An Ounce of Prevention: Decreasing Painful Interventions in the NICU

Despite a proliferation of literature relative to pain physiology, assessment, and treatment, pain management in NICUs remains inconsistent—most often focused on assessment and treatment rather than prevention. The acceptance of pain as an inevitable part of NICU hospitalization is part of the culture in many NICUs. This article is intended to encourage discussion of pain prevention in the NICU, with a goal of creating a new “minimal-pain” NICU culture. The focus of NICU pain management programs should be on decreasing the number of painful events the NICU patient experiences. Areas for consideration include assessing the performance of procedures by novice versus experienced NICU personnel, reevaluating the role of pediatric residents in the treatment of NICU patients, evaluating the use of umbilical lines and peripherally inserted central catheters to reduce the frequency of peripheral punctures, and evaluating the admission process for ways to reduce neonatal pain and stress. This article discusses the physiology of pain in the neonate, identifies adverse outcomes related to repeated pain, and proposes practice changes that can prevent unnecessary pain in neonatal care.

Scenario: The patient is a near-term infant with bilateral chest tubes who requires neither oxygen or ventilator support. The NICU care team is gathered at the bedside for morning rounds. Near the end of rounds, one team member asks, “What are we doing for pain control?” The nurse indicates there is a standing order for “as needed” fentanyl, which is controlling pain well. Another team member questions the need for opiate pain treatment, citing the risk of respiratory depression with the resultant need for ventilator support. The fentanyl order is discontinued, and no other pain medications are ordered.

The following morning, the patient chart is reviewed. Despite elevated pain assessment scores through the night, the infant received no further pain medications. The night nurse had requested an order for pain medications; the request was denied because of “risk of respiratory depression.” The infant was treated with nonpharmacologic pain interventions, which did not bring the pain scores into acceptable ranges.