EDITORIAL COMMENTARY

Pain in Neonates

Amit Upadhyay

Received: 7 May 2013 /Accepted: 7 May 2013 /Published online: 22 May 2013# Dr. K C Chaudhuri Foundation 2013

There is ample evidence that neonates beyond 26 wk ofgestation age perceive pain. Newborns are often exposed tovarious invasive procedures in intensive care units such asvenepuncture, lumbar puncture, intubation, nasogastric ororogastric tube (OTG) insertion. Pain in neonates has beenshown to cause short and long-term adverse effects. Itsconsequences include altered pain sensitivity to permanentneuro-anatomical, behavioral and emotional changes toeven learning disabilities [1]. Exposure to repeated paincan lead to either exaggerated or attenuated response [2].

Measurement of pain can be tricky in neonates. Physio-logical parameter (heart rate, oxygen saturation) and behav-ioral parameters like duration of cry, Neonatal Facial CodingScale (NFCS), Neonatal Infant Pain Scale (NIPS), Prema-ture Infant Pain Profile (PIPP), and Visual Analogue Scale(VAS) etc. have been used as surrogate markers of pain innon-verbal subjects. A recent study from authors’ institutereported good correlation between some of these scales(NIPS and NFCS) [3]. Non-invasive measurement of corti-sol (in saliva) has also been shown to reliably measure painin neonates [4]. Providing adequate pain management forprocedure-related pain is desirable for infants in the NICU.Despite significant knowledge of effects of pain on devel-oping brain, use of pain relieving measures for commonpainful procedures is still relatively uncommon in India.The main reason for lack of practice could be lack ofawareness among health care professionals about adverseeffects of pain, poor doctor-patient ratios in NICU/clinics,difficulty in diagnosis of pain and lack of studies demon-strating long-term benefits of pain relieving measures. Tostandardize the management of pain during various painfulprocedures, Canadian Pediatrics Society has come up with

practice guidelines for management of pain [5]. Breast feed-ing [6], expressed breast milk [7], and sucrose-glucose invarying concentration (10–50 %) [8, 9] have been shown toreduce procedural pain in neonates in neonatal ICU, OPDand immunization.

The study by Nimbalkar et al. in this issue evaluatesknowledge and perception of nursing staff about pain inchildren [10]. It reinforces the common perception thathealth care professionals are not trained enough in diagnosisand management of pain in non-verbal patients like chil-dren. It would have been interesting to compare knowledgeand perception of nurses to that of resident doctors andfaculty of department of Pediatrics. This study advocatesthat lectures and tutorial of nursing and medical profes-sionals in pain assessment and management should be in-cluded in their curriculum.

The other study in this issue on pain alleviation duringOTG insertion is quite relevant because OTG is required inmost sick neonates irrespective of their disease. Pandey etal. report that orogastic tube insertion causes pain in pre-terms and single dose of 24 % lingual sucrose reduces painscores [11]. Though the study is a well conducted random-ized controlled trial, exclusion of eligible subjects afterobtaining consent is undesirable. The randomized, doubleblind, placebo controlled design and decoding of randomi-zation and allocation concealment only after the statisticalanalysis are the strengths of the study. However, there isconcern that use of high concentration of sucrose can lead tofeed intolerance and hyperglycemia followed by reboundhypoglycemia in preterm babies. So incidence of feed intol-erance and blood glucose levels after sucrose feeding shouldhave been reported by authors. The most effective dose ofsucrose for pain alleviation is not known. Pain relief hasbeen reported with as little as 0.05 mL [12] or 0.1 mL [13]or 0.5 mL [14] of 24 % sucrose. The authors could haveused lesser amount of sucrose solution (0.1 to 0.5 mL) inplace of 2 mL to avoid hypothesized glycemic problems.

A. Upadhyay (*)Department of Pediatrics, LLRM Medical College, Meerut,Uttar Pradesh 250004, Indiae-mail: anuamit7@rediffmail.com

Indian J Pediatr (June 2013) 80(6):446–447DOI 10.1007/s12098-013-1078-8

Recent studies have also demonstrated that expressed breastmilk (EBM) is at least as effective in reducing the pain inneonates during minor painful procedures [7]. Thus, use ofEBM in the other limb, instead of or addition to 24 % sucrosewould have been desirable. The authors did not mention ex-perience with previous painful procedures in each group as itmay affect baby’s response to pain. Authors have reported thata case developed cardio respiratory arrest during the procedurein sucrose group. Whether sucrose or gastric tube insertioncontributed to the mortality will be interesting to audit.

Sucrose or similar sweet solutions significantly reducethe clinical observational scores [9], but whether their abilityto reduce the pain score is a good surrogate marker forreduction in pain is still not clear. Although true pain per-ception is difficult to measure in non-verbal population,neural activity in nociceptive pathways is probably a moredirect measure than behavioral and physiological assess-ment. A recent study reported that although sucrose de-creased clinical observation scores, there was no reductionin nociceptive brain activity and magnitude or latency of thespinal nociceptive reflex withdrawal response. It also had noeffect on the neural activity in sensory pain circuits in thebrain or the spinal cord [14].

Further studies are needed to evaluate the effect of sucrose,breast milk or other non-pharmacological measures in high-riskgroups like extreme premature neonates exposed to repeatedpainful stimuli. The studies should aim to report effect of thesemeasures on long-term cognitive and behavioral outcomesrather than only immediate surrogate responses to pain.

Conflict of Interest None.

References

1. American Academy of Pediatrics, Committee on Fetus and New-born, Section on Surgery and Section on Anesthesiology and PainMedicine. Prevention and management of pain in the neonate: Anupdate. Pediatrics. 2006;118:2231–41.

2. Chaudhary R, Goswami G, Chikkanna S, Upadhyay A. Repeatedpainful stimuli may affect pain response in neonates of more than34 weeks post conceptional age. Vancouver: Pediatric AcademicSociety; 2010. Abstract:4425.571.

3. Dwivedi AK, Upadhyay A, Gupta NK, et al. Comparison ofvapocoolant spray and EMLA cream along with breastfeedingfor reducing pain due to 1st DPT vaccination in young infants: Arandomized controlled trial. Boston: Pediatric Academy of Society;2012. Abstract: 1502.93.

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8. Goswami G, Upadhyay A, Gupta NK, Chaudhry R, Chawla D,Sreenivas V. Comparison of analgesic effect of direct breast feeding,oral 25% dextrose solution and placebo during 1st DPT vaccinationin healthy term infant: A randomized, placebo controlled trial. IndianPediatr. 2012 Dec 5 (Epub ahead of print).

9. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in new-born infants undergoing painful procedures. Cochrane DatabaseSyst Rev. 2010;1:CD001069.

10. Nimbalkar AS, Dongara AR, Ganjiwale JD, Nimbalkar SM. Painin children: Knowledge and perceptions of the nursing staff at arural tertiary care teaching hospital in India. Indian J Pediatr. 2012;doi:10.1007/s12098-012-0848-z [Epub ahead of print].

11. Pandey M, Datta V, Rehan HS. Role of sucrose in reducingpainful response to orogastric tube insertion in preterm neonates.Indian J Pediatr. 2012; doi:10.1007/s12098-012-0924-4 [Epub aheadof print].

12. Johnston CC, Stremler RL, Stevens BJ, Horton LJ. Effectivenessof oral sucrose and simulated rocking on pain response in pretermneonates. Pain. 1997;72:193–9.

13. Johnston CC, Filion F, Snider L, Majnemer A, Limperopoulos C,Walker CD, et al. Routine sucrose analgesia during the first weekof life in neonates younger than 31 weeks’ postconceptional age.Pediatrics. 2002;110:523–8.

14. Slater R, Cornelissen L, Fabrizi L, Patten D, Yoxen J,Worley A, et al.Oral sucrose as an analgesic drug for procedural pain in newborninfants: a randomized controlled trial. Lancet. 2010;376:1225–32.

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