Dealing with Pain and Stress in the NICU: from a Neuroprotective Angle

By Steven Lam
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When our babies are in the NICU, it can be greatly stressful for everyone involved. Our babies may often be stressed due to maternal separation, noise and bright lights, procedures, and other events.
 
The types of pain that our babies can experience in the NICU include:

1. Acute pain (e.g. from procedures)
2. Post-operative pain
3. Inflammatory pain
4. Visceral pain (e.g. from a UTI)
5. General chronic pain 

Like most infants, preterm infants also have pain responses, although they may be immature and less localized than in older infants. They often experience hyperalgesia (exaggerated pain responses), allodynia (pain from things that are not normally painful) and a longer latency in their responses.
 
These pain responses include physiological changes like heart rate, blood pressure, and oxygen levels, and hormone responses. They may also display behavioral signs of pain such as changes in their facial expression, body movements and of course crying.

However, it is important to note, that not all responses, like crying, moving, tachycardia, and perturbations in blood pressure are pain responses. Therefore it is important to properly assess infant pain.
 
Most Neonatal Pain tests usually evaluate for acute procedural pain, and not for discomfort or chronic pain because immature infants have inconsistent responses.

​One such test is the Premature Infant Pain Profile or PIPP score. The PIPP score uses gestational age, behavioral state, heart rate, oxygen saturation and facial expressions such as the brow bulge, eye squeeze, and nasolabial furrow.

But how can pain affect our babies in the long-term?

It is possible that pain may affect long-term memory, pain perception and responses, and possibly alter social and cognitive development. Therefore it is obvious to try and address pain and stress in the NICU, especially acute and chronic pain.
 
Chronic Pain or Stress is much more difficult to assess, and often times may be superimposed by other types of pains like from procedures or inflammatory pain.
 
When addressing acute pain, due to procedures, it is important to look at the procedure itself and whether it is necessary but also if local anesthetics are available.

While morphine has been used for more serious procedures, the long-term risks may not be ideal. Other sedatives may also have other negative side effects and have been shown to show that there is insufficient evidence to recommend use of them during therapeutic hypothermia.
 
So if these aren’t working what can we do?

There has been a shift in approach in trying to limit the number of painful/stressful procedures and interventions as well as creating a less stressful NICU environment by involving the parents.

These includes many non-pharmacological approaches from swaddling, pacifiers, music, and family-centered care.

Sucrose has been used as a neonatal analgesia which did result in lower PIPP scores but no changes in pain specific cortical activity or reflexes indicating that it is not pain relief. 
 
However, maternal holding of the infant has shown greater promise in reducing pain.

While this may lead to some issues where nursing staff may seem to be challenged by the parents, dialogue between nurse-parent collaboration may provide the best outcome for young ones. I

​Parental participation may prove to be the one of the safest options that can be combined with other methods until more work is done in pharmacological methods where evidence supports positive outcomes.
 

References:

1. Pain and Stress in the NICU | Protecting the Developing Brain, Christine A. Gleason, M.D., Professor of Pediatrics, University of Washington/Seattle Children’s
2. Anand KJS. Management of Pain in the NICU. J Perinatol 27: 2007
3. Anand KJS et.al. Br J Anaesth 101, 2008  
4. Allegaert K et.al. Eur J Pediatr 168: 2009
5.  Axelin A et.al. J Perinat Neo Nurs 2015
6.  Bembich S et.al. JAMA Pediatr 169: 2015
7.  Wassink G et.al. Sem Fetal Neonatal Med 2015
8.  Wilkinson DJC et.al. “Sugaring the Pill: Ethics and Uncertainties in the Use of Sucrose for Newborn Infants” Arch Pediatr Adolesc Med 166: 629-33, 2012