July 8, 2008 — Over a 2-week period, neonates in intensive care underwent a median of 10 painful procedures per day, 79% without analgesia, in a  study from Paris.

"The number of painful procedures is so high that the first step to improve procedural pain management must significantly reduce these numbers," the authors, led by Ricardo Carbajal,
MD, from the Hôpital d'enfants Armand Trousseau, in Paris, France, write.

"The knowledge that some vulnerable neonates underwent 153 tracheal aspirations or 95 heel sticks in a 2-week period should elicit a thoughtful and relevant analysis on the necessity and the risk/benefit ratio for our clinical practices," they observe.

The study is published in the July 2 issue of the Journal of the American Medical Association.

Vulnerable Neonates, Long-Term Consequences From Pain

Compared with older children and adults, neonates are more sensitive to pain, and multiple lines of evidence suggests that repeated and prolonged exposure to pain alters a neonate's subsequent pain processing, long-term development, and behavior. "It is essential, therefore, to prevent or treat pain in neonates," and there are numerous pharmacological and nonpharmacological treatments that can alleviate procedural pain in these infants, the group writes.

Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain, they add.

They aimed to report the findings from epidemiological data on neonatal pain collected from direct bedside observations of neonates in Paris as part of the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study.

This prospective observational study collected around-the-clock bedside data on all painful or stressful procedures performed in 430 neonates admitted to 13 of 14 intensive care units in tertiary care centers in Paris. Data were collected from the first 14 days of admission, during a 6-week period.

Painful procedures were considered as those that invaded a neonate's bodily integrity, and stressful procedures were defined as those that mainly caused physical uneasiness or annoyance.

Nonpharmacological analgesia included administering sweet solutions or allowing nonnutritive sucking. Pharmacological analgesia included intravenous opioids and topical drugs.

The average gestational age was 33 weeks and the average intensive care unit stay was 8.4 days.

The investigators identified 44 painful procedures, of which the 6 most common were nasal aspiration (28.9% of the procedures), tracheal aspiration (23.3%), heel stick (19.8%), adhesive removal (12.7%), gastric tube insertion (2.4%), and venipuncture (1.8%).

Of the 16 identified stressful procedures, the 6 most frequent were nursing care (39.2%), oral aspiration (26.9%), washing the neonate (8.5%), blood pressure measurement (8.5%), X-rays (6.0%), and infant weighing (5.8%).

Average of 16 Painful or Stressful Procedures Each Day

During the study period, neonates experienced 42,413 painful and 18,556 stressful first-attempt procedures and 10,366 painful and 1180 stressful supplemental-attempt procedures.

Each neonate experienced a mean of 16 painful plus stressful procedures each day, and some experienced as many as 62 procedures each day.

Number of Painful and Stressful Procedures in Neonates in ICU

Procedure      In 2 Weeks      Per Day
                141 (107)      16 (9)

Painful or stressful procedures, n, mean (SD)      
                 98 (78)      12 (8)

Painful procedures, n, mean (SD)      
                115 (4 – 613)      16 ( 0 – 62)

Painful or stressful procedures, n, median (range)               75 (3 – 364)      10 (0 – 51)

Painful procedures, n, median (range)      

ICU = intensive care unit

Of the 42,413 painful procedures, only 20.8% were carried out with specific analgesia before the procedure: 2.1% were performed with pharmacological-only therapy, 18.2% with nonpharmacological therapy, and 0.4% with