• Discomfort, pain or stress can be associated with routine care and invasive procedures. Babies are unable to report pain; use observational skills and clinical judgment

Key recommendations

• Routine assessments to detect pain using a validated assessment tool 
• Minimise number of painful procedures
• Prevent/reduce acute pain from invasive procedures using non-pharmacological and pharmacological methods
• Anticipate and treat post-operative pain

Types of pain

Symptoms and signs

• Lack of behavioural responses does not exclude pain

• Sudden pain and distress may indicate acute deterioration e.g. bowel perforation
• Physiological changes cannot be sustained long-term

• Assess within 1 hr of admission
• Frequency of further assessments will depend on baby’s clinical condition, underlying diagnosis and pain score (see Frequency of assessment below)

Pain assessment tools

• Separate tools may be needed to assess acute and prolonged pain 
• Use validated pain assessment tools [Pain Assessment Tool (PAT) and Premature Infant Pain Profile (PIPP)]
• See Abstinence syndrome guideline for assessment of babies with neonatal abstinence syndrome

Pain assessment not indicated/unsuitable

Use of pain assessment tool

• Note gestational age
• Observe baby’s behaviour for 15–30 sec then gently touch baby’s limb to determine muscle tone/tension (can be done during routine handling)
• Note:
  • physiological conditions that may influence score (in cyanotic heart disease, baby’s colour may score normal unless there is a change in the intensity of the cyanosis or duskiness due to pain)
  
  
  • medications that may affect behaviour or physiological responses
  
  
  • environmental triggers (sudden bright lights, noise, activity) may cause a stress response. Document on chart or in notes at time of score
• When score is above tool’s recommended thresholds, initiate comfort measures or analgesia

Frequency of assessment

• All babies to have pain assessment within 1 hr of admission
• Minimum frequency of subsequent assessments depends on level of care
  • intensive care: hourly with observations
  • high dependency: 4-hrly
  • special care: as condition dictates
  • post-operatively: hourly for first 8 hr, then 4-hrly until 48 hr post-op (more frequently if signs of distress/discomfort)
• If baby shows signs of distress/discomfort perform additional assessments 

Indications

• Birth trauma
• Iatrogenic injury
• Before, during and after any painful procedure
• Severe illness e.g. NEC, meningitis 
• To aid ventilation 
• Preparation for transfer if ventilated
• Whilst undergoing therapeutic hypothermia
• Post-operatively
• End-of-life care
• Formal assessment indicates pain
• If non-pharmacological techniques are ineffective or not appropriate, progress to pharmacological agents (e.g. post-surgery, severe illness, major injury, congenital malformations and palliative care)

Non-pharmacological pain relief

• Gently repositioning baby 
• Light swaddling (blanket/nest), prolonged restrictive swaddling may be associated with increased risk of developmental hip dysplasia
• Comfort/containment holding
• Reducing light, noise, and activity around baby
• Soothing voice
• Nappy change
• Non-nutritive sucking (NNS) (dummy or gloved finger) [see Non-nutritive sucking (NNS) guideline]
• Kangaroo care (see Kangaroo care guideline)
• Breastfeed (see Breastfeeding guideline)
• Sucrose
• Mother’s expressed breast milk (MEBM) – no additives

Reassess after 30 min

• If pain score in upper range, institute comfort measures and administer prescribed analgesia/seek medical review
• If score continues to rise, consider increasing dose of analgesia and reassess after 30 min
  • if clinical concerns – medical review
• If score constantly below baseline and analgesia maintained, reduce dosage 
• Record effectiveness of pain management in care plan

Sucrose

• Sucrose 24% solution and breast milk provide a quick, short-term analgesic effect (given orally)
• NNS increases effectiveness
• Use in conjunction with environmental and behavioural measures to relieve pain (e.g. positioning, swaddling, containment holding, kangaroo care)
  • may be given to ventilated babies with care

Contraindications to sucrose

Administration

• Use commercially available sucrose 24% solution and follow manufacturer’s guidelines regarding storage and use
• Maximum 8 doses in 24 hr
• Avoid risk of choking/aspiration – ensure baby is awake
• Drop dose onto tongue, buccal membrane, or dummy and wait 2 min before starting procedure
• For procedures lasting >5 min, repeat dose (maximum 2 further doses)
• Continue environmental and behavioural management strategies during procedure
• Observe baby's cues and allow ‘time-out’ to recover 
• Document administration of sucrose as per local policy 

Management of procedural pain

Management of prolonged or chronic pain

Pharmacological pain management

• Give medication in conjunction with non-pharmacological measures
• The following drugs may be useful:
  • diamorphine
  • fentanyl
  • morphine
  • paracetamol
• Details of these drugs can be found in the Neonatal Formulary

Suggested medication for procedures

Specific situations

Simple surgical procedures