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## Complete Summary

#### GUIDELINE TITLE

Prevention and management of pain in the neonate: an update.

#### BIBLIOGRAPHIC SOURCE(S)

American Academy of Pediatrics Committee on Fetus and Newborn, American
Academy of Pediatrics Section on Surgery, Canadian Paediatric Society
Fetus and Newborn Committee, Batton DG, Barrington KJ, Wallman C.
Prevention and management of pain in the neonate: an update.
Pediatrics 2006 Nov;118(5):2231-41. \[136 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17079598)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Academy of
Pediatrics. Prevention and management of pain and stress in the neonate.
American Academy of Pediatrics. Committee on Fetus and Newborn.
Committee on Drugs. Section on Anesthesiology. Section on Surgery.
Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics
2000 Feb;105(2):454-61.

All clinical reports and policy statements from the American Academy of
Pediatrics automatically expire 5 years after publication unless
reaffirmed, revised, or retired at or before that time.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute pain

#### GUIDELINE CATEGORY

Management\
Prevention

#### CLINICAL SPECIALTY

Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To emphasize that despite increased awareness of the importance of
    pain prevention, neonates in the neonatal intensive care unit (NICU)
    continue to be exposed to numerous painful minor procedures daily as
    part of their routine care

-   To present objective means of assessing neonatal pain by health care
    professionals

-   To describe effective strategies to prevent and treat pain
    associated with routine minor procedures

-   To review appropriate methods to prevent and treat pain associated
    with surgery and other major procedures

#### TARGET POPULATION

Neonates (preterm to 1 month of age)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Assessment of pain and stress using multidimensional tools

2.  Care protocols that minimize painful disruptions

3.  Combination of oral sucrose/glucose and other nonpharmacologic
    measures, including nonnutritive sucking, kangaroo care, facilitated
    tuck, swaddling, developmental care, for minor routine procedures

4.  Topical anesthetics for venipuncture, lumbar puncture, and
    intravenous catheter insertion

5.  Coordinated strategy for pain management in surgery, including
    sufficient anesthesia, routine assessment of pain, opioids as the
    basis for postoperative analgesia after major surgery (in the
    absence of regional anesthesia), and acetaminophen as an adjunct to
    opioids or regional anesthesia

6.  Analgesia for chest-drain insertion including general
    nonpharmacologic measures, slow infiltration of the skin site with a
    local anesthetic before incision, systemic analgesia (e.g.,
    fentanyl)

7.  Analgesia for chest-drain removal including general nonpharmacologic
    measures and short-acting, rapid-onset systemic analgesics

8.  Local anesthetic eye drops and oral sucrose for retinal examinations

9.  Opiate-based pain relief for retinal surgery

**Note**: The following medications are considered but not recommended:
routine use of continuous infusions of morphine, fentanyl, or midazolam
in chronically ventilated preterm neonates; non-steroidal
anti-inflammatory agents.

#### MAJOR OUTCOMES CONSIDERED

-   Pain as measured by assessment tools

-   Physiologic and behavioral indicators of pain

-   Adverse effects of pharmacological interventions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Assessment of Pain and Stress in the Neonate**

1.  Caregivers should be trained to assess neonates for pain using
    multidimensional tools. Refer to Table 1: Pain Assessment Tools in
    the original guideline document for description of most commonly
    used assessment tools, physiologic and behavioral indicators of pain
    for each tool, and other information.

2.  Neonates should be assessed for pain routinely and before and after
    procedures.

3.  The chosen pain scales should help guide caregivers in the provision
    of effective pain relief.

**Reducing Pain from Bedside Care Procedures**

1.  Care protocols for neonates should incorporate a principle of
    minimizing the number of painful disruptions in care as much as
    possible.

2.  Use of a combination of oral sucrose/glucose and other
    nonpharmacologic pain-reduction methods (nonnutritive sucking,
    kangaroo care, facilitated tuck, swaddling, developmental care)
    should be used for minor routine procedures.

3.  Topical anesthetics can be used to reduce pain associated with
    venipuncture, lumbar puncture, and intravenous catheter insertion
    when time permits but are ineffective for heel-stick blood draws,
    and repeated use of topical anesthetics should be limited.

4.  The routine use of continuous infusions of morphine, fentanyl, or
    midazolam in chronically ventilated preterm neonates is not
    recommended because of concern about short-term adverse effects and
    lack of long-term outcome data.

**Reducing Pain from Surgery**

1.  Any health care facility providing surgery for neonates should have
    an established protocol for pain management. Such a protocol
    requires a coordinated, multidimensional strategy and should be a
    priority in perioperative management.

2.  Sufficient anesthesia should be provided to prevent intraoperative
    pain and stress responses to decrease postoperative analgesic
    requirements.

3.  Pain should be routinely assessed by using a scale designed for
    postoperative or prolonged pain in neonates.

4.  Opioids should be the basis for postoperative analgesia after major
    surgery in the absence of regional anesthesia.

5.  Postoperative analgesia should be used as long as pain-assessment
    scales document that it is required.

6.  Acetaminophen can be used after surgery as an adjunct to regional
    anesthetics or opioids, but there are inadequate data on
    pharmacokinetics at gestational ages less than 28 weeks to permit
    calculation of appropriate dosages.

**Reducing Pain from Other Major Procedures**

1.  Analgesia for chest-drain insertion comprises all of the following:

    a.  General nonpharmacologic measures

    b.  Slow infiltration of the skin site with a local anesthetic
        before incision unless there is life-threatening instability (if
        there was inadequate time to infiltrate before insertion of the
        chest tube, local skin infiltration after achieving stability
        may reduce later pain responses and later analgesic
        requirements)

    c.  Systemic analgesia with a rapidly acting opiate such as fentanyl

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2.  Analgesia for chest-drain removal comprises the following:

    a.  General nonpharmacologic measures

    b.  Short-acting, rapid-onset systemic analgesic

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3.  Although there are insufficient data to make a specific
    recommendation, retinal examinations are painful, and pain-relief
    measures should be used. A reasonable approach would be to
    administer local anesthetic eye drops and oral sucrose.

4.  Retinal surgery should be considered major surgery, and effective
    opiate-based pain relief should be provided.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Prevention, reduction, or elimination of pain

#### POTENTIAL HARMS

-   There is a risk of methemoglobinemia after use of topical
    lidocaine-prilocaine cream in certain situations.

-   Because of the physiologic and metabolic immaturity of the neonate,
    doses of medications that are effective for the reduction of pain
    may be close to the doses that cause toxicity.

-   Rectal acetaminophen should be used cautiously because of erratic
    absorption.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

In the original statement, stress and chronic pain were briefly
discussed in addition to acute pain. However, neither chronic pain nor
stress has been specifically defined for the neonate, and only an
intuitive understanding of these concepts is possible. Therefore, this
updated statement deals primarily with acute pain prevention.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Academy of Pediatrics Committee on Fetus and Newborn, American
Academy of Pediatrics Section on Surgery, Canadian Paediatric Society
Fetus and Newborn Committee, Batton DG, Barrington KJ, Wallman C.
Prevention and management of pain in the neonate: an update.
Pediatrics 2006 Nov;118(5):2231-41. \[136 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17079598)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Feb (revised 2006 Nov)

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society\
Canadian Paediatric Society - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Fetus and Newborn\
Section on Surgery

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee on Fetus and Newborn, 2005-2006*: Ann R. Stark, MD,
*Chairperson*; David H. Adamkin, MD; \* Daniel G. Batton, MD; Edward F.
Bell, MD; Susan E. Denson, MD; William A. Engle, MD; Gilbert I. Martin,
MD

*Liaisons*: \*Keith J. Barrington, MD, Canadian Paediatric Society;
Tonse N.K. Raju, MD, National Institutes of Health; Laura Riley, MD,
American College of Obstetricians and Gynecologists; Kay M. Tomashek,
MD, Centers for Disease Control and Prevention; \*Carol Wallman, MSN,
RNC, NNP, National Association of Neonatal Nurses

*Staff*: Jim Couto, MA

*Section on Surgery, 2005-2006*: Donna A. Caniano, MD, *Chairperson*;
Michael D. Klein, MD; Richard R. Ricketts, MD; Brad W. Warner, MD; Keith
P. Lally, MD; Kurt D. Newman, MD; Thomas R. Weber, MD; Richard G.
Azizkhan, MD; Mary L. Brandt, MD; A. Alfred Chahine, MD; Frederick J.
Rescorla, MD; Michael A. Skinner, MD; George W. Holcomb, III, MD;
Frederick C. Ryckman, MD

*Staff*: Chelsea Kirk

*\* Lead author*

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Academy of
Pediatrics. Prevention and management of pain and stress in the neonate.
American Academy of Pediatrics. Committee on Fetus and Newborn.
Committee on Drugs. Section on Anesthesiology. Section on Surgery.
Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics
2000 Feb;105(2):454-61.

All clinical reports and policy statements from the American Academy of
Pediatrics automatically expire 5 years after publication unless
reaffirmed, revised, or retired at or before that time.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;118/5/2231).

Print copies: Available from the American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on November 16, 2000. The information
was verified by the guideline developer on January 8, 2001. This summary
was updated on May 3, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs). This NGC summary was completed by ECRI on January 10,
2007. The information was verified by the guideline developer on January
23, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

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Date Modified: 11/10/2008