Prevention of Pain in Neonates

To the Editor: The prevention of pain in neonates should be the goal of all caregivers, but the evidence for improved clinical outcomes with adequate pain control in newborns has been limited. The results of the NEOPAIN trial, the largest randomized controlled trial to date to evaluate benefits of pain control in critically ill neonates, indicated that morphine infusion in ventilated preterm infants controlled pain but had no beneficial effects on pulmonary outcomes and neurological morbidities.^{1 - 2} The use of open-label morphine doses was associated with significant adverse effects.^{1 - 2} Potential long-term benefits of pain control on neurodevelopmental outcomes for these infants have not yet been assessed. Summary proceedings from the Neonatal Pain Control Group again identified significant gaps in knowledge and raised concerns about possible adverse effects of analgesic exposure on long-term global developmental outcomes.³

In the absence of a clear risk-benefit analysis favoring use of pharmacologic analgesics, it is concerning that the conclusions of the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study by Dr Carbajal and colleagues⁴ may encourage use of pharmacologic analgesics for procedures that may not be associated with significant pain. The authors concluded that nearly 80% of painful procedures were performed without specific analgesia but offered little or no evidence to support that all procedures categorized as painful in this study were actually associated with pain. Direct assessment of pain during each recorded procedure would have been helpful in answering this question but was not done.

Without this information, use of specific analgesics is highly questionable for several procedures reported as painful. These include nasal aspiration, adhesive removal, removal of intravenous line, and tracheal extubation. Nasal aspiration and adhesive removal alone accounted for 41.6% of all painful procedures and contributed significantly to the study conclusions. Use of analgesics before these procedures should be individualized but should not be necessary or required each time. There should be little controversy about neonatal pain management for painful procedures such as surgeries, lines and chest tube placements, and intubations, but any suggestion to use analgesics for all nasal aspiration and adhesive removal procedures seems excessive and may cause more harm than benefit in these vulnerable infants.