ASK THE EXPERTS For reprint orders, please contact: [email protected]
The management of pain in infants Celeste Johnston†: Celeste Johnston is an Emeritus
Professor at McGill University School of Nursing, Montreal and a scientist at IWK Health Center, Halifax. Her research, funded by Canadian Institutes of Health Research, Quebec Research Fund, SickKids Foundation, Nova Scotia Health Research Foundation and the Mayday Fund, has, over the past three decades, focused on pain in infants, particularly preterm newborns.
News & Views News Journal Watch
When treating pain in infants/young children, what are the most important considerations a practitioner should make? QQ
There are many considerations that practitioners must make when considering pain in infants and young children, and the most important one is to know and appreciate that rapid developmental changes are occurring. Knowing the physical as well as cognitive level of development of the infant will influence how the pain is approached; including how it is assessed, what the comprehension of the pain experience is, how drugs are metabolized and excreted and what nonpharmacological approaches could be used. A preterm infant is significantly different than a full-term infant in several important ways, and even a preterm infant less than 32 weeks gestational age is different from one who is 36 weeks gestational age. For example, ascending pathways develop sooner than descending pathways, so that a preterm infant of 27 weeks gestational age may actually feel pain more strongly, with fewer inhibitory mechanisms, than a full-term infant [1] . Clearance of drugs is another major issue with infants, with young infants’ immature livers unable to clear opiate-based painkillers well, leading to potentially dangerous side effects [2] . †
An adult patient can communicate their pain & the extent of their pain much more easily than infants. Is this a big challenge in the management of infant pain? QQ
Ask the Experts Interview
Assessing pain in infants was the major challenge in managing their pain two decades ago. Since that time much work has been done, so that now there are tens of validated pain assessment tools for infants [3] . Basically these measures can be divided into physiological or behavioral parameters. Changes in heart rate and oxygen saturation levels are the most common physiological changes and are routinely monitored in hospitalized infants. Typically, the heart rate increases and concomitantly, oxygen saturation levels decrease in response to pain. These parameters are not specific to pain. They may change due to important conditions such as fever and hemorrhage, so that without more information, to rely on them solely as an indication of pain could be problematic. Behavioral responses such as facial actions that form a grimace, crying or body tensing tend to be more specific to pain. Several measures incorporate both physiological and behavioral components and these are most widely recommended. New research is examining brain activity in response to pain [4] , and shows promise but also poses challenges
School of Nursing, 3506 University Street, Montreal, Canada; [email protected]
10.2217/PMT.11.54 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(6), 505–507
ISSN 1758-1869
505
NEWS & VIEWS ASK THE EXPERTS such as which area of the brain to monitor, since pain is a complex phenomenon and involves various parts of the brain. In your experience, what are the other challenges encountered when dealing with pain in infants? QQ
Infants who have extended periods of pain or discomfort, such as with chronic disease, or who must remain intubated for extended periods (more than hours), are the most challenging ones both to assess and treat. They often have become exhausted from their pain and show a more apathetic response than the response we see in infants in acute pain [5,6] . The best way to treat pain of intubated infants has yet to be determined. Methods that were thought to work, such as opiates which are used with success in adults and older children, had detrimental effects over time with newborns [7] . Parents will usually be very concerned with their children’s welfare. How important is it for a practitioner to communicate & liaise with the parent to optimize the management of pain in their infant (i.e., the role parental involvement plays)? QQ
Parents are the best partners practitioners can have. They know their child best and can help interpret individualized responses to pain and will also know what might work best for their infant. If practitioners make it clear to parents that everyone involved in caring for their infant is interested in making comfort a high priority and express intent to work together, the infant is likely to receive the best care. Mothers vary as much as infants in their caregiving style and how they interpret and react to their infants pain cues and practitioners need to be sensitive to these variations and not expect all parents to behave similarly. The most important part is to agree to partner with them and find a way that works best for the infant. What is the role of palliative care & nonpharmacological interventions in the management of pain in infants? QQ
Much pain that infants experience come from procedures. Promoting maximum comfort is the goal of palliative care, and
506
Pain Manage. (2011) 1(6)
while pharmacologic agents may be appropriate in some instances, nonpharmacological interventions are being recognized as a mainstay of comfort, particularly for the procedural pain. Sweet taste, with over 40 studies on its efficacy, has now become a standard of care for procedural pain in infants, although there remain some questions about its longterm use, especially for very or extremely preterm neonates [8–10] . Recent work on maternal interventions such as breastfeeding, skin-to-skin contact, commonly called Kangaroo Care, or, in the absence of the mother, facilitated tucking, music, pacifiers have all been shown to be effective in diminishing pain response [11,12] . There are several appealing aspects of maternal involvement in pain management: it gives back the maternal role of comforting to the mother, it promotes mother–infant bonding, it costs nothing, and, of course, it is as effective as other methods. Have you experienced an improvement in the maintenance of professional healthcare practices in a neonatal setting? QQ
There have been significant improvements over the past two decades in pain management of infants [13] . Two decades ago, there was almost no pain management for neonates, including adequate management of post-surgical pain. Post-operative pain is now well managed and with the testing of nonpharmacological interventions, procedural pain is better managed than it was. Nevertheless, the level of management falls far below a universal level, with reports typically suggesting that about half of nonsurgical procedural pain is not being addressed. What important changes need to take place in infant pain management in the near future (areas within pain management in infants that require further research)? QQ
There are several areas that require research in pain management in infants. It would be critical to find a way to adequately and safely treat pain associated with ongoing intubated respiratory support, for example a large trial of nonsteroidal
future science group
ASK THE EXPERTS anti-inflammatory agents and adjuvant nonpharmacological therapies for this group of infants. Better assessment, specific to intubated infants, is also required [6,14] . Moving the level of procedural pain management from half to almost universal, perhaps exceptionally emergent procedures, is a realizable goal with research examining complex issues of healthcare delivery [15,16] . While there is still some controversy surrounding sweet taste analgesia, research is needed to determine what ages or populations are less vulnerable to potential negative effects of its repeated use and which ones require more caution and judicious use of it, as well as using animal models to test long-term risks or benefits of sweet taste. While interventions by mothers such as
breastfeeding or Kangaroo Care appear to be effective, their effect over repeated procedures has yet to be determined. Another easily researched question would be if caretakers other than mothers could provide comfort as well.
Bibliography
6
1
Fitzgerald M, Walker SM. Infant pain management: a developmental neurobiological approach. Nat. Clin. Pract. Neuro. 5(1), 35–50 (2009).
2
Simons SH, Anand KJ. Pain control: opioid dosing, population kinetics and side-effects. Semin. Fetal Neonatal Med. 11(4), 260–267 (2006).
3
Ranger M, Johnston CC, Anand KJ. Current controversies regarding pain assessment in neonates. Semin. Perinatol. 31(5), 283–288 (2007).
4
5
Slater R, Boyd S, Meek J, Fitzgerald M. Cortical pain responses in the infant brain. Pain 123(3), 332; author reply 332–334 (2006). Aranda JV, Carlo W, Hummel P, Thomas R, Lehr VT, Anand KJ. Analgesia and sedation during mechanical ventilation in neonates. Clin. Ther. 27(6), 877–899 (2005).
NEWS & VIEWS
Financial & competing interests disclosure C Johnston has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
7
8
Hummel P, van Dijk M. Pain assessment: current status and challenges. Semin. Fetal Neonatal Med. 11(4), 237–245 (2006).
12 Johnston C, Campbell-Yeo M, Fernandes A,
Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst. Rev. 3, CD14008435 (2010).
Anand KJ, Hall RW, Desai N et al. Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Lancet 363(9422), 1673–1682 (2004).
13 Johnston CC, Barrington K, Taddio A,
Holsti L, Grunau RE. Considerations for using sucrose to reduce procedural pain in preterm infants. Pediatrics 125(5), 1042–1047 (2010).
14
Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J. Perinatol. 28(1), 55–60 (2008).
Carbajal R, Filion F. Pain in Canadian NICU’s: have we improved over the past 12 years? Clin. J. Pain. 27(3), 225-232 (2010).
9
Johnston CC, Filion F, Snider L et al. How much sucrose is too much sucrose? Pediatrics 119(1), 226 (2007).
10
Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst. Rev. 1, CD001069 (2010).
15
Stevens B. Challenges in knowledge translation: integrating evidence on pain in children into practice. Can. J. Nurs. Res. 41(4), 109–114 (2009).
11
Cignacco E, Hamers JPH, Stoffel L et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systematic literature review. Eur. J. Pain 11(2), 139–152 (2007).
16
Stevens B, Riahi S, Cardoso R et al. The influence of context on pain practices in the NICU: perceptions of health care professionals. Qual. Health Res. 21(6), 757–770 (2011).
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Roshaine Gunawardana, Commissioning Editor [email protected]
future science group
www.futuremedicine.com
507
The management of pain in infants Celeste Johnston†: Celeste Johnston is an Emeritus
Professor at McGill University School of Nursing, Montreal and a scientist at IWK Health Center, Halifax. Her research, funded by Canadian Institutes of Health Research, Quebec Research Fund, SickKids Foundation, Nova Scotia Health Research Foundation and the Mayday Fund, has, over the past three decades, focused on pain in infants, particularly preterm newborns.
News & Views News Journal Watch
When treating pain in infants/young children, what are the most important considerations a practitioner should make? QQ
There are many considerations that practitioners must make when considering pain in infants and young children, and the most important one is to know and appreciate that rapid developmental changes are occurring. Knowing the physical as well as cognitive level of development of the infant will influence how the pain is approached; including how it is assessed, what the comprehension of the pain experience is, how drugs are metabolized and excreted and what nonpharmacological approaches could be used. A preterm infant is significantly different than a full-term infant in several important ways, and even a preterm infant less than 32 weeks gestational age is different from one who is 36 weeks gestational age. For example, ascending pathways develop sooner than descending pathways, so that a preterm infant of 27 weeks gestational age may actually feel pain more strongly, with fewer inhibitory mechanisms, than a full-term infant [1] . Clearance of drugs is another major issue with infants, with young infants’ immature livers unable to clear opiate-based painkillers well, leading to potentially dangerous side effects [2] . †
An adult patient can communicate their pain & the extent of their pain much more easily than infants. Is this a big challenge in the management of infant pain? QQ
Ask the Experts Interview
Assessing pain in infants was the major challenge in managing their pain two decades ago. Since that time much work has been done, so that now there are tens of validated pain assessment tools for infants [3] . Basically these measures can be divided into physiological or behavioral parameters. Changes in heart rate and oxygen saturation levels are the most common physiological changes and are routinely monitored in hospitalized infants. Typically, the heart rate increases and concomitantly, oxygen saturation levels decrease in response to pain. These parameters are not specific to pain. They may change due to important conditions such as fever and hemorrhage, so that without more information, to rely on them solely as an indication of pain could be problematic. Behavioral responses such as facial actions that form a grimace, crying or body tensing tend to be more specific to pain. Several measures incorporate both physiological and behavioral components and these are most widely recommended. New research is examining brain activity in response to pain [4] , and shows promise but also poses challenges
School of Nursing, 3506 University Street, Montreal, Canada; [email protected]
10.2217/PMT.11.54 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(6), 505–507
ISSN 1758-1869
505
NEWS & VIEWS ASK THE EXPERTS such as which area of the brain to monitor, since pain is a complex phenomenon and involves various parts of the brain. In your experience, what are the other challenges encountered when dealing with pain in infants? QQ
Infants who have extended periods of pain or discomfort, such as with chronic disease, or who must remain intubated for extended periods (more than hours), are the most challenging ones both to assess and treat. They often have become exhausted from their pain and show a more apathetic response than the response we see in infants in acute pain [5,6] . The best way to treat pain of intubated infants has yet to be determined. Methods that were thought to work, such as opiates which are used with success in adults and older children, had detrimental effects over time with newborns [7] . Parents will usually be very concerned with their children’s welfare. How important is it for a practitioner to communicate & liaise with the parent to optimize the management of pain in their infant (i.e., the role parental involvement plays)? QQ
Parents are the best partners practitioners can have. They know their child best and can help interpret individualized responses to pain and will also know what might work best for their infant. If practitioners make it clear to parents that everyone involved in caring for their infant is interested in making comfort a high priority and express intent to work together, the infant is likely to receive the best care. Mothers vary as much as infants in their caregiving style and how they interpret and react to their infants pain cues and practitioners need to be sensitive to these variations and not expect all parents to behave similarly. The most important part is to agree to partner with them and find a way that works best for the infant. What is the role of palliative care & nonpharmacological interventions in the management of pain in infants? QQ
Much pain that infants experience come from procedures. Promoting maximum comfort is the goal of palliative care, and
506
Pain Manage. (2011) 1(6)
while pharmacologic agents may be appropriate in some instances, nonpharmacological interventions are being recognized as a mainstay of comfort, particularly for the procedural pain. Sweet taste, with over 40 studies on its efficacy, has now become a standard of care for procedural pain in infants, although there remain some questions about its longterm use, especially for very or extremely preterm neonates [8–10] . Recent work on maternal interventions such as breastfeeding, skin-to-skin contact, commonly called Kangaroo Care, or, in the absence of the mother, facilitated tucking, music, pacifiers have all been shown to be effective in diminishing pain response [11,12] . There are several appealing aspects of maternal involvement in pain management: it gives back the maternal role of comforting to the mother, it promotes mother–infant bonding, it costs nothing, and, of course, it is as effective as other methods. Have you experienced an improvement in the maintenance of professional healthcare practices in a neonatal setting? QQ
There have been significant improvements over the past two decades in pain management of infants [13] . Two decades ago, there was almost no pain management for neonates, including adequate management of post-surgical pain. Post-operative pain is now well managed and with the testing of nonpharmacological interventions, procedural pain is better managed than it was. Nevertheless, the level of management falls far below a universal level, with reports typically suggesting that about half of nonsurgical procedural pain is not being addressed. What important changes need to take place in infant pain management in the near future (areas within pain management in infants that require further research)? QQ
There are several areas that require research in pain management in infants. It would be critical to find a way to adequately and safely treat pain associated with ongoing intubated respiratory support, for example a large trial of nonsteroidal
future science group
ASK THE EXPERTS anti-inflammatory agents and adjuvant nonpharmacological therapies for this group of infants. Better assessment, specific to intubated infants, is also required [6,14] . Moving the level of procedural pain management from half to almost universal, perhaps exceptionally emergent procedures, is a realizable goal with research examining complex issues of healthcare delivery [15,16] . While there is still some controversy surrounding sweet taste analgesia, research is needed to determine what ages or populations are less vulnerable to potential negative effects of its repeated use and which ones require more caution and judicious use of it, as well as using animal models to test long-term risks or benefits of sweet taste. While interventions by mothers such as
breastfeeding or Kangaroo Care appear to be effective, their effect over repeated procedures has yet to be determined. Another easily researched question would be if caretakers other than mothers could provide comfort as well.
Bibliography
6
1
Fitzgerald M, Walker SM. Infant pain management: a developmental neurobiological approach. Nat. Clin. Pract. Neuro. 5(1), 35–50 (2009).
2
Simons SH, Anand KJ. Pain control: opioid dosing, population kinetics and side-effects. Semin. Fetal Neonatal Med. 11(4), 260–267 (2006).
3
Ranger M, Johnston CC, Anand KJ. Current controversies regarding pain assessment in neonates. Semin. Perinatol. 31(5), 283–288 (2007).
4
5
Slater R, Boyd S, Meek J, Fitzgerald M. Cortical pain responses in the infant brain. Pain 123(3), 332; author reply 332–334 (2006). Aranda JV, Carlo W, Hummel P, Thomas R, Lehr VT, Anand KJ. Analgesia and sedation during mechanical ventilation in neonates. Clin. Ther. 27(6), 877–899 (2005).
NEWS & VIEWS
Financial & competing interests disclosure C Johnston has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
7
8
Hummel P, van Dijk M. Pain assessment: current status and challenges. Semin. Fetal Neonatal Med. 11(4), 237–245 (2006).
12 Johnston C, Campbell-Yeo M, Fernandes A,
Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst. Rev. 3, CD14008435 (2010).
Anand KJ, Hall RW, Desai N et al. Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Lancet 363(9422), 1673–1682 (2004).
13 Johnston CC, Barrington K, Taddio A,
Holsti L, Grunau RE. Considerations for using sucrose to reduce procedural pain in preterm infants. Pediatrics 125(5), 1042–1047 (2010).
14
Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain. J. Perinatol. 28(1), 55–60 (2008).
Carbajal R, Filion F. Pain in Canadian NICU’s: have we improved over the past 12 years? Clin. J. Pain. 27(3), 225-232 (2010).
9
Johnston CC, Filion F, Snider L et al. How much sucrose is too much sucrose? Pediatrics 119(1), 226 (2007).
10
Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst. Rev. 1, CD001069 (2010).
15
Stevens B. Challenges in knowledge translation: integrating evidence on pain in children into practice. Can. J. Nurs. Res. 41(4), 109–114 (2009).
11
Cignacco E, Hamers JPH, Stoffel L et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systematic literature review. Eur. J. Pain 11(2), 139–152 (2007).
16
Stevens B, Riahi S, Cardoso R et al. The influence of context on pain practices in the NICU: perceptions of health care professionals. Qual. Health Res. 21(6), 757–770 (2011).
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Roshaine Gunawardana, Commissioning Editor [email protected]
future science group
www.futuremedicine.com
507
