540043
research-article2014
CPJXXX10.1177/0009922814540043Clinical PediatricsSabic et al
Commentary
Newborn and Infant Pain Control
Clinical Pediatrics 2015, Vol. 54(7) 613–614 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814540043 cpj.sagepub.com
Dajana Sabic, BA1, Collin Blattner, BS1, and Michael Metts, DO1 Unlike most patients, babies are incapable of rating their pain on a scale of 0 to 10, and yet from the moment they take their first breath, newborns are exposed to pain. Heel lancets, circumcisions, injections, and immunizations are all vital components of ensuring a healthy baby. Although a cry is an almost expected response from a baby, how can one be certain that unnecessary pain is not being inflicted? Due to the sensitive nature of a newborn and the risks associated with traditional pain control, this article aims to review pharmacologic and alternative treatments for pain management in newborns. Studies have shown that babies may be more sensitive to pain than older individuals. A scarceness of inhibitory neurotransmitters in unmyelinated fibers, large receptive fields, and a higher concentration of substance P receptors all support this hypothesis.1 Infants do not simply display a reflex response to nociception; they develop the neuronal connections to experience all aspects of pain perception while still in the womb.2 The 5 S’s are a well-known physical intervention developed by pediatrician Dr. Harvey Karp that decrease infantile pain during painful procedures.3 The 5 S’s involve swaddling the baby, placing the baby on its side or stomach as an adult swings with a pacifier in its mouth to suck on, and softly shushes the infant. Implementing the 5 S’s prior to painful procedures has been shown to increase analgesia compared to sucrose water, which has traditionally been used to calm infants. Although combination therapy would be surmised to be more effective, there is no synergistic effect of using sucrose with the 5 S’s. In one study, a modified Riley Infant Pain Scoring Method analyzed quality of cry, facial grimace, and body movement to determine the infant’s post-vaccination pain score.3 Another study demonstrated a synergistic response in pain reduction when skin-to-skin contact and dextrose solution were administered.4 Other approaches to pain control included breastfeeding and distraction with a toy, but the results are not as well documented as traditional therapy.3 Acetaminophen and topical anesthetics are relatively safe, traditional approaches to reducing pain during immunizations and injections, but while effective, they have certain downfalls.3 Recent literature has shown administering acetaminophen before primary immunization decreases immune response.5 Topical
anesthetics like lidocaine/prilocaine cream are also effective for subcutaneous and intramuscular injection pain control and do not affect vaccine immunogenicity. Despite these attributes, the onset of action ranges from 10 minutes to an hour, and therefore must be placed an hour prior to injection, which may not be practical in all instances.6 Heel lancets are used for routine neonatal metabolic disease screening, blood glucose monitoring, and other blood tests in the newborn nursery and neonatal intensive care unit. It is important to perform heel blood sampling on the side of the foot, extending posteriorly from a point between the fourth and fifth toes and running parallel to the lateral aspect of the heel. Alternatively, a line extending posteriorly from the middle of the great toe running parallel to the medial aspect of the heel may be used; a depth of less than 2.4 mm is desirable to minimize pain and bruising.7 In a study assessing the most effective form of pain control for this procedure, feeding and breastfeeding were found to be superior compared to the control, nonnutritive sucking, being held by the mother, and oral glucose solution. The assessment measured physiologic markers of pain including heart rate, oxygen saturation, respiratory rate, blood pressure, facial expression, body movements, and cry.8 Another study suggested that a 25% glucose solution was more effective at reducing pain and crying times when compared to breastfeeding prior to heel lancets and venipuncture.9 Oral sucrose with or without facilitated tucking has also been shown to decrease pain while facilitated tucking alone was not as effective.10 Unfortunately, topical anesthetics that decrease pain from injection do not confer the same benefit with heel sticks.2 While more research must be done, a plausible explanation may include increased sensory discrimination and decreased absorption due to thicker, more callus skin found on the heel. Nonetheless, consistent results are difficult to attain because various pain scales have been implemented to assess pain reduction from oral 1
Des Moines University, Des Moines, IA, USA
Corresponding Author: Michael Metts, Department of Specialty Medicine, Des Moines University, 3200 Grand Ave, Des Moines, IA 50312, USA. Email: [email protected]
614 sucrose/glucose use. Literature shows tremendous support for the use of oral sucrose/glucose, but the question of its ability to relieve pain remains unanswered. Some claim that sucrose or sugar may confer pleasure to the infant instead of acting as an analgesic.11 Other sources suggest the sucrose has analgesic properties similar to endogenous opioids since its effects can be reversed with administration of naloxone, an opioid antagonist.12 In conclusion, no concrete method exists to determine if sucrose water or methods such as the 5 S’s have true analgesic properties. However, observational pain score reduction may provide benefit to an infant and should be implemented when possible. Through use of appropriate traditional and alternative methods for pain control, babies will be comfortable, and future appointments and procedures will not be tainted by prior negative experiences. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Mathew PJ, Mathew JL. Assessment and management of pain in infants. Postgrad Med J. 2003;79:438-443. 2. Carbajal R, Nguyen-Bourgain C, Armengaud J. How can we improve pain relief in neonates? Expert Rev Neurother. 2008;8:1617-1620. 3. Harrington JW, Logan S, Harwell C, et al. Effective analgesia using physical interventions for infant immunizations. Pediatrics. 2012;129:815-823.
Clinical Pediatrics 54(7) 4. Gomes Chermont A, Fabio Magno Falcao L, Henrique Laurindo de Souza Silva E, De Cassia Xavier Balda R, Guinsburg R. Skin-to-skin contact and/or oral 25% dextrose for procedural pain relief for term newborn infants. Pediatrics. 2009;124:1101-1107. 5. Prymula R, Siergrist C, Chlibek R, et al. Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Lancet. 2009;374:1339-1350. 6. Schechter NL, Zempsky WT, Cohen LL, McGrath PJ, McMurray CM, Bright NS. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007;119:1184-1198. 7. Blumenfeld TA, Turi GK, Blanc WA. Recommended site and depth of newborn skin punctures based on anatomical measurements and histopathy. Lancet. 1979;10:230-233. 8. Weissman A, Aranovitch M, Blazer S, Zimmer EZ. Heel-lancing in newborns: behavioral and spectral analysis assessment of pain control methods. Pediatrics. 2009;124:921-926. 9. Bueno M, Stevens B, Ponce de Camargo P, et al. Breast milk and glucose for pain relief in preterm infants: a noninferiority randomized controlled trial. Pediatrics. 2012;129:664-670. 10. Cignacco EL, Sellam G, Stoffel L, et al. Oral sucrose and “facilitated tucking” for repeated pain relief in preterms: a randomized controlled trial. Pediatrics. 2012;129: 299-308. 11. Costa MC, Eckert GU, Fortes BG, Fortes Filho JB, Silveira RC, Procianoy RS. Oral glucose for pain relief during examination for retinopathy of prematurity: a masked randomized clinical trial. Clinics (Sao Paulo). 2013;68:199-203. 12. Elserafy FA, Alsaedi SA, Louwrens J, Bin Sadiq B, Mersal AY. Oral sucrose and a pacifier for pain relief during simple procedures in preterm infants: a randomized controlled trial. Ann Saudi Med. 2009;29:184-188.
Copyright of Clinical Pediatrics is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
research-article2014
CPJXXX10.1177/0009922814540043Clinical PediatricsSabic et al
Commentary
Newborn and Infant Pain Control
Clinical Pediatrics 2015, Vol. 54(7) 613–614 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814540043 cpj.sagepub.com
Dajana Sabic, BA1, Collin Blattner, BS1, and Michael Metts, DO1 Unlike most patients, babies are incapable of rating their pain on a scale of 0 to 10, and yet from the moment they take their first breath, newborns are exposed to pain. Heel lancets, circumcisions, injections, and immunizations are all vital components of ensuring a healthy baby. Although a cry is an almost expected response from a baby, how can one be certain that unnecessary pain is not being inflicted? Due to the sensitive nature of a newborn and the risks associated with traditional pain control, this article aims to review pharmacologic and alternative treatments for pain management in newborns. Studies have shown that babies may be more sensitive to pain than older individuals. A scarceness of inhibitory neurotransmitters in unmyelinated fibers, large receptive fields, and a higher concentration of substance P receptors all support this hypothesis.1 Infants do not simply display a reflex response to nociception; they develop the neuronal connections to experience all aspects of pain perception while still in the womb.2 The 5 S’s are a well-known physical intervention developed by pediatrician Dr. Harvey Karp that decrease infantile pain during painful procedures.3 The 5 S’s involve swaddling the baby, placing the baby on its side or stomach as an adult swings with a pacifier in its mouth to suck on, and softly shushes the infant. Implementing the 5 S’s prior to painful procedures has been shown to increase analgesia compared to sucrose water, which has traditionally been used to calm infants. Although combination therapy would be surmised to be more effective, there is no synergistic effect of using sucrose with the 5 S’s. In one study, a modified Riley Infant Pain Scoring Method analyzed quality of cry, facial grimace, and body movement to determine the infant’s post-vaccination pain score.3 Another study demonstrated a synergistic response in pain reduction when skin-to-skin contact and dextrose solution were administered.4 Other approaches to pain control included breastfeeding and distraction with a toy, but the results are not as well documented as traditional therapy.3 Acetaminophen and topical anesthetics are relatively safe, traditional approaches to reducing pain during immunizations and injections, but while effective, they have certain downfalls.3 Recent literature has shown administering acetaminophen before primary immunization decreases immune response.5 Topical
anesthetics like lidocaine/prilocaine cream are also effective for subcutaneous and intramuscular injection pain control and do not affect vaccine immunogenicity. Despite these attributes, the onset of action ranges from 10 minutes to an hour, and therefore must be placed an hour prior to injection, which may not be practical in all instances.6 Heel lancets are used for routine neonatal metabolic disease screening, blood glucose monitoring, and other blood tests in the newborn nursery and neonatal intensive care unit. It is important to perform heel blood sampling on the side of the foot, extending posteriorly from a point between the fourth and fifth toes and running parallel to the lateral aspect of the heel. Alternatively, a line extending posteriorly from the middle of the great toe running parallel to the medial aspect of the heel may be used; a depth of less than 2.4 mm is desirable to minimize pain and bruising.7 In a study assessing the most effective form of pain control for this procedure, feeding and breastfeeding were found to be superior compared to the control, nonnutritive sucking, being held by the mother, and oral glucose solution. The assessment measured physiologic markers of pain including heart rate, oxygen saturation, respiratory rate, blood pressure, facial expression, body movements, and cry.8 Another study suggested that a 25% glucose solution was more effective at reducing pain and crying times when compared to breastfeeding prior to heel lancets and venipuncture.9 Oral sucrose with or without facilitated tucking has also been shown to decrease pain while facilitated tucking alone was not as effective.10 Unfortunately, topical anesthetics that decrease pain from injection do not confer the same benefit with heel sticks.2 While more research must be done, a plausible explanation may include increased sensory discrimination and decreased absorption due to thicker, more callus skin found on the heel. Nonetheless, consistent results are difficult to attain because various pain scales have been implemented to assess pain reduction from oral 1
Des Moines University, Des Moines, IA, USA
Corresponding Author: Michael Metts, Department of Specialty Medicine, Des Moines University, 3200 Grand Ave, Des Moines, IA 50312, USA. Email: [email protected]
614 sucrose/glucose use. Literature shows tremendous support for the use of oral sucrose/glucose, but the question of its ability to relieve pain remains unanswered. Some claim that sucrose or sugar may confer pleasure to the infant instead of acting as an analgesic.11 Other sources suggest the sucrose has analgesic properties similar to endogenous opioids since its effects can be reversed with administration of naloxone, an opioid antagonist.12 In conclusion, no concrete method exists to determine if sucrose water or methods such as the 5 S’s have true analgesic properties. However, observational pain score reduction may provide benefit to an infant and should be implemented when possible. Through use of appropriate traditional and alternative methods for pain control, babies will be comfortable, and future appointments and procedures will not be tainted by prior negative experiences. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Mathew PJ, Mathew JL. Assessment and management of pain in infants. Postgrad Med J. 2003;79:438-443. 2. Carbajal R, Nguyen-Bourgain C, Armengaud J. How can we improve pain relief in neonates? Expert Rev Neurother. 2008;8:1617-1620. 3. Harrington JW, Logan S, Harwell C, et al. Effective analgesia using physical interventions for infant immunizations. Pediatrics. 2012;129:815-823.
Clinical Pediatrics 54(7) 4. Gomes Chermont A, Fabio Magno Falcao L, Henrique Laurindo de Souza Silva E, De Cassia Xavier Balda R, Guinsburg R. Skin-to-skin contact and/or oral 25% dextrose for procedural pain relief for term newborn infants. Pediatrics. 2009;124:1101-1107. 5. Prymula R, Siergrist C, Chlibek R, et al. Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Lancet. 2009;374:1339-1350. 6. Schechter NL, Zempsky WT, Cohen LL, McGrath PJ, McMurray CM, Bright NS. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007;119:1184-1198. 7. Blumenfeld TA, Turi GK, Blanc WA. Recommended site and depth of newborn skin punctures based on anatomical measurements and histopathy. Lancet. 1979;10:230-233. 8. Weissman A, Aranovitch M, Blazer S, Zimmer EZ. Heel-lancing in newborns: behavioral and spectral analysis assessment of pain control methods. Pediatrics. 2009;124:921-926. 9. Bueno M, Stevens B, Ponce de Camargo P, et al. Breast milk and glucose for pain relief in preterm infants: a noninferiority randomized controlled trial. Pediatrics. 2012;129:664-670. 10. Cignacco EL, Sellam G, Stoffel L, et al. Oral sucrose and “facilitated tucking” for repeated pain relief in preterms: a randomized controlled trial. Pediatrics. 2012;129: 299-308. 11. Costa MC, Eckert GU, Fortes BG, Fortes Filho JB, Silveira RC, Procianoy RS. Oral glucose for pain relief during examination for retinopathy of prematurity: a masked randomized clinical trial. Clinics (Sao Paulo). 2013;68:199-203. 12. Elserafy FA, Alsaedi SA, Louwrens J, Bin Sadiq B, Mersal AY. Oral sucrose and a pacifier for pain relief during simple procedures in preterm infants: a randomized controlled trial. Ann Saudi Med. 2009;29:184-188.
Copyright of Clinical Pediatrics is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
