Study reveals pain management challenges in premature babies

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A new study examining pain management in premature infants in Sweden has revealed critical insights into the experiences of newborns in neonatal intensive care units. Conducted over 4.5 years, the research analyzed the prevalence, causes, and treatments of pain in 3,686 infants born between 22 and 31 weeks of gestation. Data were collected from the Swedish Neonatal Quality Register, with observations spanning over 185,000 days of care.¹

The findings highlight that the youngest and most fragile infants, those born at 22 to 23 weeks of gestation, endure the highest number of painful medical conditions and daily intensive care procedures during their first month of life. These procedures often include ventilator treatments, tube feeding, blood vessel catheter insertions, and surgeries.¹

“There is a strong correlation between acute morbidity and being born very early. The earlier a baby is born, the more intensive care it needs. Intensive care involves procedures that can be painful, such as ventilator treatment, tube feeding, insertion of catheters into blood vessels, and surgical procedures. It also requires various tests and investigations that may involve pain,” said Mikael Norman, professor of paediatrics at Karolinska Institutet and lead researcher of the study.¹

The study revealed that 11.6% of the infants experienced painful conditions, while 84.1% were exposed to at least 1 potentially painful procedure. Despite this, only 74.6% of the infants had reported pain, indicating possible underreporting or challenges in pain recognition. Infants born at less than 28 weeks’ gestational age faced the highest rates of exposure to painful procedures, with 80% to 98% undergoing such procedures within the first 28 days after birth. However, these infants often displayed fewer visible signs of pain, making assessment more difficult.²

The study found that 90% of the most premature infants underwent painful procedures. However, health care professionals reported pain in only 45% of these cases. Norman suggested that while pain prevention or treatment may explain this disparity, there could be other factors involved.¹

“Somewhat surprisingly, the smallest babies who were most exposed to pain had the lowest proportion of treatment with morphine. This may be a case of undertreatment,” he said.¹

Morphine use is carefully balanced in neonatal care due to its potential side effects, such as lowering blood pressure. This caution may have contributed to its limited use, despite the high exposure to painful procedures in these infants.²

Pain scales were employed in 75% of cases to assess pain, with tools like the Astrid Lindgren and Lund Children's Hospital Pain Scale (ALPS-Neo) being commonly used. Pharmacological pain treatments were administered to 81.7% of infants, with the majority receiving topical or oral medications. However, the study noted that intravenous pain treatments were more frequently used in older and less premature infants.²

One limitation of the study was its inability to measure the severity or duration of pain, as caregivers answered only “yes” or “no” to whether an infant experienced pain in the preceding 24 hours.²

“This could range from short-term, so-called procedural pain from, for example, a needle prick during a test to more continuous pain due to various medical conditions,” explained Norman.¹

He emphasized that while severe pain is not left untreated, there are challenges in identifying pain in premature infants. “This involves developing better rating scales or physiological techniques to measure pain. Better pain treatments are also needed, perhaps with combinations of drugs with less risk of side effects,” he added.¹

Norman underscored the importance of improving pain management, noting that pain can negatively impact brain development in premature infants.¹

“The vision for all neonatal care is to be pain-free. The results of this survey will be of great importance for improving neonatal care and for future research in the field,” he concluded.¹

References:

1. Karolinska Institutet. Preterm babies receive insufficient pain management. Eurekalert. January 27, 2025. Accessed January 27, 2025. https://www.eurekalert.org/news-releases/1071622

2. Graham H, Razaz N, Håkansson S, Blomqvist YT, Johansson KD, Persson M, Nyholm A, Norman MG. Pain in very preterm infants—prevalence, causes, assessment, and treatment. A nationwide cohort study. PAIN. January 21, 2025. DOI:10.1097/j.pain.0000000000003528