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39

Analgesia and Sedation

in the Newborn

6

Victoria Tutage Lehr

Mirjana Lulic-Botica

Vadim Bronshtein

Gloria B. Valencia

Jacob V. Aranda

A. Introduction

The American Academy of Pediatrics (AAP) Prevention and

Management of Pain and Stress in the Neonate statement

emphasizes the need for humane treatment of pain in infants

(1). Historically, barriers to adequate pain management in neonates have been related to the question of pain perception in

the newborn (2,3). This question is no longer debated and, in

the past 25 years, great strides have been made in the assessment and management of pain in newborns (4). Procedural

analgesia for neonates is well established (1,5–8). However,

pain management and sedation practices continue to vary

among practitioners (4,9–12). There is an overall paucity of

pharmacokinetic (PK) and pharmacodynamic (PD) data for

many analgesics and sedatives secondary to the varying infant

gestational ages and weights. Studies in critically ill neonates

are complicated by co-morbid conditions, genetic polymorphisms, complex drug regimens, and ethical issues (12–16).

Neonatal pain management requires careful selection and dosing of medications, appropriate assessment and monitoring,

and the ability to promptly recognize and manage adverse

effects. Improvements in neonatal pain management have

been driven by advances in the knowledge of developmental

neurobiology, developmental pharmacokinetics and pharmacodynamics of analgesics; and the development of age-appropriate

tools for pain assessment and of current best evidence in clinical

practice for this vulnerable population (17–20).

This chapter offers general guidelines for the management of analgesia and sedation in newborn infants undergoing procedures that are frequently performed in neonates

who require care in the neonatal intensive care unit (1,5–

8,11). Selection of the optimal sedative for the management

of stress in ventilated infants is less clear and is beyond the

scope of this chapter (21,22).

B. Definitions

1. Analgesia: A condition in which nociceptive stimuli are

perceived but not interpreted as pain; usually accompanied by sedation without loss of consciousness (23).

2. Conscious sedation: A medically controlled state of

depressed consciousness that allows protective reflexes

to be maintained, retains the ability to maintain a patent airway independently and continuously, and permits appropriate responses by the patient (1).

3. Deep sedation: A medically controlled state of

depressed consciousness or unconsciousness from

which the patient is not easily aroused. It may be

accompanied by a partial or complete loss of protective

reflexes and includes the inability to maintain a patent

airway independently and respond purposefully to

stimulation (1)

4. Tolerance: The ability to resist the action of a drug or

the requirement for increasing doses of a drug, with

time, to achieve a desired effect (23,24)

5. Withdrawal: The development of a substance-specific

syndrome that follows the cessation of, or reduction in,

intake of a psychoactive substance previously used or

administered regularly (23)

6. Neonatal abstinence syndrome: Onset of withdrawal

symptoms in neonates upon cessation of an agent associated with physical dependence (23,24)

C. General Indications

1. Any condition or procedure known to be painful

(1,11,17) (see E)

2. Physiologic indications consistent with perception of

pain (8,18–20)