Repeated pain in newborn babies can be under-diagnosed and thus under-treated, risking long-term cognitive and other complications, say Swedish experts after a recent nation-wide study.
The research, published in the journal PAIN, sheds light on the prevalence, causes and treatment of pain in these vulnerable infants. Using over four years of detailed data, the researchers highlighted gaps in care and suggested paths to better pain management.
Each year, millions of preterm infants face unique challenges due to their early arrival. Among the most concerning is their vulnerability to pain, as their immature nervous systems amplify the risks associated with medical procedures.
Research shows that repeated pain exposure during critical developmental stages can disrupt brain development, potentially leading to long-term cognitive, psychological, and physical difficulties.
Current neonatal care focuses on reducing these risks, but assessing pain in preterm infants is particularly challenging. Their subtle pain responses can be difficult to interpret, often leading to under-diagnosis.
However, existing research on pain in newborns focuses predominantly on isolated procedures rather than providing a broader understanding of pain prevalence and treatment. Moreover, extremely preterm infants remain underrepresented in such studies. A better understanding of pain in infants is important for refining neonatal care and minimising adverse outcomes for this vulnerable population.
The current study
To address this knowledge gap, this Swedish cohort study, led by the Karolinska Institutet, analysed pain prevalence, causes, assessment, and treatment in very preterm infants born between 22 and 31 weeks of gestation.
Their research utilised data from the Swedish Neonatal Quality Register, which encompassed 3 686 infants discharged from hospitals between January 2020 and June 2024, covering a total of 185 000 days of neonatal care.
They focused on multiple dimensions of neonatal pain, including exposure to painful conditions and procedures, use of pain assessment tools, and pharmacological interventions. Pain assessment was documented daily by neonatal care staff based on observable behaviour and medical procedures.
The study analysed potentially painful procedures like respiratory support, ventilator treatment, tracheal intubation, surgical interventions, and skin punctures. Additionally, data on gestational age and postnatal age were used to identify trends in pain prevalence and management strategies.
Infants were categorised into two-week gestational intervals to assess differences in pain experiences and treatment approaches.
Furthermore, the researchers examined the prevalence of pharmacological treatments, including topical, oral, intramuscular, and intravenous methods, and their association with gestational age.
The study aimed to visualise patterns of neonatal pain and identify gaps in clinical practices to improve outcomes. However, it did not determine the duration or severity of pain for each day reported, as caregivers only answered whether an infant had experienced pain within the past 24 hours.
Key findings
The research confirmed that preterm infants frequently experience pain. The study found that 90% of extremely preterm infants (born at 22–23 weeks) underwent painful procedures, with many requiring nearly daily painful interventions during the first month of life.
However, pain documentation was significantly lower, with only 45% of these infants reported to have experienced pain – suggesting challenges in recognising and recording pain in neonatal care.
The researchers also observed that the smallest infants, despite undergoing the most painful procedures, had the lowest proportion of morphine treatment, raising concerns about possible under-treatment.
While healthcare professionals aim to minimise pain, the study findings suggest that current pain relief strategies may not be fully effective for the most vulnerable infants.
Pain assessment remains inconsistent. The study found that caregivers recorded pain assessments daily, but the specific scales used and their effectiveness in evaluating neonatal pain require improvement. The authors say there is a need for better rating scales and physiological techniques to ensure pain is recognised and treated appropriately.
Additionally, the findings revealed regional and temporal variations in pain management, with larger healthcare regions reporting higher pain prevalence and treatment rates.
The study emphasised the importance of tailored, gestational age-specific strategies to ensure effective pain management in preterm infants and mitigate the risks of long-term developmental impacts.
Conclusions
Overall, the study highlighted the widespread pain experienced by very preterm infants and the inconsistencies in pain assessment and treatment. Despite advancements in neonatal care, gaps remain in recognising and managing pain effectively.
The findings call for standardised, gestational age-specific protocols to improve pain management and ultimately reduce the developmental and long-term health risks associated with untreated neonatal pain.
Study details
Pain in very preterm infants – prevalence, causes, assessment, and treatment. A nationwide cohort study
Graham, Hillarya; Razaz, Nedaa; Håkansson, Stella et al.
Published in Pain on 21 January 2025
Abstract
Studies on pain in preterm infants have usually been confined to observations of painful procedures, and information from extremely preterm infants is limited. Using registry data from a Swedish nationwide cohort, this study explored the epidemiology of pain in very preterm infants, its causes, assessments, and treatment strategies. We included liveborn infants <32 weeks' gestational age (GA) discharged between January 2020 and June 2024. Proportions of infants exposed to potentially painful procedures, experiencing pain, assessed with pain scales, and receiving pharmacological treatment were calculated by each postnatal day. Among 3686 infants (mean birthweight 1176 g, GA 28.2 weeks), 11.6% had a painful condition and 84.1% were exposed to at least 1 potentially painful procedure. In total, 74.6% experienced pain, corresponding to 28,137/185,008 (15.2%) days of neonatal care. For every 2-week increase in GA, significantly lower proportions of infants experienced pain. In infants <28 weeks of GA, proportions with reported pain were approximately half the rate of painful procedures, while in infants born at 28 to 31 weeks, reported pain closely matched exposure to painful procedures. Pain scales were used in 75.0% of the infants. Pharmacological pain treatment was administered to 81.7% of infants, primarily topically or orally. Among infants with pain, proportions treated intravenously were larger at higher GAs. Despite effective analgesia/anaesthesia, many very preterm infants experience pain. Visualising pain epidemiology, procedures, conditions, and treatment by postnatal and gestational age may guide clinical management and generate research hypotheses to reduce short- and long-term adverse effects.
See more from MedicalBrief archives:
Supportive touch and less painful procedures help prem babies
Premature babies’ death rates slashed by skin-to-skin contact – US analysis