MANAGEMENT OF

NEONATAL PAIN
Perina-NICU Rumah Sakit Universitas Indonesia
Ns. Raudha Ilmi Farid
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NS. RAUDHA ILMI FARID, S.KEP

2017-2018 Nursing Profession Degree, Faculty of Nursing UI
Educational Background
2013-2017 Bachelor of Nursing, Faculty of Nursing UI

2020-Present Primary Nurse, Neonatal Intensive Care Unit, RSUI

Working Experience
2018-2019 Associate Nurse, Intensive Care Unit, RSUI

Seminar, Workshop and Training

2021 Seminar and Workshop Webinar Update BTCLS, Emergency Dept RSUI
2021 Update Neonatal Resucitation, Faste
2021 Neuroemergency Nursing Life Support for Neonatal, Pediatric, & Adult, AHAevent
2020 HIV Prevention of Mother To Child Transmission (PMTCT), PKVHI Depok
2020 Implementation of aEEG in Neonatal Unit, IDAI UKK Neonatologi
2019 Neonatal Nursing Training Level 2, Neonatology RSCM @nsraudha
2019 Training of LBW Management with Kangaroo Mather Care, Perinasia nersraudha.blogspot.com

Paper and Publication

2021 The 7th Virtual Biennial International Nursing Conference: Comparison of Mother’s Therapeutic Touch and Voice Stimulus in
Reduce Pain in Premature Infants Undergoing Invasive Procedures
2018 Implementation of Audiotory Stimulation of Qor’anic Murottal on Patient with TB Meningitis in Neurology Ward of 5th floor,
Zone A in RSCM
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OUTLINE
Definition and Background
Pathophysiology of Pain
Sign and Symptoms
Long-term Consequences of Pain And Stress in Neonates
Pain Assessment
Nursing Diagnosis Of Pain
Management and Intervention
• Farmakologis
• Nonfarmakologis
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……“an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or
described in terms of such damage”
~ International Association for the Study of Pain (IASP)
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BACKGROUND: DEVELOPMENT OF SENSORY NERVE

Peripheral cutaneous sensory receptors develop in the perioral, facial,

7.5–15 weeks’ gestation. palmar, and abdominal areas and proximal extremities.

Spinal reflexes are able to respond to noxious stimuli, and neurons

8–19 weeks’ gestation. populate the dorsal root ganglion.

Mucous membranes and remaining cutaneous areas are populated with

20 weeks’ gestation. sensory nerve endings.

Thalamic afferents involved in conscious perception of pain reach the

20–24 weeks’ gestation. subplate zone and the cortical plate.

23–27 weeks’ gestation. Thalamic afferents reach the visual cortex.

26–28 weeks’ gestation. Thalamic afferents reach the auditory cortical plate
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TYPES OF PAIN IN THE NEONATE

1 Birth Trauma

2 Acute Procedural Pain

3 Acute Postoperative Pain

4 Chronic Pain
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PROCEDURAL PAIN
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PROCEDURAL PAIN
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PROCEDURAL PAIN
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PATHOPHYSIOLOGY OF PAIN
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SIGN AND SYMPTOMS

Common Signs Of Pain In The Neonate
↑ HR, ↑↓ RR, ↑↓ BP, changes in facial expression such as brow bulge, eyes
squeezed shut, nasolabial furrow, crying, palmar sweating, and increased
movement.
Physiologic Changes Due To Pain
↑ oxygen consumption, ventilation-perfusion mismatch, ↑ gastric acidity, and
disturbance of sleepwake cycle. Infants experiencing prolonged pain may exhibit
↓ HR, ↓ RR, ↓ oxygen consumption, lethargy, ↓ perfusion, and cool
extremities.
Metabolic And Hormonal Changes Related To Pain
↑ plasma renin (after venipuncture in term infants); ↑ plasma epinephrine and
norepinephrine (after chest physiotherapy (PT) and ETT suctioning in preterm
infants); ↑ plasma cortisol levels (after circumcision without anesthesia); release
of growth hormone, glucagon, cortisol, and aldosterone; and ↓ insulin secretion
(preterm and term infants undergoing surgery with minimal anesthesia).
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CONSEQUENCES OF PAIN & STRESS IN NEONATES

1 Hypoxia, acidosis, hypercarbia, respiratory distress, and hyperglycemia.

2 Increased catabolism and hypermetabolism.
3 Increase susceptibility to infection and increase morbidity and suboptimal outcomes.
Untreated neonatal pain can lead to: altered pain sensitivity (either an inability to respond
4 to pain or an exaggerated physiologic response to pain) with permanent neuroanatomic and
behavior outcomes.
5 Long-term effects: emotional and behavioral abnormalities, along with learning disabilities.
Repeated exposure to noxious stimuli. This can cause physiologic and behavioral
disorganization, leading to changes in the neurodevelopmental system of the infant. This
6
may cause the infant to develop an inability to respond to pain or an exaggerated
physiologic response to painful stimuli in the future.
7 Gomella 8Ed
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Victoria, N. C., & Murphy, A. Z. (2016). Exposure to Early Life Pain: Long Term Consequences and Contributing Mechanisms. Current opinion
in behavioral sciences, 7, 61–68. https://doi.org/10.1016/j.cobeha.2015.11.015
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CONSEQUENCES OF PAIN & STRESS IN NEONATES

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PAIN ASSESSMENT
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PAIN ASSESSMENT
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NURSING DIAGNOSIS: NANDA

• NANDA 2020
• SDKI
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STANDAR DIAGNOSIS KEPERAWATAN INDONESIA

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Pain Management
and Intervention
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MANAGEMENT AND INTERVENTION: NONPHARMACOLOGY

1 Kangaroo Care Or Skin To-skin Care 5 Facilitated Tuck Position

2 Breast Feeding And Breast Milk 6 Music/Voice

3 Nonnutritive Suck (NNS) 7 Massage

4 Swaddling
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KANGAROO CARE OR SKIN-TO-SKIN CARE

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BREAST FEEDING AND BREAST MILK

Nurses Times

Nurture Heal Grow

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NON-NUTRITIVE SUCKING (NNS)

AND SWADDLING
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FACILITATED TUCK
POSITION
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MUSIC/VOICE
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MANAGEMENT AND INTERVENTION:

PHARMACOLOGY
NON-MEDICATION
Sucrose 12% - 50% (Gomella, Giuseppe)
• 0.012 to 0.12 g or 0.05 to 0.5 mL of a 24% solution.
• Recommended dosage is 0.1 to 1 mL (0.2 to 0.5 mL/kg) of
24% sucrose 2 minutes before the procedure.
• It lasts approximately 4 minutes

Glucose (Gomella)
20% to 30% glucose solutions. No recommendation for dose or timing of administration.
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MANAGEMENT AND INTERVENTION:

PHARMACOLOGY
MEDICATION
• Topical anesthetic agent: EMLA (eutectic mixture of 2.5% lidocaine and 2.5% prilocaine) cream (most
commonly used and studied), 4% tetracaine gel, 4% liposomal lidocaine (shorter onset of action), and
S-Caine Peel (7% lidocaine and 7% tetracaine cream)
• Subcutaneous infiltration with lidocaine (0.5–1% lidocaine).
• Opioids: Morphine, Fentanyl, Alfentanil, Sufentanil, and Remifentanil
• Acetaminophen: Ofirmev
• NSAIDs: The use of NSAIDs for pain control in newborns has not been recommended because of too
many side effects (pulmonary hypertension and renal insufficiency and platelet dysfunction)
• Sedation: Benzodiazepines (Midazolam), Lorazepam
• Sedation: Chloral hydrate: short-term sedation, such as for CT and MRI
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PROCEDURAL PAIN
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PROCEDURAL PAIN
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TERIMA
KASIH
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REFERENCES
• Victoria, N. C., & Murphy, A. Z. (2016). Exposure to Early Life Pain: Long Term Consequences and Contributing Mechanisms. Current opinion in behavioral sciences, 7, 61–
68. https://doi.org/10.1016/j.cobeha.2015.11.015
• Taplak AŞ, Bayat M. Comparison the Effect of Breast Milk Smell, White Noise and Facilitated Tucking Applied to Turkish Preterm Infants During Endotracheal Suctioning on Pain and
Physiological Parameters. J Pediatr Nurs. 2021 Jan-Feb;56:e19-e26. doi: 10.1016/j.pedn.2020.07.001. Epub 2020 Jul 18. PMID: 32690406.
• Kyololo OM, Stevens BJ, Songok J. Procedural Pain in Hospitalized Neonates in Kenya. J Pediatr Nurs. 2021 May-Jun;58:15-20. doi: 10.1016/j.pedn.2020.11.007. Epub 2020 Dec 3. PMID:
33279820.
• Baarslag MA, Jhingoer S, Ista E, Allegaert K, Tibboel D, van Dijk M. How often do we perform painful and stressful procedures in the paediatric intensive care unit? A prospective
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• Boggini T, Pozzoli S, Schiavolin P, Erario R, Mosca F, Brambilla P, Fumagalli M. Cumulative procedural pain and brain development in very preterm infants: A systematic review of clinical and
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• Brummelte S, Chau CM, Cepeda IL, Degenhardt A, Weinberg J, Synnes AR, Grunau RE. Cortisol levels in former preterm children at school age are predicted by neonatal procedural pain-
related stress. Psychoneuroendocrinology. 2015 Jan;51:151-63. doi: 10.1016/j.psyneuen.2014.09.018. Epub 2014 Sep 28. PMID: 25313535; PMCID: PMC4268136.
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• Mojtaba, V., Sarhangi, F., Azarmnejad, E., Javadi, M., Tadrisi, S. D., Rejeh, N., & Vaismoradi, M. (2021). The effect of the mother's heartbeat sound on physiological parameters and pain
intensity after blood sampling in neonates in the intensive care unit: A randomized controlled clinical trial. Journal of Neonatal Nursing, 27(2), pp. 123-128. doi:10.1016/j.jnn.2020.07.006
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physiological function in preterm infants receiving minor invasive procedures. Journal of Neonatal Nursing, 24(6), 318-324. https://doi.org/10.1016/j.jnn.2018.08.001
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