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Running head: EBP PROJECT PART 5

EBP Project Part 5

Meghan O’Neal

Frostburug State University

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The neonatal population has become a true passion of mine even though I have only been

working closely with them for ten months now. After diving into an intensive care unit following

graduation from nursing school I never would have expected to become so passionate about my

patients. Neonatal pain control is something that I see and work with every day at work.

Unfortunately there are many unanswered questions, however I am hopeful that through

continued research like the kind I have prepared will continue to lead the healthcare teams in the

right direction for controlling our babies’ pain levels.

Pain control in the neonatal population is a hard vital sign to keep track of. Doctors today

often say that the pain scale should be the fifth vital sign when assessing the adult population.

However, the pain level in a neonate is often over looked because he or she cannot simply give

the physician a number on the 1 to 10 pain scale. Because it is unknown what kind of pains and

how much pain our infants are actually feeling, the methods for pain control are limited. Oral

sucrose has been a method for pain relief in the neonatal population for many years, however is

this really enough to ease the pain of a difficult intubation? Narcotics are also often used,

specifically a Fentanyl drip or a Morphine drip. Is this inappropriate to begin narcotic use such a

young age if oral sucrose does the trick? These are just some of the questions that come to mind

when thinking about the neonatal population.

This neonatal population is any infant under 28 days old. The pain scale used to

determine which form of pain relief would be best would be the PIPP scale or the NIPS scale

depending on the age of the baby. PIPP is for any baby considered premature and NIPS is any

baby 0-2 months. The PIPP scale uses a baseline score, heart rate, and oxygen level. These

numbers are the average of the neonate’s first four sets of vital signs. After the baseline numbers

are established the PIPP scale is then ready to be used. The neonate will receive points
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depending on how close or far their vital signs are from the baseline scores. Besides vital signs

this pain scale also assess’ gestational age, brow bulge, eye squeeze, and nasolabial furrow. All

of these signs are significant indicators when it comes to assessing the pain of a patient who

cannot tell them himself. After looking over these unclear findings regarding pain relief I was

able to come up with a research question. Which form of pain relief is most effective in the

neonatal population, oral sucrose or narcotics? The purpose of this statement is to determine

whether oral sucrose or narcotics work the best when trying to control pain in the neonatal

population.

When it comes to the PICO question for this research project the answer was simple. Are

narcotics the best way to properly control pain in the newborn population (under 30 day sold) for

all types of procedures, or is oral sucrose a safer and equally as effective pain control method?

There is no better way to condense the neonatal pain control issue than to face it head on with

this question. The “P” which stands for the patient population would be any newborns under

thirty days old experiencing pain. The “I” would represent pain reduction with the use of

narcotics and oral sucrose. The “C” for comparison can be described as oral sucrose only for

pain reduction, verses interventions using narcotics and oral sucrose. The “O” for outcome

would then finish up with being able to determine which form of pain relief is clinically the best

for all potentially painful procedures.

During the research process I was able to use databases such as the Nursing &Allied

Health source. By using search terms such as “Neonatal pain relief”, “Neonatal narcotic use”,

“Neonatal sucrose for pain relief”, and “Neonatal pain assessment.” I was also able to refine my

search by using the filter option to view only peer reviewed articles, scholarly journals, full text

availability, and a published date before 2000. This extensive research took place over the week
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of October the 9th. Each reference was able to provide a different insight into this research

process and truly give me a better picture of the entire problem. Hardcastle (2010) describes how

sucrose does help with pain relief as evidence by the pain scale and vital sign assessments.

Whereas Anand (2005) reveals that the use of opioids for moderate to severely painful

procedures does reduce the pain level for infants. In congruence with these ideas, Garry (2006)

explains how the dorsal penile nerve block reduces the pain in neonatal male’s more than topical

lidocaine. In contrast to this article, I found another by Anand (2007) that explained how there

are many answers depending on the procedure and not one narcotic the answer for all

procedures. In addition, Evans (2005) added that both the severity of illness and the total number

of prior painful procedures had a significant influence on pain scores. Finally, through Zeller’s

(2014) article I was able to learn more about the fact that sucrose is the most widely studied

nonpharmacological intervention for pain management in neonates. The studies show reduced

crying, facial grimacing, and motor activity when sucrose is given prior to minor painful

procedures such as heel sticks, circumcisions, and IV insertions. Each of these articles

contributed greatly to my research and were able to provide a variety of viewpoints for a better

all-around picture of what neonatal pain control really looks like.

The first practice recommendation comes from a Randomized Control Trial (RCT) of a

multitude of analgesic medications as well as oral sucrose. Many different procedures were

examined and the neonatal population was closely evaluated for a decrease in pain with and

without the help of medications and oral sucrose. After reading this RCT one practice

recommendation that could be implemented in the clinical setting would be to use both oral

sucrose and one of the analgesic medications. Anand (2005) states “Different drug classes and/or

modes of administration may be combined to optimize efficacy and minimize the occurrence of
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adverse effects” (p 866). In order to target the pain from a variety of angles, two forms of relief

could be utilized in order to provide optimal pain relief.

A second practice recommendation comes from evidence provided in a Literature Review

about pharmacological approaches with the neonatal population. This review describes how a

variety of procedures elicit different types of pain. In addition to the different types of pain there

is also different forms of assessment for pain. These different types of pain and procedures then

demand different forms of pain relief. Anand states (2007)

The multifaceted issues of pain management can be addressed in different ways rather

than relying on the ‘one-drug-fits-all’ approach (Table 3). Exposure to repetitive pain

occurs commonly in preterm and term neonates. Pain assessment methods are currently

available specific for acute pain, but newer methods are currently being developed to

evaluate prolonged pain. An appropriate approach to the management of pain needs to

assess the type of pain the neonate is experiencing. For acute physiological pain, avoiding

invasive procedures, utilizing sucrose pacifiers, and topical/local anesthetics can be

useful. For postoperative pain, a short duration (24 to 48 h) of opioid therapy,

positioning, removing drains, and considering adjuvant therapies would be appropriate.

For inflammatory pain, caused by meningitis or phlebitis, anti-inflammatory

agents should be considered. Opioids can be used in this setting if the pain is

severe or extensive. (p 89)

In conclusion, the medical team monitoring a neonate’s pain should base the drug choice off of

the circumstances at hand.

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Finally, a third practice recommendation comes from another Literature Review focusing

on oral sucrose. This review examined a variety of studies regarding pain relief as well as the

assessment of pain in the neonatal population. It was concluded here that the change in vital

signs is an accurate way to interpret pain in the neonatal population. This third and final best

practice recommendation would be to use oral sucrose for most of the common painful

procedures and evaluate patient per patient for more serious invasive procedures on whether or

not to use opioid medications. Hardcastle (2010) states

In conclusion it appears evident that sucrose provides analgesia in neonates and is more

effective with the use of non-nutritive sucking (pacifiers). It is effective for painful

procedures such as heel pricks and venipuncture. (p 21)

Oral sucrose is effective in reducing the amount of pain in the neonatal population and should be

used for minor procedures such as venipunctures, and heel sticks.

After spending many months, weeks, days, and hours researching such a unknown topic

as pain control I am very happy to conclude that research shows narcotic use along with the use

of the age old oral sucrose will allow our neonatal population to remain pain free or close to it

during painful procedures.

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References

Anand, K. J. S., Celeste^Johnston, C., Oberlander, T. F., Taddio, A., Tutag Lehr, V., & Walco,

G. A. (2005). Analgesia and local anesthesia during invasive procedures in the

neonate. Clinical Therapeutics, 27(6), 844-76. doi:http://dx.doi.org.proxy-

fs.researchport.umd.edu/10.1016/j.clinthera.2005.06.018

Anand, K. J. S. (2007). Pharmacological approaches to the management of pain in the neonatal

intensive care unit. Journal of Perinatology, 27, S4-S11. doi:http://dx.doi.org.proxy-

fs.researchport.umd.edu/10.1038/sj.jp.7211712

Evans, J. C., McCartney, E. M., Lawhon, G., & Galloway, J. (2005). Longitudinal comparison of

preterm pain responses to repeated heelsticks. Pediatric Nursing, 31(3), 216-21. Retrieved

from http://proxy-fs.researchport.umd.edu/login?url=https://search-proquest-com.proxy-

fs.researchport.umd.edu/docview/199529331?accountid=27669

Garry, D. J., Swoboda, E., Elimian, A., & Figueroa, R. (2006). A video study of pain relief

during newborn male circumcision. Journal of Perinatology, 26(2), 106-10.

doi:http://dx.doi.org.proxy-fs.researchport.umd.edu/10.1038/sj.jp.7211413
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Hardcastle, T. (2010). Sucrose has been shown to have analgesic properties when administered

to neonates and infants: Is there the potential for its use in post-operative pain

management? The Journal of Perioperative Practice, 20(1), 19-22. Retrieved from

http://proxy-fs.researchport.umd.edu/login?url=https://search-proquest-com.proxy-

fs.researchport.umd.edu/docview/217752119?accountid=27669

Zeller, B., PharmD., & Giebe, Jeanne, MSN,N.N.P.-B.C., R.N. (2014). Pain in the neonate:

Focus on nonpharmacologic interventions. Neonatal Network, 33(6), 336-40. Retrieved

from http://proxy-fs.researchport.umd.edu/login?url=https://search-proquest-com.proxy-

fs.researchport.umd.edu/docview/1628380377?accountid=27669