Stories of Children′s Pain

Linking Evidence to Practice

Bernie Carter, Joan Simons

• Publisher: SAGE Publications Ltd
• Year: 2014
• ISBN:
  9781473905054
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Working with a child in pain is difficult, unavoidable and especially challenging when the child cannot explain what they are feeling. In this important book, Bernie Carter and Joan Simons bring together experience, evidence and research to deconstruct the topic and present the reality of children?s pain.

Each chapter starts with a personal story from a child, a family member or a healthcare professional. The stories are drawn from a wealth of original research, and focus the reader on the individual child and their family. The chapter then goes on to introduce the relevant research, theory and implications for practice, so health professionals can use the evidence to support compassionate, child-centred care.

Among the topics addressed are:

- Ethical dilemmas

- Assessing pain

- Working in different settings

- Inexplicable pain

It is valuable reading for any healthcare student or professional working with children of all ages.

Chapter 1

Managing Neonatal Pain

Lucas’s and Lily’s Stories

Lucas’s story

I think one of the most difficult aspects of being a neonatal nurse is anticipating the behavioural cues of neonates to ensure that their needs are met. When babies are very immature it is difficult to interpret their cues and easy to forget that although the baby may not cry or show obvious signs of pain that they are still feeling pain from procedures we undertake. At our NHS Trust we have a Guideline for the Assessment and Management of Pain and Sedation in Neonates which acts as a clear reminder to us all about the importance of ensuring good pain relief prior to undertaking invasive procedures. For a baby requiring intensive care, assessment of pain should be undertaken hourly, however in critical situations I’m not always sure we remember as well as we should.

The little boy I was caring for, called Lucas, was ventilated on synchronised intermittent mandatory ventilation with pressures of 18/4 and a rate of 60bpm. He had a morphine infusion running at 20mcgs/kg/hour. Lucas started becoming agitated and there had been a slight drop in his oxygen saturations. I could also see some secretions in his ET tube so decided to undertake ET suction to clear the tube. This can be an uncomfortable procedure. As Lucas was already on a morphine infusion I asked his mother to utilise the ‘containment technique’ while I undertook the suction. His mum placed her hands gently but continuously over Lucas’s head and legs to comfort him while I undertook the procedure. Containment has been shown to speed recovery from procedures with babies demonstrating less oxygen desaturations, lower heart rates and less behavioural cues demonstrating pain. I quickly undertook the suction and he recovered quickly. By undertaking containment his mum was able to undertake a vital care role for him and his stress and pain levels during the procedure were reduced.

Lily’s story

This story involves the management of neonatal pain during the insertion of a chest drain by an Advanced Neonatal Nurse Practitioner (ANNP). The little girl called Lily was born at 24 weeks gestation and was 48 hours old when she developed a pneumothorax and required insertion of a chest drain. This is a very invasive procedure and is known to be very painful. I needed to ensure that Lily was kept as pain-free as possible during the procedure, and I didn’t want to cause any undue stress that could impact on her condition further.

The Trust Guideline for the Assessment and Management of Pain and Sedation in Neonates asks us to consider if the procedure definitely needs to happen, could the procedure wait until later, or could a less painful procedure be used. Due to the emergency nature of her condition the answer to all of these (except the first one) was no and it was essential that the chest drain was inserted straight away. The little girl was already receiving a morphine infusion as she was being ventilated. I discussed with the consultant neonatologist if Lily also required some local lignocaine around the insertion site or if a bolus of morphine to sedate Lily further would be more appropriate. We decided not to use the local lignocaine as the type of chest drains we use involve the insertion of a single needle as would an injection of lignocaine. So as she was ventilated I prescribed and gave a bolus of 100mcgs/kgs of morphine in addition to her maintenance morphine to increase her pain relief. I asked the staff nurse caring for her to perform containment to try to reduce her stress further using non-pharmacological methods. The insertion was undertaken as quickly as possible. As she was so premature it was very difficult to interpret her stress cues but I hope that Lily had adequate relief by using both pharmacological and non-pharmacological methods.

Introduction

Both Lucas’s and Lily’s pain stories clearly demonstrate the daily challenge of meeting the needs of premature babies requiring intensive care. The nurses telling these stories demonstrated concern in minimising the level of pain experienced by the babies while they carried out essential procedures, not knowing if these vulnerable infants were actually experiencing pain or not. These stories articulate some of the complexities involved in managing neonatal pain.

This chapter will first explore the historical perspective that still influences the management of neonatal pain. This will be followed by an exploration of the amount of pain typically encountered by babies in neonatal intensive care units (NICUs) and the need for proactive pain management by nurses. A number of pain tools which have been designed for assessment of neonatal pain will be considered while acknowledging the challenges in identifying or recognising pain in very premature babies. Many essential painful procedures are undertaken with neonates, and require nurses to act to minimise their negative impact. Non-pharmacological methods of pain relief as outlined in the two stories will be explored as well as the part parents can play in helping to manage their babies’ pain, followed by a focus on what pain management guidelines are available to assist nurses and parents in this particularly challenging area of pain management.

Neonatal pain in context

Babies often experience high levels of pain in NICU. One study suggests that premature babies experience 100–150 painful procedures in the first week of life (Herrington 2007). Most of these procedures are considered to be minor, such as a heel prick, the insertion of an intravenous cannula or suctioning. However, cumulatively these minor painful procedures make up the largest part of painful exposure for premature babies. Stevens et al. (2003) reported that neonates underwent more than 10 painful procedures a day, with those at highest risk receiving more painful procedures and being administered the least amount of analgesia during the first days of life. This is exemplified in Lily’s story, where a very premature baby, two days old, required a painful life-saving procedure.

Every year in England and Wales one in eight babies is born prematurely. In the United States the incidence is also one in eight or 540,000 babies annually (March of Dimes 2011). It is known that the rate of premature births is rising (WHO 2012) and with improved technology and advances in neonatology very premature babies are surviving. These very premature babies require intensive care involving both very close monitoring and repeated procedural interventions which are essential for their survival. However, these repeated unavoidable painful procedures produce significant painful cortical responses (Slater et al. 2006), and pose a real challenge for neonatal nurses to recognise and respond to effectively. At the end of Lily’s story the nurse expresses her concern for Lily and hopes she had adequate pain relief, suggesting that managing pain well in neonates is a real challenge for nurses, and may cause them anxiety and stress. However, the nature of their treatment means painful procedures are unavoidable.

Anand (2001), recognised as a pioneer in the research of infant pain, suggests that premature infants have the necessary neurotransmitters to transmit pain, but are poorly equipped physiologically to inhibit pain, leaving them hypersensitive to acute pain. This hypersensitivity to pain can lead, over time, to a lowering of their pain threshold and result in preterm babies interpreting ordinary non-painful stimulus, such as holding, as painful. The consequences also endure over time as demonstrated by a classic study conducted by Grunau et al. (1994) who compared the pain perceptions of two groups of toddlers: one group had extremely low birthweights and had experienced repeated painful procedures as neonates; the second group had received minimal painful procedures. At three years and four-and-a-half years the children in the extremely low birthweight group had significantly higher scores for pain hypersensitivity than the children in the full-term group.

The effect of the cumulative pain experience in NICU

There is something quite unique in relation to the topic of pain in neonates. This group of babies are incredibly vulnerable to the experience of pain due to their immaturity and yet it is their very immaturity that demands the need for intensive care for their survival. However, intensive care of this nature includes life-saving procedures that are often very painful, a good example of which is Lily’s story of needing a chest drain. It is necessary to consider the consequences of this high incidence of pain on this vulnerable group.

The newborn period is a time of rapid brain development and therefore makes premature babies very vulnerable (Kostovic and Judas 2010). Despite this recognition however, it is not yet fully understood what effect early pain-related stress has on the newborn neurologically. Brummelte et al. (2012), in the only study of its kind to date, conducted brain scans on 86 babies born very prematurely (24–32 weeks), collecting detailed information on the number of painful procedures between scans. The results demonstrated effects on subcortical structures in the brain, suggesting that repeated early procedural pain may be linked with impaired brain development.

The time a premature baby spends in a Neonatal Intensive Care Unit (NICU) is critical for their overall growth and neurodevelopment. Therefore procedures carried out during this period may effect the neurological development of their early life (Fabrizi and Slater 2012).

Bouza (2009) suggests that preterm neonates are more vulnerable to stress and painful procedures and have heightened responses to successive stimuli. There is a need therefore for therapeutic interventions to provide comfort and analgesia for preterm babies. Bauer et al. (2004) studied the stress demonstrated by neonates in response to the experience of pain. They found an increase in oxygen consumption, energy expenditure and heart rate. Slater et al. (2012) found a significant relationship between procedural pain and oxidative stress in preterm neonates. It is clear that stress and increased energy expenditure are likely to have a negative impact on the babies’ resources for cognitive and physiological development and maturity, with the result that the length of time in hospital in likely to be increased.

Longer-term consequences of pain have also been explored: Walker et al. (2009) performed quantitative sensory testing in 43 babies born extremely prematurely (recruited from the EPICure study, babies born at less than 26 weeks gestation in 1995) and found a generalised decreased sensitivity to all thermal modalities. They concluded that changes in neurological functioning can be detected many years after an extreme preterm birth. In Lucas’s story the nurse described containment for a heel prick procedure. This is an example of a pain-minimising intervention for one of the most common painful procedures carried out in NICU.

Having considered the amount of pain neonates experience in NICU and the likely impact of that pain, there is a real need for pain to be effectively managed. This will be explored in the next section.

Management of neonatal pain

Neonatal pain is often poorly managed and many painful procedures are carried out without any effort to relieve pain. A survey of neonatal pain management across the UK (Robins 2007) found varying standards of pain management of neonates. More than half of neonatal units did not have a protocol for pain relief, less than half administered analgesia before chest drain insertion and 75–80 per cent did not give analgesia before cannulation, heel pricks or venepuncture, despite evidence of simple effective measures such as the use of sucrose for pain relief for simple procedures (Kassab et al. 2012). The picture is one of a lack of priority given to dealing with or anticipating pain in many NICUs across the UK. A previous study by Rennix et al. (2004) found a similar picture with only 10 per cent of units giving analgesia prior to heel sticks. In Lily’s story the nurse recognises the potential for Lily to experience considerable pain. In response to this she considers a local anaesthetic but realises that providing this would mean two painful procedures for the baby rather than one. She therefore opts for a bolus dose of morphine to provide sedation during the painful procedure. This story demonstrates the sort of dilemma neonatal nurses are often faced with, and the need to be well informed in making strategic decisions about what route to take in dealing with neonatal pain.

A study in Norway (Andersen et al. 2007) involving 90 clinical staff in two NICUs found that although the majority rated most of the listed procedures as moderately painful for neonates, analgesics were rarely used. This finding led the authors to conclude that neonatal pain is not sufficiently managed and analgesics as well as comfort measures are under-utilised.

It is worth considering here what the literature has to offer in relation to what influences nurses’ pain management which may provide insight into why neonatal pain appears to be poorly managed. Nimbalkar et al. (2012), who surveyed nurses in relation to their knowledge of neonatal pain across a paediatric department, found that nurses’ lack of knowledge and their attitudes were hindering pain management. Nurses identified doctors not prescribing analgesics as a barrier to managing neonatal pain. These findings are supported by a study by Latimer et al. (2009) who found that the management of procedural pain for neonates was more likely to be evidence-based when there was higher nurse–doctor collaboration. Other positive influences were identified as caring for higher-intensity infants and where nurses had unexpected increases in work assignments. These findings could suggest that nurses who care for high-intensity infants were more likely to have a neonatal nursing qualification which gave them more confidence and therefore the ability to develop good working relationships with doctors as well as cope with the unpredictability in their role, such as unexpected increases in work assignments.

Despite the wider picture from the literature being quite negative both Lucas’s and Lily’s storie...

Table of contents

• Cover Page
• Halftitle
• Sage
• Title
• Copyright
• Contents
• List of Figures and Tables
• About the Authors
• Acknowledgements
• Publisher’s Acknowledgements
• Introduction: In the Beginning …
• 1 Managing Neonatal Pain
• 2 Pain Management: Advice on Discharge
• 3 Managing Procedural Pain
• 4 Pain in Sickle Cell Disease
• 5 Parents Managing their Children’s Pain
• 6 Existential Pain and the Importance of Place and Presence
• 7 Managing Pain in a PICU
• 8 Assessing and Managing Pain in a Child who is Cognitively Impaired
• 9 Fear, Pain and Illness
• 10 Acute Pain Developing into Chronic Pain
• 11 Language, Metaphor, Imagery and the Expression of Pain
• 12 Minor Injury, Acute Pain, Wounds and What Really Hurts
• 13 Non-pharmacological Methods of Pain Relief
• 14 Neuropathic Pain
• 15 Organisational Imperatives and Individual Responsibility to Avoid Poor Pain Management
• Conclusion: An Ending as Well as Potential New Beginnings
• Index