Preterm babies receive insufficient pain management

Every day for 4.5 years, neonatal care staff have recorded the occurrence of pain, the causes of pain, and how pain is assessed and treated in premature babies in Sweden. The study covers 3,686 babies born between 22 and 31 weeks of gestation from 2020 to 2024. The total observation time was just over 185,000 days of care. Data were collected in the Swedish Neonatal Quality Register.

In the evaluation of the register data, the researchers found that babies born extremely early, in weeks 22 to 23, had the highest proportion of painful medical conditions and almost daily painful intensive care procedures throughout the first month after birth. However, this is not surprising.

“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,” says Mikael Norman, professor of paediatrics at the Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and lead researcher of the study.

90 percent of the most extremely preterm infants had to undergo painful procedures. Despite this, healthcare professionals reported that only 45 percent of babies experienced pain - which may be because pain was largely prevented or treated. However, a check of the  drugs administered suggests other explanations may exist.

“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,” says Mikael Norman.

One limitation is that the study could not determine the duration or severity of pain for each day reported.

“The caregivers only answered yes or no to the question of whether the infant had experienced any pain in the last 24 hours. 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.

“Much is done to alleviate pain in babies. No child in neonatal care is left with severe pain untreated,” he continues.

However, it is a problem and a challenge that healthcare professionals are not always able to determine whether children are in pain.

“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,” says Dr Norman.

It is very important to improve pain management for premature babies, as we now know that their development is negatively affected by the strong signals in the brain that pain causes.

“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,” concludes Mikael Norman.

The research was mainly funded by Region Stockholm, the Childhood Foundation of the Swedish Freemasons in Stockholm, and the Swedish Research Council.

Publication

“Pain in very preterm infants – prevalence, causes, assessment and treatment. A nationwide cohort study”Graham H, Razaz N, Håkansson S, Thernström Blomqvist Y, Johansson K, Persson M, Nyholm A, Norman M, Pain, online 27 January, 2025, doi: 10.1097/j.pain.0000000000003528

Facts:

Pain in newborns is not self-reported as in older children and adults. To objectively assess the presence of pain in newborns, healthcare professionals use different pain scales instead. The scales are based on recording the baby's breathing, facial expressions, movements, and comfortability. However, very premature babies show less evidence of pain than babies born at term, such as only frowning or moving less.

In morphine treatment, there is a fine line between pain relief and a drop in blood pressure, which is a side effect. Very premature babies already have very low blood pressure and crossing this line can lead to circulatory collapse, which can be very serious. This is probably one reason why the very young babies were given less morphine than perhaps they should have been given, given the high proportion in pain.

Source: Mikael Norman.