Neonatal pain management in sub-Saharan Africa
Authors: Adejumoke Idowu Ayede
Journal: The Lancet Child & Adolescent Health (2020)

Many procedures that cause pain (eg, heel prick, injections) are carried out in neonates and such pain needs to be assessed and then properly managed.1Hall RW Anand KJS Pain management in newborns.Clin Perinatol. 2014; 41: 895-924Summary Full Text Full Text PDF PubMed Scopus (136) Google Scholar Most of these procedures are part of routine care while some might be part of major surgeries. Whatever the source of pain might be, parents expect their baby's pain to be prevented, although total elimination of pain might not always be possible.1Hall RW Anand KJS Pain management in newborns.Clin Perinatol. 2014; 41: 895-924Summary Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 2Suleiman Z Kolawole I Adegboye K et al.Analgesia for procedural pain: Current practice among Nigerian paediatricians.Port Harcourt Med J. 2019; 13: 13-18Crossref Google Scholar, 3Aime Nshimirimana D Pain Assessment among African Neonates.Am J Pediatr. 2016; 2: 4-9Crossref Google Scholar, 4Simons SHP van Dijk M Anand KS Roofthooft D van Lingen RA Tibboel D Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates.Arch Pediatr Adolesc Med. 2003; 157: 1058-1064Crossref PubMed Scopus (421) Google Scholar, 5Allegaert K Tibboel D van den Anker J Pharmacological treatment of neonatal pain: in search of a new equipoise.Semin Fetal Neonatal Med. 2013; 18: 42-47Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Reduction in the extent and intensity of pain in neonates is of increasing global concern.2Suleiman Z Kolawole I Adegboye K et al.Analgesia for procedural pain: Current practice among Nigerian paediatricians.Port Harcourt Med J. 2019; 13: 13-18Crossref Google Scholar, 3Aime Nshimirimana D Pain Assessment among African Neonates.Am J Pediatr. 2016; 2: 4-9Crossref Google Scholar, 4Simons SHP van Dijk M Anand KS Roofthooft D van Lingen RA Tibboel D Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates.Arch Pediatr Adolesc Med. 2003; 157: 1058-1064Crossref PubMed Scopus (421) Google Scholar, 5Allegaert K Tibboel D van den Anker J Pharmacological treatment of neonatal pain: in search of a new equipoise.Semin Fetal Neonatal Med. 2013; 18: 42-47Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar The resultant effect of neonatal pain can be serious, potentially leading to physiological, behavioural, and cognitive changes particularly when pain is persistent. Neonates in pain have been shown to have decreased heart rate and oxygen consumption; erratic respiration; cardiovascular, hormonal, and metabolic problems; and a lack of facial expressions, which could have short-term and long-term adverse effects.1Hall RW Anand KJS Pain management in newborns.Clin Perinatol. 2014; 41: 895-924Summary Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 2Suleiman Z Kolawole I Adegboye K et al.Analgesia for procedural pain: Current practice among Nigerian paediatricians.Port Harcourt Med J. 2019; 13: 13-18Crossref Google Scholar, 3Aime Nshimirimana D Pain Assessment among African Neonates.Am J Pediatr. 2016; 2: 4-9Crossref Google Scholar, 4Simons SHP van Dijk M Anand KS Roofthooft D van Lingen RA Tibboel D Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates.Arch Pediatr Adolesc Med. 2003; 157: 1058-1064Crossref PubMed Scopus (421) Google Scholar Although awareness in neonatal pain assessment and management has been increasing, little corresponding improvement has been seen in clinical practice probably because of a scarcity of published guidelines and little knowledge of and training in effective pain assessment and management of newborn babies in developing countries, especially in sub-Saharan Africa. The reduced availability of and access to pain management drugs also remains a challenging issue.1Hall RW Anand KJS Pain management in newborns.Clin Perinatol. 2014; 41: 895-924Summary Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 3Aime Nshimirimana D Pain Assessment among African Neonates.Am J Pediatr. 2016; 2: 4-9Crossref Google Scholar, 6Nasir AA Ameh EA Abdur-Rahman LO Kolawole IK Oyedepo OO Adeniran JO Postoperative pain management in children: a survey of practices of pediatric surgeons in Nigeria.J Clin Sci. 2017; 14: 119-125Crossref Google Scholar A survey of 37 consultant paediatric surgeons and trainees in Nigeria found that postoperative pain assessment was not done routinely and almost half of the respondents reported the use of clinical judgement to assess pain.6Nasir AA Ameh EA Abdur-Rahman LO Kolawole IK Oyedepo OO Adeniran JO Postoperative pain management in children: a survey of practices of pediatric surgeons in Nigeria.J Clin Sci. 2017; 14: 119-125Crossref Google Scholar In another survey of 240 consultant paediatricians and residents in Nigeria, only 46% assessed procedural pain and 51% routinely administered analgesia, with breastfeeding and topical analgesic drugs being the most commonly prescribed.2Suleiman Z Kolawole I Adegboye K et al.Analgesia for procedural pain: Current practice among Nigerian paediatricians.Port Harcourt Med J. 2019; 13: 13-18Crossref Google Scholar In these and similar settings in many sub-Saharan African countries, most facilities also have few health-care institutional guidelines for pain assessment and treatment.2Suleiman Z Kolawole I Adegboye K et al.Analgesia for procedural pain: Current practice among Nigerian paediatricians.Port Harcourt Med J. 2019; 13: 13-18Crossref Google Scholar, 6Nasir AA Ameh EA Abdur-Rahman LO Kolawole IK Oyedepo OO Adeniran JO Postoperative pain management in children: a survey of practices of pediatric surgeons in Nigeria.J Clin Sci. 2017; 14: 119-125Crossref Google Scholar, 7Albertyn R Rode H Millar AJW Thomas J Challenges associated with paediatric pain management in Sub Saharan Africa.Int J Surg. 2009; 7: 91-93Crossref PubMed Scopus (30) Google Scholar, 8Powell RA Kaye RM Ddungu H Mwangi-Powell F Advancing drug availability-experiences from Africa.J Pain Symptom Manage. 2010; 40: 9-12Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 9Harding R Powell RA Kiyange F Downing J Mwangi-Powell F Provision of pain- and symptom-relieving drugs for HIV/AIDS in sub-Saharan Africa.J Pain Symptom Manage. 2010; 40: 405-415Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar The need for proper evaluation and use of available, affordable, acceptable, and effective means of treatment is crucial across all levels of health care but most importantly in first-level facilities where most morbidity and mortality occur. Several methods exist by which pain can be assessed and treated in neonates. The methods used vary across different health-care settings globally and depend on available resources, cultural practices, and health workers skills.1Hall RW Anand KJS Pain management in newborns.Clin Perinatol. 2014; 41: 895-924Summary Full Text Full Text PDF PubMed Scopus (136) Google Scholar In their systematic review and meta-analysis in The Lancet Child & Adolescent Health, Cian Wade and colleauges10Wade C Frazer JS Qian E et al.Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis.Lancet Child Adolesc Health. 2020; (published online July 28.)https://doi.org/10.1016/S2352-4642(20)30182-6Summary Full Text Full Text PDF Scopus (6) Google Scholar have critically appraised published literature to synthesise existing knowledge on adequate analgesia in neonates that has accumulated over 66 years (1953–2019). They then worked with a multidisciplinary panel of 17 Kenyan health-care professionals to develop clinical guidelines adapted to the local health-care context. The authors found a high level of certainty for the superiority of breastfeeding and oral sugar solutions—and a moderate level of certainty for the superiority of expressed breastmilk—over placebo or no intervention in the management of neonatal pain. However, taking into account contextual factors such as the risk of reusing or sharing bottles of sugar solution, the panel recommended breastfeeding as first-line analgesic treatment; for those unable to breastfeed, expressed breastmilk was preferred over oral sugar (≥10% concentration). Additionally, the panel recommended parental presence during procedures and skin-to-skin contact. Some questions have yet to be answered by this study. For instance, does the analgesic effect of breastfeeding remain superior in all procedures? Are the findings generalisable to other low-income countries apart from Kenya? And would the recommendations be feasible or acceptable in other settings? Potential similarities in many sub-Saharan African countries exist in the context of the level of health-care facilities, type of clinical procedures, and cost of health-care services, but the cultural practices and beliefs, availability of expertise, and referral pathways might vary from setting to setting, as is typical in most low-income and middle-income countries. Therefore, the clinical guideline developed from this systematic review and meta-analysis needs to be validated in other settings outside of Kenya. The mechanisms of an analgesic effect of breastfeeding need to be studied.7Albertyn R Rode H Millar AJW Thomas J Challenges associated with paediatric pain management in Sub Saharan Africa.Int J Surg. 2009; 7: 91-93Crossref PubMed Scopus (30) Google Scholar Further research is also needed to find the most suitable and effective pharmacological analgesic for use in neonates.5Allegaert K Tibboel D van den Anker J Pharmacological treatment of neonatal pain: in search of a new equipoise.Semin Fetal Neonatal Med. 2013; 18: 42-47Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar A multinational study that recruits a large population of neonates going through routine procedures under relatively similar conditions is needed to establish the potential usefulness of breastfeeding across multiple populations.4Simons SHP van Dijk M Anand KS Roofthooft D van Lingen RA Tibboel D Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates.Arch Pediatr Adolesc Med. 2003; 157: 1058-1064Crossref PubMed Scopus (421) Google Scholar This Article emphasises that health-care providers need to anticipate the need for analgesia in every procedure in advance and promote involvement of parents before, during, and after procedures. Additionally, Wade and colleagues have shown that existing knowledge supports breastfeeding as a safe and effective analgesia for neonates undergoing routine procedures in the Kenyan setting. I declare no competing interests. Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysisWe have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings. Full-Text PDF Open Access