Managing a Neonate in an Intensive Care Unit

Managing a Neonate in an Intensive Care Unit

Clare Morfoot

This chapter will focus on the non-pharmacological management of pain in the neonate. Although this scenario is based on a premature infant, the principles of care included within this chapter are also relevant to the term neonate. Pharmacological pain measures will not be addressed as these are covered in other relevant chapters.


Activity of living: communication.

Question 1. Assessment: How would you assess whether Molly is in pain?

Until the 1980s, neonates were regarded as incapable of experiencing pain due to the immaturity of their nervous system (Agakidou et al. 2021). However, it is now widely acknowledged that premature infants possess the neurological capacity to perceive pain (Anand & Hickey 1987; Simons & Tibboel 2006) with evidence of hypersensitivity to noxious stimuli when compared to adults (Fitzgerald & Beggs 2001; Ranger & Grunau 2015), due to the immaturity of descending inhibitory pathways, larger pain perception areas in the spinal cord and the volume of pain receptors lying closer to the skin.

Although many definitions of pain acknowledge its subjective, emotional, and sensory nature, the inclusion of an emotional component, means that they fail to accurately reflect the neonatal pain experience. In addition, it can be challenging to differentiate between discomfort, stress, and pain, particularly in the non-verbal infant (Olsson et al. 2021).

At 32 weeks’ gestation, Molly is capable of feeling pain and it is essential that healthcare professionals observe Molly for specific pain indicators (Table 13.1), in order to adequately assess and treat her pain. Molly’s response to pain may result in physiological, behavioural, metabolic, and hormonal changes (Witt et al. 2016).

Table 13.1 Examples of neonatal pain indicators.

Behavioural responses Physiological parameters Chemical changes
Facial expression e.g. grimace, cupped tongue, brow bulge, naso-labial furrow, open mouth, eye squeeze, pursed lips, taut tongue ↑↓ heart rate ↑ stress hormone production
Cry (may be silent if intubated) ↑↓ respiratory rate ↑ blood glucose
Body movement e.g. splayed digits, arching, hand swiping, clenching of fists and toes, limb withdrawal, rigidity, flaccidity ↑↓ oxygen saturations ↓ insulin
Changes in sleep/wake cycle, for example hyper-alert or lethargic, irritability ↑↓ blood pressure

Numerous neonatal pain assessment scales exist for different infant populations and types of pain, although not all of these are validated (Olsson et al. 2021). Most tools tend to focus on the observation of behavioural and physiological responses, with the evaluation of chemical indicators often reserved for research, since these require additional painful, invasive, diagnostic procedures to detect them. It is important to remember that the sick, preterm, sedated, paralysed, or ventilated infant may not be capable of demonstrating the anticipated behavioural responses to pain. A few examples of commonly cited and validated neonatal pain assessment tools include:

  • Premature Infant Pain Profile (PIPP)

    • This tool assesses seven items, including behavioural and physiological indicators, each scoring 0–3. The revised scale (PIPP-R) also incorporates contextual factors, such as gestational age and sleep state, thereby acknowledging that infants who are sleeping or extremely preterm may be unable to demonstrate a typical behavioural response (Stevens et al. 2014). This tool is validated for both premature and term infants for acute procedural and postoperative pain (Gibbins et al. 2014; Witt et al. 2016).

  • Neonatal Infant Pain Score (NIPS)

    • This is the second most cited tool within studies about procedural pain assessment (Olsson et al. 2021). The scale evaluates six behavioural and physiological indicators with a maximum score of seven. It is used for both preterm and term infants and is validated for acute procedural pain (Witt et al. 2016).

  • CRIES (Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness)

    • This tool assesses five behavioural and physiological indicators, each attracting a score of 0–2. It is validated for both premature and term infants for postoperative pain (Olsson et al. 2021; Witt et al. 2016).

The accurate assessment of pain is not only an important ethical consideration but also key to reducing the risk of significant short- and long-term deleterious consequences that are associated with continued exposure to pain (American Academy of Pediatrics Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine 2016). Despite international recommendations emphasising the importance of neonatal pain assessment, a European multicentre study demonstrated that only ten percent of premature infants and a third of admissions to neonatal intensive care are assessed for pain (Anand et al. 2017). Lack of knowledge, concerns regarding the validity of pain assessment scales and the availability of guidelines all appear to influence the use of such tools (Carlsen Misic et al. 2021).

Question 2. Planning: How would you prepare Molly and her family for painful invasive diagnostic procedures?

Preparing Molly

During her admission to the neonatal unit, Molly will be exposed to significant environmental stressors, including noxious sound, light, smell, taste, and touch, at a time when she would otherwise be developing in utero. Failure to minimise the adverse impact of the neonatal environment or the stress and pain associated with invasive procedures may jeopardise Molly’s neurodevelopment and adversely impact her long-term outcomes (Altimier & Phillips 2016). In contrast, the adoption of neuroprotective, family oriented, developmental approaches to neonatal care will promote more positive outcomes (Altimier & Phillips 2016).

The assessment of Molly’s behavioural cues (Table 13.2) allows the healthcare professional to interpret how Molly is coping with the stressors of the environment (Als & Butler 2008; Warren & Bond 2010). For example, Molly may display avoidance behaviours, such as splayed digits or side swiping during attempts at blood sampling or cannulation. If such avoidance behaviours are observed, the environment must be modified and where possible, procedures should be delayed. During these invasive procedures, appropriate pain management strategies must be employed.

Table 13.2 Examples of behavioural cues.

Avoidance behaviour Approach behaviour
Sneezing Hands together
Hiccoughing Grasping
Yawning Hands to face
Grimacing Hands to mouth
Limp or stiff posture Smooth movements
Sudden or jerky movements Orientation to voice or sound
Trembling Flexed posture
Finger splay Relaxed expression
Arm swiping Mouth making ‘ooh’ shape
Arm salute Sucking
Crying Smooth transition from sleep to wake
Looking away Snuggling

The timing of all procedures should be individualised and planned to ensure that Molly has adequate rest to promote growth and development. Procedures should coincide with other caregiving activities wherever possible. Invasive procedures should not be performed around Molly’s feed times to avoid vomiting and the risk of aspiration.

Preparing Molly’s Family

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Mar 23, 2024 | Posted by in Uncategorized | Comments Off on Managing a Neonate in an Intensive Care Unit

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