How should we manage pain in ventilated neonates?

Newborn babies, even if extremely preterm, show responses to pain. The major stress responses seen with surgical pain are associated with serious adverse medical outcomes. There is an ethical imperative to consider pain relief in babies, despite the fact that they cannot verbalise their experience. Ventilator support, and accompanying treatments are described as distressing in adults, and are associated with an endocrine stress response in babies. Opiates have been shown to reduce physiological instability in sick newborn babies. Despite this, they have not been shown to reduce morbidity when given by infusion in ventilated infants, and in view of their serious side effects probably should not be used routinely in this way. It is logical and may be appropriate to give opiates peri-operatively and in babies likely to have severe pain (either from an underlying disease process such as necrotising enterocolitis, or during certain procedures). It is now accepted practice to use a potent analgesic/sedative for elective intubation and as cover for the treatment of retinopathy of prematurity. Topical anaesthetic creams reduce the pain response when used in anticipation of phlebotomy or vascular cannulation. Intra-oral sucrose is effective cover for procedures associated with mild to moderate distress, but its role in preterm infants is uncertain. Nursing interventions to reduce environmental stress, although commonly used, have not consistently been shown to be of benefit.