In April 2019, an expert panel met at the annual Neonatal Neurocritical Care Special Interest Group ( meeting to review approaches to measuring and managing pain in the NICU. 5 An important modifiable factor that has been gaining interest in the clinical and research setting is pain in the neonatal intensive care unit (NICU). 2, 3, 4 More recent studies are shifting the paradigm of brain injury in the preterm infant from a “one-hit brain injury” to overall alteration in trajectory of brain maturation. 1 Neurodevelopmental challenges in infants born preterm often follow severe intraventricular hemorrhage (IVH) and white matter injury (WMI). Despite advances in neonatal intensive care, preterm birth remains a leading cause of neurodevelopmental disability. Improved neonatal intensive care has reduced the mortality and increased the survival of preterm infants. The rate of preterm birth is rising around the world. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge appropriate containment and an optimal environment should be standard when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain.
Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU).
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