Modern health care has brought innumerable benefits to newborn health. But at the same time, it has also introduced the experience of pain very early in life. It is now routine care for newborns to receive various injections or have blood drawn within 24 h of life.
For infants who are sick or premature, the pain experiences are frequent and often severe, with neonates requiring intensive care admission encountering approximately 14 painful procedures daily in the hospital. These invasive procedures range from repetitive heel sticks to minimally invasive or open surgeries, and these occur during a critical period of neurodevelopment when the nervous system is very vulnerable due to immaturity and neuroplasticity.
In recent decades, much of the world has experienced a continued increase in preterm births with an estimated 15 million babies born prematurely each year globally. Babies born at term spend 4.9 days in the neonatal intensive care unit (NICU). The average length of stay in the NICU for extremely preterm infants is 81 days, and can extend to more than 4 months at times.
One of the most frequently performed invasive procedures in the NICU is a heel stick, or heel lance/needle prick. This procedure is a pinprick puncture into the heel of a newborn used to obtain blood samples for screening laboratory tests, glucose levels, general chemistries, complete blood counts, and toxicology screening.
Generally, to obtain adequate amounts of blood for testing, the heel must be squeezed, which is more painful for newborns than venipunctures. Another painful procedure that may be required for newborns with significant respiratory compromise is endotracheal intubation, a procedure performed on both adults and infants that allows access to the airway to provide respiratory support via mechanical ventilation.
Adult patients report mechanical ventilation to be a source of pain, discomfort, and depression. As the procedural numbers rise, the likelihood of developing hypersensitivity and/or persistent pain at the site of damage (chronic post-surgical pain) increases within months following surgery.
Research shows that early life pain has significant long-term effects on neurosensory, cognition, behaviour and health outcomes that persist into childhood and even adulthood. As they cannot verbalise their pain experience and depend on others to recognise, assess and manage their pain, neonates may suffer immediate or long-term consequences of unrelieved pain.
A combination of factors, such as the underestimation of pain or concerns for potential adverse effects of pain killer meds, lead practitioners to withhold or inadequately dose these medications. There can be negative impact on psychosocial behaviours, varied behavioural pain responses and reorganization of pain processing when these babies grow up.
The treating team, especially the nurse can help reduce pain by:
1. Repositioning (positioning the neonate, appropriate to their gestational maturation, supporting limbs/ trunk)
2. Swaddling (neonates can be wrapped in a cloth or blanket, with their arms and legs tucked in, to make them feel secure)
3. Nesting (a positioning aid or roll that is placed around the neonate to help contain them and make them feel safe and secure by imitating a womb-like environment)
4. Facilitated tucking (holding a neonate so that their limbs are in close proximity to the trunk)
5. Containment holding (the caregiver can use two hands to hold the baby and make them feel secure)
6. Decreasing environmental sensors (noise/ light)
7. Tactile soothing (still gentle touch can be provided by caregivers placing their hand on the neonate’s head and abdomen/back).
Parents can help reduce pain by performing non-nutritive sucking (use of a dummy to promote sucking without breast milk or infant formula), breast feeding as appropriate, allowing neonate to grasp a finger, skin to skin care for the newborn (Kangaroo Care) and talking to their baby.
Clustering, developmental or cue based care can significantly contribute in reducing pain and promoting intact neurodevelopment. It is the practise of grouping care to minimise the number of times a neonate is handled. By reducing episodes of handling, periods of sleep can be protected and stress can be minimised. If neonates are displaying signs of stress (such as increased heart rate or facial expression), fewer procedures can be clustered on the next occasion and comfort measures can be provided.
High level of clinical acuity and good decision making plays an important role in reducing the number of times a newborn is sampled for blood, or is intubated. Talk to your treating team about this and help develop a less painful NICU experience in every sense.
Rational Baby Care 