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Policy: Manage neonates’ pain without drugs when possible :

January 25, 2016

Health care professionals who work with newborns should aim to limit painful procedures and manage mild pain without medication when possible, according to an updated AAP policy.

“When we have to use medications, we should be very thoughtful and be very mindful of the risks and benefits of using each different kind of drug,” said lead author Erin L. Keels, A.P.R.N., M.S., N.N.P.-B.C., the National Association of Neonatal Nurses’ liaison to the AAP Committee on Fetus and Newborn (COFN).

The policy statement Prevention and Management of Procedural Pain in the Neonate: An Update from COFN and the AAP Section on Anesthesiology and Pain Management is available at and will be published in the February issue of Pediatrics.Health care professionals who work with newborns should aim to limit painful procedures and manage mild pain without medication when possible.Health care professionals who work with newborns should aim to limit painful procedures and manage mild pain without medication when possible.

Communication barriers can make neonatal pain difficult to assess and manage. There are more than 40 neonatal assessments tools, some of which are included in a table in the policy. However, there is no gold standard, according to Keels, director of the Neonatal Nurse Practitioner Program at Nationwide Children’s Hospital in Ohio.

“The cues from baby to baby are just a little bit different, and we’re still trying to figure that out, how best to be able to evaluate each baby’s level of pain individually,” she said.

Keels stressed the importance of assessing this pain so it can be documented and tracked. Pain that is not well-managed can have short- and long-term effects on neurodevelopment, behavior and cognitive function.

For mild to moderate pain, practitioners should look to nonpharmacologic interventions, which are backed by additional research in the updated policy. These approaches include skin-to-skin contact, facilitated tucking, sensorial stimulation, swaddling, nonnutritive sucking and massage.

“The challenge is sort of changing our culture and our workflows in the NICU (neonatal intensive care unit) to make the time or get the resources and the people to help us do that while we’re performing a procedure,” Keels said.

The next level of care would be oral sucrose and/or glucose, which should be tracked as medications. For those whose pain cannot be managed with these approaches, doctors should weigh the risks and benefits of pharmacologic interventions like opioids, benzodiazepines and other drugs.

For some procedures like circumcision, chest drain insertion and removal, and nonemergency intubations, the Academy recommends routine pain management. However, more research is needed as to the best way to manage pain during other procedures like mechanical ventilation.

Whichever course practitioners choose, Keels stressed the need to keep families in the loop.

“I think the best thing we can do in the NICU is to really talk to the families about pain and pain management and what our approach is and the rationale for it and really try to involve them in it,” Keels said.


  • Create a pain prevention and treatment plan that includes judicious use of procedures, routine pain assessment, use of pharmacologic and nonpharmacologic therapies for minor procedures, and effective medications for surgery and major procedures.
  • Use validated neonatal pain assessment tools before, during and after painful procedures.
  • Use nonpharmacologic strategies like facilitated tucking, nonnutritive sucking, breastfeeding, providing expressed human milk or sensorial stimulation to decrease pain during short-term mild to moderately painful procedures.
  • Consider oral sucrose and/or glucose solutions for neonates undergoing mild to moderately painful procedures either alone or in combination with other strategies. When used for pain management, prescribe and track these as a medication.
  • Weigh the risks and benefits of using pharmacologic treatments based on available evidence.
  • Health care providers and family members should receive continuing education on assessment and management of pain.
  • More research should be conducted on pain assessment tools and strategies to prevent or ameliorate pain.
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