker; 1985:262-270.

8. American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 1998;101(6):1079-1088.

9. Suresh S, Anand KJS. Opioid tolerance in neonates: mechanisms, diagnosis, assessment, and management. Semin in Perinatol. 1998;22(5):425-433.

10. Robertson RC, Darsey E, Fortenberry JD, Pettignano R, Hartley G. Evaluation of an opiate-weaning protocol using methadone pediatric intensive care patients. Pediatr Crit Care Med. 2000;1(2):119-123.

11. Furdon SA, Eastman M, Benjamin K, Horgan MJ. Outcome measures after standardized pain management strategies in postoperative patients in the neonatal intensive care unit. J Perinat Neonat Nurs. 1998;12(1):58-69.