Neonatal Pain Research Articles

Reduction of Environmental Noise Impact on Preterm Babies in NICU by Using Ear Plugs

Objective − To determine if using ear plugs reduce the impact of noise on preterm babies admitted to neonatal intensive care units in terms of changes in their vital parameters and their discomfort level, assessed using the Neonatal Infant Pain Scale (NIPS) score.Materials and Methods − This is an interventional study conducted in a tertiary level neonatal intensive care unit (NICU) (Bangalore, India) over a period of 3 months, ranging from June 2022 to September 2022. This study included 20 preterm babies with different gestational ages and birth weights who were admitted to the NICU during that period. The babies’ response to noise, in terms of changes in heart rate, respiratory rate, blood pressure, oxygen saturation and discomfort level, were assessed with ear plugs and without ear plugs on alternate days and the results were recorded. Descriptive statistics were used for statistical analysis. Results − On days 1 and 3, mean heart rate and systolic blood pressure were lower in babies wearing ear plugs (141.55±2.42 SD and 60.1±11.58, respectively) than in the same babies without ear plugs (157.55±2.52 SD and 61.85±1.6 SD, respectively) on days 2 and 4. The mean oxygen saturation was higher in babies wearing ear plugs (96.7%±0.80 SD) than in the same babies without the intervention (93.75%±1.29 SD). The mean NIPS score was lower with the intervention (2.05±0.22) than without ear plugs (5.05±0.22 SD).Conclusion – Ear plugs were an effective alternative in situations where noise in the NICU cannot be consistently maintained at a lower level than the standard recommendation by the AAP of 45 decibels.

"Thai Nurses' and Midwives' Perceptions Regarding Barriers, Facilitators, and Competence in Neonatal Pain Management".

Effective neonatal pain management is reliant upon the expert care of nurses and midwives working in neonatal intensive care units (NICUs). Previous research has explored barriers, facilitators, and some aspects of nurse competence in managing neonatal pain; however, this research has been predominantly performed in Western countries. To date, little is known about the barriers, facilitators, and perceived competence of Thai nurses and midwives in relation to neonatal pain management in NICUs. Exploring Thai nurses' and midwives' perceptions in these areas is crucial for understanding the contextual nuances of neonatal pain management, which can guide the provision of care for these high-risk neonates. To investigate nurses' and midwives' perceptions of barriers, facilitators, and competence regarding effective neonatal pain management in Thai NICUs. Data were collected using virtual one-to-one, semistructured interviews with 12 neonatal nurses and midwives between July and August 2021 in 3 units of 2 tertiary hospitals in Southern Thailand. Inductive thematic analysis was used to examine interview data. These data revealed following 3 major themes: ( a ) barriers to effective neonatal pain management, ( b ) facilitators of effective neonatal pain management, and ( c ) perceptions of competence. Assisting nurses and midwives in overcoming barriers and strengthening facilitators while enhancing their competence may result in better neonatal pain management. This study adds to our understanding that further research is needed to develop the interventions designed to change at individual, unit, and organizational levels, particularly implementing parent-friendly visitation and ongoing professional development in neonatal pain management.

Analgesic Effect of Low-Level Laser Therapy before Heel Lance for Pain Management in Healthy Term Neonates: A Randomized Controlled Trial.

Currently, the prevention, assessment, and management of procedural pain in neonates continues to challenge clinicians and researchers. Objective. To investigate the analgesic effect of low-level laser therapy (LLLT) during heel lance compared to breast milk (BM) feeding in healthy term neonates. In this randomized controlled trial, healthy term neonates who underwent heel lance were randomly assigned to an LLLT or a BM group. The LLLT group received laser therapy to the heel lance site for 20 s before heel lance. The BM group received 5 mL expressed BM via a syringe before heel lance. The primary outcomes were behavioral responses. The secondary outcomes were physiological responses and levels of salivary cortisol and α-amylase. A total of 125 neonates were included, of whom 55 in the LLLT group and 59 in the BM group completed the study. There were no significant differences in latency to first cry and cry duration between the two groups. The squeeze time was significantly shorter in the LLLT group than in the BM group (p = 0.047). There were no significant differences in pain scores, heart rate, respiratory rate, oxygen saturation, and blood pressure before and after heel lance between the two groups. There were no significant differences in salivary cortisol and α-amylase levels in the LLLT group before and after heel lance; however, the differences were significant in the BM group. These findings suggest that the analgesic effect of LLLT is similar to that of BM during heel lance in healthy term neonates. LLLT has potential as an analgesic treatment.

Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review

Background Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. Objective This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. Methods We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. Results The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40–100% worldwide. TH alters most drugs’ metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. Conclusions No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.

Evaluating an educational program for enhancing neonatal intensive and special care nurses’ and midwives’ competence with neonatal pain management: A quasi-experimental study

Competence in neonatal pain management is influenced by the clinician’s knowledge, attitudes, and skills. The impact of an educational program on enhancing competence among Thai neonatal nurses and midwives has never been explored. This study aims to evaluate the impact of an educational program to increase nurses’ and midwives’ competence in neonatal pain management in Thai neonatal intensive and special care units (NI/SCUs). A web-based learning package with pre-, post-, and follow-up online questionnaire was administered to 68 neonatal nurses and midwives. There was a substantial increase in the total mean scores of knowledge, attitudes, and perceived self-competence in the post- and follow-up phases compared to the pre-test phase (p < 0.001). The educational program had a significant impact on Thai NI/SCU nurse and midwife competence regarding neonatal pain management. Ongoing education is needed to sustain clinicians’ competence in this area.

Tube Laparostomy as Initial and Sole Intervention for Neonates with Idiopathic Pneumoperitonium.

Objective: To determine the efficacy of tube laparostomy an initial and sole surgical intervetion in neonates diagnosed with idiopathic pneumoperitonium. Study Design: Retrospective study. Setting: Department of Pediatric Surgery, Ghulam Muhammad Mahar Medical College Sukkur and Department of Pediatric Surgery, Chandka Medical College Larkana. Period: 1st April 2020 till 30th March 2023. Material &amp; Methods: Tube laparostomy was done in Operation Theater under local anesthesia in all neonates with pneumoperitonium. After the procedure all patients were kept in neonatal intensive care unit for close observation. Patients draining gut contents in the drain underwent exploratory laparotomy while who clinically improved with only serous discharge in the drains and recovered smoothly were labeled as cases of idiopathic or benign pneumopertonium. Data was collected that included, age, gender, weight, efficacy of the procedure, need to do exploratory laparotomy, post-operative pain scores assessed with the help of neonatal infant pain assessment, total hospital stay length and mortality. Results: A total of 178 cases of neonatal pneumoperitonium were diagnosed during the study period. Out of these 178 cases only 23 (12.92%) were labelled as idiopathic pneumoperitonium on the basis of absence of gut contents in the drainage. Out of these 23 cases, 22 (95.65%) were successfully treated with laparostomy and one case was proceeded with exploratory laparotomy. Post procedure NIPS score remained low and favorable with mean and standard deviation of 1.83±1.4. Total length of hospital stay ranged from 4 days to 15 days. Mean and standard deviation of hospital stay was 6.22±2.8 days. Conclusion: It is concluded in our study that tube laparostomy in cases of idiopathic pneumoperitonium is very efficacious treatment option. This procedure is is easy to do, can be safely done in critically ill patients, can be done under local anesthesia, results in lesser post-operative pain scores and reduces the hospital stay length and cost of treatment.

Human vs machine towards neonatal pain assessment: A comprehensive analysis of the facial features extracted by health professionals, parents, and convolutional neural networks

Neonates are not able to verbally communicate pain, hindering the correct identification of this phenomenon. Several clinical scales have been proposed to assess pain, mainly using the facial features of the neonate, but a better comprehension of these features is yet required, since several related works have shown the subjectivity of these scales. Meanwhile, computational methods have been implemented to automate neonatal pain assessment and, although performing accurately, these methods still lack the interpretability of the corresponding decision-making processes. To address this issue, we propose in this work a facial feature extraction framework to gather information and investigate the human and machine neonatal pain assessments, comparing the visual attention of the facial features perceived by health-professionals and parents of neonates with the most relevant ones extracted by eXplainable Artificial Intelligence (XAI) methods, considering the VGG-Face and N-CNN deep learning architectures. Our experimental results show that the information extracted by the computational methods are clinically relevant to neonatal pain assessment, but yet do not agree with the facial visual attention of health-professionals and parents, suggesting that humans and machines can learn from each other to improve their decision-making processes. We believe that these findings might advance our understanding of how humans and machines code and decode neonatal facial responses to pain, enabling further improvements in clinical scales widely used in practical situations and in face-based automatic pain assessment tools as well.

Developing a model of neonatal nurse-controlled analgesia: A Delphi study.

To develop a nurse-led model of analgesia to manage post-operative pain in the surgical neonate. A four-round e-Delphi study was conducted from March to December 2022. An e-Delphi method was used seeking a consensus of 70% or greater. Fifty-one experts were invited to join the panel. Members consisted of multi-disciplinary healthcare professionals who work in areas associated with neonatal care. In round 1, 49 statements relative to neonatal pain assessment and management were distributed to the panel. Panel members were asked to rate their level of agreeance on a Likert scale from 1 to 5 (1 = strongly disagree to 5 = strongly agree). Ratings equal to or greater than 4 represented agreement, 3 indicated uncertainty and 2 or less disagreement with the proposed statement. An opportunity for free-text responses after each statement was provided. This iterative process continued for three rounds. In the fourth and final round, the completed model of neonatal nurse-controlled analgesia was presented along with a further opportunity to provide feedback on the final version. Four rounds of statements and voting were required to reach consensus on a model of neonatal nurse-controlled analgesia. The model consists of criteria for use, over-arching guidelines and three separate pathways based on an individual baby's pain assessment scores, need for pain relieving interventions and time-lapsed post-surgical procedure. A comprehensive model of neonatal nurse-controlled analgesia, applicable to the Australasian context, was developed in collaboration with a group of neonatal experts. This study provides a multi-modal family-integrated model to manage neonatal post-operative pain. By providing nurses with increased autonomy to assess and manage acute pain, this model has the potential to not only provide a more responsive and individualized approach to alleviate discomfort, but highlights the integral role of parent partnerships in the neonatal intensive care. This study was reported in line with the Conducting and REporting of DElphi studies (CREDE) guidance on Delphi studies. No patient or public contribution was utilized for this study.

Effects of different types of neonatal pain on somatosensory and cognitive development in male juvenile rats.

Premature infants are inevitably exposed to painful events, including repetitive procedures, inflammation, or mixed stimulation that may induce long-term behavioral outcomes. Here, we set up three neonatal painful models to investigate their long-term effect on somatosensation and cognition. Three types of neonatal pain models in rat were set up. Rat pups were randomly assigned to four groups. The needling pain (NP) group received repetitive needle pricks on the paws from the day of birth (PD0) to postnatal day 7 (PD7) to mimic the diagnostic and therapeutic procedures. The inflammatory pain (IP) group received the injection of carrageenan into the left hindpaw at PD3 to induce IP in peripheral tissues. The mixed pain group received a combination of the NP and IP (NIP). The control (CON) group was untreated. We performed behavioral and biochemical testing of juvenile rats (PD21-PD26). The NIP group showed a longer hypersensitivity than the NP group, when given a secondary inflammatory stimulation. NP led to insensitivity to anxiety-causing stimuli and impairment of fear memory both aggravated by NIP. NP reduced the expression of synapse-related molecules (GluN1/PSD95/GFAP) in the medial prefrontal cortex, and NIP exacerbated this decrease. The corticosterone secretion in the NIP group increased after the behavioral task, compared with those in other three groups. A combination of NP with inflammation occurring in the neonatal period might aggravate the adverse effects of each on somatosensory and cognitive development of rats, the mechanism of which might be associated with the increase of corticosterone secretion and the dysregulation of synaptic molecules.

Long-term Effects of Cannabidiol and/or Fentanyl Exposure in Rats Submitted to Neonatal Pain

The current study aimed to evaluate anxiety behavior, hippocampal ionized calcium-binding adaptor molecule 1 (Iba1) and cannabinoid receptor 1 (CB1) gene expression, and nociceptive response in adulthood after a combination of fentanyl and cannabidiol (CBD) for nociceptive stimuli induced during the first week of life in rats. Complete Freund’s adjuvant-induced inflammatory nociceptive insult on postnatal day (PN) 1 and PN3. Both fentanyl and CBD were used alone or in combination from PN1 to PN7. Behavioral and nociceptive tests were performed at PN60 and PN62. The expression of the microglial calcium-binding proteins Iba1 and CB1 was detected in the hippocampus using reverse Quantitative polymerase chain reaction (qPCR) and immunohistochemistry. Our results suggest that the anxiety behavior response and immune activation in adult life depend on the CBD dose combined with fentanyl for the nociceptive stimuli induced during the first week of life. Treatment of neonatal nociceptive insult with CBD and opioids showed significant dose-dependent and male-female differences. The increased gene expression in the hippocampus of the analyzed cannabinoid gene supports this data. In addition, treatment with fentanyl led to an increase in CB1 protein expression. Moreover, the expression of Iba1 varied according to the administered dose of CBD and may or may not be associated with the opioid. A lower dose of CBD during the inflammatory period was associated with enhanced anxiety in adult life. PerspectiveThe treatment of nociceptive stimuli with CBD and opioids during the first week of life demonstrated significant sex differences in adult life on anxiety behavior and supraspinal pain sensitivity.

Effectiveness of maternal-targeted training on nonpharmacologic pain management on heel stick sampling: A randomized controlled trial

BackgroundHeel stick sampling, which is a common procedure in newborns, causes acute pain, and parents are aware of this. AimThe current study aimed to investigate the effectiveness of maternal-targeted training on newborn pain management, addressing the use of nonpharmacological methods and anxiety. MethodsThe study is 2-arm, parallel-group randomized controlled trial. A total of 64 mothers were included in this study. Mothers were randomly allocated to each group; intervention (n:32) and control (n=:32). Training on nonpharmacological pain management in newborns was given to the mothers in the intervention group. Data were collected with an Introductory Information Form, Nonpharmacological Pain Management Use Checklist, and State-Trait Anxiety Inventory. ResultsNonpharmacological methods were used for the procedures in the control group and the intervention group, with an absolute difference of 68.8% between groups. The difference was statistically significant (p < 0.001) and had a large effect (d = −79.222; 95% CI, −9.365 to 670.143. There was no significant difference between the groups in terms of anxiety score (p = 0.558). ConclusionDemonstrates the clinical relevance and feasibility of training targeting maternal on neonatal pain management during the heel stick sampling procedure.Practice Implications: When non-pharmacological methods in pain management of newborns were recommended by the nurse, maternal involvement in pain management increased significantly, suggesting that nurses have a key role in ensuring parental involvement.Clinical Trial Registration: NCT05173662.

The Use of Dexmedetomidine in Preterm Infants: A Single Academic Center Experience.

Preterm newborns (PTNBs) often require sedation and analgesia. Dexmedetomidine (DEX) is used to provide sedation in extremely PTNBs, even though information on such use is limited. The objective of this research is to describe the use of DEX in these patients in a single academic center. This is a retrospective study of PTNBs receiving DEX from January 1, 2010, through December 31, 2018, at the Cleveland Clinic Children's Hospital, a tertiary academic center operating 2 Level III and 1 Level IV neonatal intensive care units (NICUs). Inclusion criteria were gestational age (GA) <36 weeks and receipt of DEX for >2 days. Adequacy of clinical response was based on achieving Neonatal Pain, Agitation and Sedation Scale (N-PASS) scores <3. Hypotension, bradycardia, and respiratory depression were recorded as the incidence as adverse events. A total of 105 patients were included. The birth weight median was 870 g (IQR, 615-1507); the GA median was 26 weeks (IQR, 24-31). The duration of DEX infusion averaged 7 days. The DEX dose averaged 0.4 mcg/kg (IQR, 0.3-0.45). Bradycardia was observed in 35 patients (57%) weighting <1 kg and in 7 patients (18%) >1 kg (p < 0.01). There was no difference in the incidence of other adverse events between these groups. However, infants <1 kg required more pharmacologic interventions to maintain N-PASS score <3. DEX was well tolerated overall and provided adequate sedation to PTNBs in this cohort. From this study, we recommend a starting dose of 0.2 to 0.4 mcg/kg/hr and titrating up hourly until adequate sedation is achieved.

Implementation of a knowledge translation and exchange intervention for pain management in neonates

Objective To describe the implementation process of a multifaceted knowledge translation and exchange intervention to improve pain management practices, and to evaluate the adoption of this intervention by health professionals during painful procedures in neonates. Methods A quasi-experimental before-and-after study developed in a neonatal unit. The Evidence-Based Practice for Improving Quality intervention guided by the conceptual framework The Promoting Action on Research Implementation in Health Services was implemented in two stages (preparation and implementation). Its adoption was measured by clinical indicators related to pain management presented through descriptive statistics. Results After discussion on existing practices in the unit that needed to be changed, synthesis of current scientific evidence and local context data, members of the unit’s Research and Practice Council developed and implemented coherent and achievable goals for the change of practice in pain management, selected knowledge translation and exchange strategies, determined the target audience and indicators, and implemented the interventions. There was a 32.8% reduction in the number of painful procedures performed, an increase of 26.6-50.7% in the use of pain assessment scales and of 25.1% in the administration of oral glucose. Conclusion The multifaceted Evidence-Based Practice for Improving Quality intervention is complex, and has processes that demand knowledge and skills, commitment from the various actors involved, availability of time and financial investment. The analyzed indicators showed that the intervention resulted in positive changes in clinical practice in the management of pain in neonates.

Neonatal pain management practice in the neonatal intensive care unit of public hospitals: a survey of healthcare providers in eastern Ethiopia.

Newborns experience multiple painful and stressful procedures during their hospitalization in neonatal intensive care units (NICUs). Repeated or untreated pain can have negative consequences for the health and development of newborns. Despite the growing knowledge of pain assessment and intervention, several studies have shown that the practice of neonatal pain management among healthcare providers is poor. Therefore, data regarding neonatal pain management practice and affecting factors are essential for taking appropriate actions. This study assessed neonatal pain management practice and associated factors among healthcare providers working in the NICUs of public hospitals in eastern Ethiopia from 1 January to 28 February 2022. An institution-based cross-sectional study design was used among 372 randomly selected healthcare providers working in the NICUs of public hospitals in eastern Ethiopia. Data were collected using a pre-tested structured self-administered questionnaire and an observation checklist. The collected data were reviewed, coded and entered into Epi-data version 3.1 and exported to SPSS version 25 for analysis. Bivariate and multivariable logistic regression were used to identify the associations between outcome and predictor variables at a 95% confidence level and P-values <0.05 were considered statistically significant. The study found that 185 (53.9%; 95% confidence interval [CI] 48.4 to 59.2) of the 343 respondents had good neonatal pain management practice with a mean of 11.38 (standard deviation 3.64). Receipt of in-service training in neonatal pain management (adjusted odds ratio [AOR] 2.12 [95% CI 1.15 to 3.91]), availability of protocols and guidelines in the NICUs (AOR 2.94 [95% CI 1.74 to 4.91]) and accessibility of analgesics in the NICUs (AOR 4.302 [95% CI 2.46 to 7.53]) were significantly associated with good neonatal pain management practice. The overall practice of healthcare providers in neonatal pain management in public hospitals in eastern Ethiopia is relatively high compared with previous studies conducted in Ethiopia. Improving the availability of analgesics as well as neonatal pain management protocols and guidelines in NICUs will aid in the promotion of good neonatal pain management practices. In addition, providing ongoing in-service training on neonatal pain management will allow healthcare providers to better care for newborns in pain.

Pain Assessment and Management Practices via Education & Reinforcement (PAMPER): A Quality Improvement Initiative.

To establish neonatal pain management practices as an essential developmental supportive measure at a tertiary care unit. This quality improvement initiative was conducted as per Point-of-Care-Quality-Improvement Model over 6 mo, followed by 2 y of sustenance phase at a Neonatal Intensive Care Unit (NICU) in northern India. Infants of birth weight ≤1800 g were included and assessed for pain. Pain Assessment and Management Practices via Education and Reinforcement (PAMPER) group was created by resident doctors and nursing staff. The Premature Infant Pain Profile score was used for the assessment of pain. Limiting factors were analyzed using a fishbone diagram and interventions were done in multiple Plan-Do-Study-Act cycles. At the end of interventions, 100% of procedures were assessed for pain. The mean (standard deviation) documented pain score for the first seven days was reduced from 12.8 (0.3) in the baseline phase to 7 (2.5). These interventions helped to sustain the practice in >70% of infants in the next 2 y. Low-cost interventions improved the pain assessment and management policy of authors' NICU with the establishment of a standard protocol. Audits and reinforcement at regular intervals helped in its long-term sustenance.

Evaluation of procedural pain for neonates in a neonatal intensive care unit: a single-centre study

BackgroundTo evaluate the procedural pain experienced by neonates in a neonatal intensive care unit (NICU) setting and determine the corresponding pain grades.MethodsTwo experienced nurses independently used the Neonatal Infant Pain...

Procedural pain assessment in neonates at risk of neonatal opioid withdrawal syndrome: a scoping review protocol.

The objective of this review is to identify evidence on pain assessment during acute procedures in hospitalized neonates at risk of neonatal opioid withdrawal syndrome (NOWS). While all neonates are routinely exposed to various painful procedures, neonates at risk of NOWS have longer hospital stays and are exposed to multiple painful procedures. NOWS occurs when a neonate is born to a birth parent who identifies as having sustained opioid use (such as morphine or methadone) during pregnancy. Accurate pain assessment and management during painful procedures is critical for minimizing the well-documented adverse effects of unmanaged pain in neonates. While pain indicators and composite pain scores are valid and reliable for healthy neonates, there is no review of evidence regarding procedural pain assessment in neonates at risk of NOWS. Eligible studies will include those reporting on hospitalized pre-term and full-term neonates at risk of NOWS having pain assessments (ie, behavioral indicators, physiological indicators, validated composite pain scores) during and/or after exposure to an acute painful procedure. This review will follow the JBI scoping review methodology. Databases to be searched will include MEDLINE (Ovid), CINAHL (EBSCO), Embase, PsyclNFO (EBSCO), and Scopus. The relevant data will be extracted by 2 reviewers using a modified JBI extraction tool. The results will be summarized in narrative and tabular format, including the components of participants, concept, and context (PCC). Open Science Framework https://osf.io/fka8s .

Regional Anesthesia for Neonates.

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Comparing Opioid with Opioid-free Anesthesia Technique in Neonates Undergoing Tracheoesophageal Fistula Repair.

Tracheoesophageal fistula (TEF) is a congenital disorder that presents as a surgical emergency in neonates. In regions where neonatal intensive care unit facilities and resources are inadequate and skilled personnel are scarce, not extubating neonates on table, contributes to mortality. Our aim was to assess and compare the on-table extubation rate, extubation time, and postoperative pain scores between opioid and opioid-free anesthesia techniques in neonates undergoing surgical repair of TEF. We conducted a prospective, single-blind, randomized trial over 18 months between January 2021 and June 2022 in Safdarjung Hospital, New Delhi on 60 full-term neonates scheduled for TEF surgeries randomly allocated to two groups according to the mode of analgesia administered. Group O were given fentanyl injection 1 µg/kg intravenous (IV) loading dose with IV injection. acetaminophen at 7.5 mg/kg and top-up of 0.25 µg/kg fentanyl IV si opus sit. Group NO were given pre-surgical local infiltration and intercostal block with 0.25% and 0.5% bupivacaine, respectively, with IV acetaminophen at 7.5 mg/kg. Mean age in days, gender distribution, and weight in both groups were statistically comparable. The difference in the number of neonates extubated on table was statistically significant (p =0.002) in group NO compared to group O. Lower mean extubation time was seen in group NO (9.0 min 40.0 secs±3.0 min 3.0 secs) compared to group O (16.0 min 45.0 secs±8.0 min 5.0 secs) (p < 0.001). There was a statistically significant (p =0.010) lower Neonatal Infant Pain Scale score in group NO with mean and SD as 1.8±0.8 compared with group O, 2.5±1.1 at 90 min. In neonates undergoing TEF repair, opioid-free anesthesia is a safe and effective method, providing a better extubation rate, faster time to extubation, and better postoperative pain control.

Enhanced Recovery After Surgery (ERAS®) Consensus Recommendations for Neonatal Perioperative Pain Assessment, Education, and Management

Enhanced Recovery After Surgery (ERAS®) Consensus Recommendations for Neonatal Perioperative Pain Assessment, Education, and Management