Prevention and Management of Procedural Pain in the Neonate: An Update

The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU.

To address the gaps in knowledge, more research should be conducted...

Therefore, every health care facility caring for neonates should implement a pain-prevention program that includes strategies for minimizing the number of painful procedures performed

Despite recommendations from the AAP and other experts, neonatal pain continues to be inconsistently assessed and inadequately managed.

The prevention and alleviation of pain in neonates, particularly preterm infants, is important not only because it is ethical but also because exposure to repeated painful stimuli early in life is known to have short- and long-term adverse sequelae. These sequelae include physiologic instability, altered brain development, and abnormal neurodevelopment, somatosensory, and stress response systems, which can persist into childhood.^5–15 Nociceptive pathways are active and functional as early as 25 weeks’ gestation and may elicit a generalized or exaggerated response to noxious stimuli in immature newborn infants.¹⁶
Researchers have demonstrated that a procedure-related painful stimulus that results in increased excitability of nociceptive neurons in the dorsal horn of the spinal cord accentuates the infant’s sensitivity to subsequent noxious and nonnoxious sensory stimuli (ie, sensitization).^17,18 This persistent sensory hypersensitivity can be physiologically stressful, particularly in preterm infants.^19–22 Investigators have demonstrated increased stress-related markers and elevated free radicals after even simple procedures, such as routine heel punctures or tape removal from central venous catheters,^23,24 which can adversely affect future pain perception.⁸ Specific cortical pain processing occurs even in preterm infants; however, multiple factors interact to influence the nociceptive processing and/or behavioral responses to pain.^{14,16,25–27} Noxious stimuli activate these signaling pathways but also activate the central inhibitory circuits, thus altering the balance between the excitatory and inhibitory feedback mechanisms. The immaturity of the dorsal horn synaptic connectivity and descending inhibitory circuits in neonates results in poor localization and discrimination of sensory input and poor noxious inhibitory modulation, thus facilitating central nervous system sensitization to repeated noxious stimuli.²⁵

AAP schrieb:

..the benefits of newborn male circumcision justify access to this procedure for families who choose it..