Updated AAP Guidelines Address Procedural Pain in Newborns

Nicola M. Parry, DVM

January 28, 2016

The American Academy of Pediatrics (AAP) has released a policy statement recommending that healthcare facilities both minimize the number of painful procedures performed on newborns and routinely assess and treat pain in these patients. The statement, an update of a position paper first published in 2006, was published online January 25 and in February issue of Pediatrics.

According to the AAP Committee on Fetus and Newborn and the AAP Section on Anesthesiology and Pain Medicine, "Neonates are frequently subjected to painful procedures, with the most immature infants receiving the highest number of painful events."

Data in newborns also suggest that repeated exposure to pain early in life can lead to abnormalities in both brain development and stress responses that persist into childhood. Yet, "[d]espite recommendations from the AAP and other experts, neonatal pain continues to be inconsistently assessed and inadequately managed," the group states.

In the updated policy statement, the AAP recommends that all healthcare providers who care for newborns should aim to prevent or minimize pain in these patients. To accomplish this, each institution should develop its own written guidelines, based on best available evidence, that address prudent use of procedures, routine pain monitoring, use of drug and nondrug therapies to manage pain during minor procedures, and effective medications to manage pain during surgery.

In particular, the statement places greater emphasis on the consistent use of proven nondrug interventions, such as non-nutritive sucking and breast-feeding, which have been shown to reduce pain during short, mildly to moderately painful procedures. In contrast, clinicians should only use pharmacologic therapies such as opioids and benzodiazepines, which are currently commonly used, after carefully weighing their risks and benefits.

And although oral sucrose or glucose solutions can be effective in newborns, and therefore frequently used as analgesia, the statement indicates that the optimal dose of each of these solutions for pain relief is unknown, and because questions remain about their long-term safety, they should be prescribed and tracked as medications.

The statement emphasizes that neonatal healthcare providers and family members should receive continuing education on how to recognize, monitor, and manage pain in newborns. It also acknowledges the need for more research to address gaps in knowledge about pain assessment tools, as well as drug and nondrug strategies to prevent or reduce pain.

"Studies on pharmacokinetics and pharmacodynamics of newer medications are needed to prevent therapeutic misadventures in the most vulnerable patients in pediatric practice," the statement concludes.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 25, 2016. Full text

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