How to manage distress in newborns?

Managing Distress in Newborns

Newborn distress management requires systematic pain assessment using validated multidimensional tools, followed by aggressive implementation of nonpharmacologic interventions (oral sucrose, breastfeeding, skin-to-skin contact) for minor procedures, with pharmacologic agents reserved for major surgical interventions, while simultaneously minimizing the total number of painful procedures performed. 1

Critical Context: The Double-Hit Phenomenon

• The smallest and sickest preterm neonates face the highest risk of neurodevelopmental impairment AND are exposed to the greatest number of painful stimuli in the NICU, creating a "double-hit" phenomenon that can result in permanent neuroanatomic and behavioral abnormalities. 1

• Repeated painful exposures cause altered pain sensitivity lasting into adolescence, hyperalgesia (increased response to painful stimuli), and allodynia (pain from normally non-painful stimuli). 1

• These long-term consequences may include emotional, behavioral, and learning disabilities, though definitive human data remain limited. 1

Step 1: Systematic Pain Assessment

Use multidimensional assessment tools that combine both physiologic AND behavioral indicators, as neonates cannot self-report pain. 1

Physiologic Indicators to Monitor:

• Heart rate changes 1
• Respiratory rate alterations 1
• Blood pressure fluctuations 1
• Oxygen saturation drops 1
• Vagal tone changes 1
• Palmar sweating 1
• Plasma cortisol or catecholamine elevations 1

Behavioral Indicators to Assess:

• Facial expressions (brow bulge, eyes squeezed shut, nasolabial furrow) 1
• Body movements and posture 1
• Crying patterns 1
• Sleep quality and state arousal 1
• Tone and consolability 1

Critical Caveat for Prolonged Pain:

When pain is prolonged, neonates enter a state of passivity with minimal body movements, expressionless face, decreased heart rate and respiratory variability, and decreased oxygen consumption—mimicking energy conservation rather than displaying typical pain behaviors. 1 This can lead to underrecognition of ongoing pain.

Special Populations Requiring Attention:

• Neurologically impaired infants may not display typical behavioral pain indicators 1
• Pharmacologically paralyzed neonates cannot exhibit behavioral responses 1
• Current assessment tools have limitations for these populations 1

Step 2: Minimize Procedural Exposure

The most effective pain reduction strategy is decreasing the total number of painful procedures performed. 1

Specific Strategies to Implement:

• Bundle interventions to reduce bedside disruptions 1
• Eliminate unnecessary laboratory or radiographic procedures 1
• Use transcutaneous measurements when possible 1
• Minimize repeat procedures after failed attempts 1

Step 3: Nonpharmacologic Interventions for Minor Procedures

For routine painful procedures (needle insertions, suctioning, gavage-tube placement, tape removal), implement nonpharmacologic pain-prevention techniques as first-line interventions. 1

Evidence-Based Nonpharmacologic Methods:

• Oral sucrose or glucose administration 1
• Breastfeeding during procedures 1
• Nonnutritive sucking 1
• Kangaroo care (skin-to-skin contact) 1
• Facilitated tuck (holding arms and legs in flexed position) 1
• Swaddling 1
• Developmental care with limited environmental stimuli 1

Important Limitation:

Continuous morphine infusion in ventilated preterm neonates does NOT effectively prevent acute pain from minor procedures and may increase adverse events—avoid this approach for routine procedural pain. 1

Step 4: Pharmacologic Management for Major Procedures

• Effective pain relief is typically provided for major surgical procedures and should be standard practice. 1

• The challenge lies in balancing effective pain relief against serious adverse effects from pain medications, particularly in the smallest neonates. 1

Step 5: Staff Training and Protocol Development

Each neonatal unit must develop comprehensive pain-prevention programs with continual multidisciplinary staff training in pain recognition and use of chosen assessment tools. 1

Program Components Should Include:

• Strategies to minimize painful/stressful procedures 1
• Protocols for effective nonpharmacologic interventions 1
• Pharmacologic pain relief guidelines for all procedures 1
• Regular competency assessment in pain recognition 1

Common Pitfalls to Avoid

1. Assuming passivity equals comfort: Prolonged pain causes energy conservation that mimics lack of distress—maintain high suspicion in at-risk neonates. 1

2. Over-relying on continuous opioid infusions: These are ineffective for procedural pain and increase adverse events in ventilated preterm infants. 1

3. Underusing nonpharmacologic interventions: Despite proven efficacy, these simple interventions remain underutilized for routine procedures. 1

4. Failing to account for cumulative pain exposure: Each additional painful stimulus increases future pain sensitivity through hyperalgesia and allodynia. 1