Pain

Pain and pain relief
in infants and
children
Some questions
Background
Newborn infants do feel and experience pain procedures commonly cause avoidance responses and other expressions of pain.
demonstrated for a long time after the infant was subjected to a painful procedure without the benefit of analgesia.
Background
CNS nerve fibers for pain are myelinized already at 30 weeks GA.
are often conducted by non-myelinized fibers.
Thus, lack of myelinization does not equal lack of sensitivity to pain! Background
Mediators and transmitters for relaying pain impulses are present already in the 1st trimester.
Endogenous opioids are produced in fetal life and can be demonstrated in newborn infants who have been exposed to noxious stimuli.
Background
Background
Background
There is still no general agreement about the treatment of pain in infants: u Fear of side effects of analgetics and u Fear of development of dependency.
kinetics and other variables in infants.
Indications for pain relief and
sedation in infants and children
Strong and/or long-lasting pain/ discomfort neuromuscular blockade because of severe ventilation/oxygenation problems (?) Indications for pain relief and
sedation in infants and children
Pain/discomfort of moderate intensity and/or duration Indications for pain relief and
sedation in infants and children
Pain/discomfort of low intensity and/or short duration Analgetic drugs and techniques
in infants and children
mouth or on a pacifier has been shown to have analgetic effects.
Analgetic drugs and techniques
in infants and children
providing longer periods with calm, quiet, and reduced stimuli Analgetic drugs and techniques
in infants and children
• Can contribute to increased feeling of F Does require the investment in time to Analgetic drugs and techniques
in infants and children
should be limited to 4 mg/kg (=0.8 ml of a 5 mg/ml solution) Analgetic drugs and techniques
in infants and children
F EMLA (eutectic mixture of lidocaine and • Injections, blood tests, circumcision – Prilocaine may cause methemoglobinemia in infants by absorption through the skin of the metabolite O-toluidine Analgetic drugs and techniques
in infants and children
risk of methemoglobinemia is much less than we have feared.
infants in single doses as long as it is not combined with other drugs that cause methemoglobinemia (for example trimethoprim-sulfa).
Analgetic drugs and techniques
in infants and children
this type both in neonates and bigger children • Because of immature metabolic pathways neonates are relatively protected against paracetamol toxicity • Uptake from rectal mucosa is delayed and Analgetic drugs and techniques
in infants and children
– Inhibition of respiration by repeated/ Analgetic drugs and techniques
in infants and children
F Opiates are the ”backbone” in per- and – In experimental animals there have been suggestions of increased organ damage following asphyxia – Possibly reduced time interval between ischemia and nevronal damage in experimental animals when fentanyl is used Analgetic drugs and techniques
in infants and children
– Variable pharmacokinetics, difficult to predict half-life: Morphine 5-28 h; Fentanyl 1-6 h Analgetic drugs and techniques
in infants and children
• Fentanyl 1-3 (-10) microgram/kg every 2-3 h, or • Morphine 50-100 microgram/kg every 3-8 h, or Analgetic drugs and techniques
in infants and children
– Very little release of histamine and – Possibly less inhibition of respiration Analgetic drugs and techniques
in infants and children
• F may be preferable in pulmonary hypertension because it blocks the increase in pulmonary pressure caused bytracheal suctioning.
• Theoretically fentanyl may may be less optimal when you want to increase pulmonary flow resitsance – as may be the case in ductal dependent cardiac malformations – I don’t know whether this has actually been Analgetic drugs and techniques
in infants and children
expansion of air pockets (pneumothorax, intestinal obstruction) F Inhalation gases in the NICU are tricky to Analgetic drugs and techniques
in infants and children
analgetics are used quite frequently, but the scientific documentation is somewhat limited so far Analgetic drugs and techniques
in infants and children
F Diazepam has a very long half-life and a significant tendency for respiratory inhibition F Midazolam – frequently combined with fentanyl (ratio F:M = 1:5) in continuous infusion.
• Encephalopathy-like effects have been Analgetic drugs and techniques
in infants and children
F Has no analgetic effect, and may have a F Rapid adaptation to the sedative effect, and should not be used for a prolonged period of time as a sedative Analgetic drugs and techniques
in infants and children
F Previously frequently used for sedation F May be given orally or rectally (25-50 Analgetic drugs and techniques
in infants and children
u Children and infants feel and experience F Procedures which are painful/uncomfortable for us, are likely to be painful for sick newborns also F The need for pain relief should always be kept in F As a rule analgesia and, if necessary, sedation, should be given to newborn infants if bigger children and grown-ups would have been given such treatment UN Convention on the
Rights of the Child
whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration UN Convention on the
Rights of the Child
u ……to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment ….
u …. the right of the child to ….facilities for the treatment of illness and rehabilitation of health ….that no child is deprived of his or her right of access to such health care services.
Oslo University Hospital, Rikshospitalet is owned by Health South-East RHF and consists of Rikshospitalet, Radiumhospitalet, The Epilepsy Center and the Specialist Hospital for Rehabilitation.

Source: http://www.bioethics.ru/_Images/Catalog/402-1-33.pdf