Transcript Developmental Support - Mother Baby University

Developmental
Support
Denice Gardner, MSN, NNP-BC
Objectives
• Discuss developmental support and its
effect of the newborn
CNS Development
• Six Stages
– Stages 1-3(completed before 4th month
of gestation)
• Dorsal Induction
• Ventral Induction
• Neurogenesis
– Stages 4-6(continues during the time
the infant is in the NICU)
• Neuron migration
• Organization, including synaptogenesis
& arborization
• myelinization
CNS Development
• Neuronal & glial cells originate in the
germinal matrix
• Neuronal & glial cells migrate from
germinal matrix to their eventual location
within the CNS where they differentiate
& take on their unique functions
• Neurons formed early in life lie deeper in
cortex & neurons formed later lie in more
superficial layers
• Cortex generally has complete component
of neurons by 33 weeks gestation
CNS Development
• Organization- “the process by which the
nervous system takes on the capacity to
operate as an integrated whole”
(Blackburn, 2003)
– begins during the 6th month of gestation
and continues years after birth
• Neuron growth & connections lead to
development of brain gyri & sulci
• Organization of the CNS is critical for
cortical & cognitive development
– These processes may be particularly
vulnerable to insults from the effects
of the NICU environment.
CNS Development
• Arborization- “wiring of the brain”
– Dendritic connections between neurons
critical for processing impulses, cell-tocell communication, and communication
throughout the CNS
– Lack of connections cause
hypersensitivity, poorly modulated
behaviors, & all-or-nothing responses,
frequently seen in preterm infants in
the NICU
CNS Development
• Synaptogenesis- formation of
connection between neurons &
development of intracellular structures
& enzymes for neurotransmitter
production
– Critical for integration across all
areas of the nervous system
– Synapses continue to restructure
throughout development & is thought
to be the basis for memory & learning
CNS Development
• Organizational processes & modification
of neurons continue throughout
adulthood but are particularly
vulnerable during infancy.
• The ability of a neuron to change
structure & function has been called
plasticity. (Huttenlocher, 2003)
• The more immature the infant at birth
the greater the impact of neural
plasticity.
CNS Development
• Neuronal differentiation & organization
are controlled by the interaction of
genes & environment.
• The environment of the immature
infant in the NICU & in the early
months after discharge is critical for
brain development and later cognitive
function. (Lickliter,200a. 200b; Sizun &
Westrup, 2004)
CNS Development
• Plasticity: 2 types
– Experience-expectant: linked to brain’s
developmental timetable so specific
sensory experiences are needed at
specific times for neural development &
maturation
– Experience-dependent: involves
interaction with the environment to
develop specific skills for later use;
involves memory & learning; allows
development of flexibility, adaptation, &
individual differences in social &
intellectual development
Neurobehavioral Development
• Self-regulation: infant’s efforts to
achieve, maintain, or regain a balanced,
stable, & relaxed state of subsystem
functioning & integration.
– Maintaining normal body temp
– Regulating day-night cycles
– Learning to calm oneself & relaxing
after care
– Later in life, controlling one’s own
emotions & managing to keep one’s
attention focused
Neurobehavioral Development
• Synactive Theory of Development
(Als and colleagues)
– Autonomic/physiologic
– Motor
– State/organizational
– Attentional/interactive: involves
infant’s ability to orient & focus on
sensory stimuli (faces, sounds, objects;
i.e., external environment)
– Self-regulatory
Neurobehavioral Development
• Signs of Stability
– Autonomic system
• Even, regular respirations
• Pink, stable color
• Stable viscera with no seizures,
gagging, emesis, grunting, tremors,
startles, twitches, coughing,
sneezing, yawning, sighing
Neurobehavioral Development
– Motor system
• Smooth, controlled posture
• Smooth movement of extremities &
head
– Hand clasp
– Leg/foot brace
– Finger folding
– Hand to mouth
– Grasping
– Sucking
– Tucking
– Hand holding
• Good, consistent tone throughout
body
Neurobehavioral Development
• Signs of Stability
– State system
• Clear, well-defined sleep states
• Self-quieting consolability
• Focused, clear alertness with
animated expressions
Neurobehavioral Development
– Attentional Interaction System
• Responsivity to auditory & visual
stimuli that is bright & long in
duration
• Actively seeks out sounds and shifts
attention smoothly on his/her own
from one stimulus to another
• Face: bright-eyed, purposeful
interest varying between interest
and relaxation
– Self-regulatory System
• Able to maintain each systemautonomic, motor, state, attention
Neurobehavioral Development
• Signs of Stress
– Autonomic System
• Respirations: pauses, tachypnea,
gasping
• Color changes: paling around nostrils,
perioral cyanosis, mottling, cyanosis,
gray, flushed, ruddy
• Viscera: hiccups, gagging, grunting,
spitting, straining
• Motor: tremor/startles, twitching,
coughing, sneezing, yawning, sighing
Neurobehavioral Development
• Signs of Stress
– Motor System
• Fluctuating tone
• Flaccidity
• Hypertonicity: leg extensions, salutes,
airplaning, arching, finger splays,
tongue extensions, fisting
• Hyperflexions: trunk; extremities;
fetal tuck; frantic, diffuse activity
Neurobehavioral Development
• State System
– Diffuse states
– Sleep: twitches, sounds, jerky
movements, irregular respirations,
grimacing, fussing while sleeping
– Awake: eye floating, glassy eyed, gaze
aversion, staring, worried look,
irritability
Neurobehavioral Development
• Signs of Stress
– Attentional Interaction System
• Stress signals from other systems:
irregular respirations, yawning, gaze
aversion, hiccupping, etc..
• Becomes more stressed with more
than one mode of stimuli
– Self-Regulatory System
• May use the following to gain balance
– Lower state
– Postural changes
– Motor strategies: leg/foot bracing,
hand to mouth, sucking, etc.
– Self-quieting & consoling
Neurobehavioral Development
• Stress Reducing Strategies
– Autonomic System
• Modify environment (light, noise,
traffic)
• Positioning
• Minimal stimulation
• Swaddling
– Motor System
• Positioning
• Handling to contain limbs
• Slow, gentle handling
• Boundary rolls
• Containment/nesting
Neurobehavioral Development
• Stress Reducing Strategies
– State System
• Cluster care
• Primary nursing for better
assessment of infant cues
• Appropriate timing of activities &
daily routines
• Autonomic & motor subsystems must
have reached stability
Neurodevelopmental Development
• Stress Reducing Strategies
– Attentional Interaction System
• Adjust interactions to infant’s
tolerance level
• Provide supports necessary to bring
out best alertness
• Offer one mode of stimulation at a
time
• Use modulated voice, face, rattle,
together (baby responds best to
animate stimuli)
Sleep-Awake States
• State- level of infant’s consciousness
determined by his level of arousal and
response to stimuli
– Sleep States
• Deep sleep: closed eyes, no eye
movements, regular breathing, no
spontaneous activity
• Light sleep- low levels of activity,
rapid eye movement may be seen,
irregular respiratory movements
Sleep-Awake States
– Transitional States
• Drowsiness- activity level varies,
eyes may open & close & appear dull
& heavy
Sleep-Awake States
Awake States
• Quiet alert- interactive, alert & wideeyed appearance; attention focused
on stimuli, regular respirations,
minimal motor activity
• Active alert- increased motor
activity, heightened sensitivity to
stimuli, periods of fussiness but easily
consoled; eyes open but less bright &
attentive, irregular respirations
• Crying- increased motor activity &
color change, very responsive to
unpleasant stimuli
Organization
• Ability to integrate physiologic &
behavioral systems in response to stimuli
without disruption in the state or
physiologic function
• Maintains stable vital signs, smooth state
transitions, even movements
• Able to console himself
• Ability to maintain organization depends on
maturity level, overall well-being, and
infant’s temperament
Sensory Threshold
• Level of tolerance for stimuli in which
infant can respond appropriately
• When threshold met, becomes
overstimulated and stressed
• Preterm and neurologically impaired
infants have low thresholds
• Watch infant’s cues and respond
appropriately
Habituation
• Ability to alter response to repeated
stimuli
• When stimulus is repeated, the initial
response to it will gradually go away
• Defense mechanism for shutting out
disturbing or overwhelming stimuli
• Assess during light sleep or quiet alert
states
Positioning Malformations
• Muscle fiber development incomplete until
term
• Lower ratio of Type 1 muscle fibers to
Type 2 predisposes preterm infant to
muscle fatigue
• Restricted movement & positioning in the
NICU produce joint compression & poor
refinement of mechanical receptors
predisposing fragile infants to skeletal
deformation, shortening of muscles, &
contractures.
Positioning Malformations
• Common “Acquired Positioning
Malformations”
– Hip abduction & external rotation (frog
leg)
– Shoulder retraction & scapular
adduction (W position of arms)
– Neck extension
– Arching postures
– Abnormal head molding
Positioning Malformations
• Prevention of deformities
– Provide support for breathing &
ventilation
– Promote skin integrity
– Facilitate containment & security
– Facilitate development of flexion in
posture & movement
Positioning Deformities
• Prevention of Deformities
– Provide opportunities for midline skill
development (hand to face/mouth)
– Encourage alignment & symmetry
– Support rest/calming/comfort &
neurobehavioral organization
– Counteract abnormal posturing
– Support tolerated posturing
Positioning Guidelines
•
•
•
•
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Neutral or slightly flexed neck
Gently rounded shoulders
Flexed elbows
Trunk slightly rounded with pelvic tilt
Hips partially flexed & adducted to near
midline (no frog leg or externally rotated
hips flat against bed)
• Lower boundary for foot bracing
Positioning Guidelines
• Bedding & positioning aids should be
individually determined to meet the needs
of the infant
• Calm, organized behavior may be improved
by
– Prone position
– Side-lying position, well-supported with
hands to mid-line
– swaddling
Positioning Guidelines
• Reposition with hands-on care or when
behavioral cues indicate discomfort
• Use appropriately sized-diapers to
preserve normal hip alignment
• Avoid tension from lines or tubing such
as ET tubes, IV lines, og tubes, etc..to
prevent pressure deformities.
Positioning Guidelines
• Use slow, gentle rolling motion with
containment of extremities &
providing a pacifier when
repositioning sick or preterm infants.
• Once repositioned, monitor breathing
pattern, color, O2 Sats, HR,
respiratory rate & pattern,
behavioral cues, & stability of
position.
Positioning Guidelines
• Observe infant’s developmental
capabilities. If infant fighting
containment or boundaries, infant
should be allowed to go without.
Transitioning infants out of boundaries
and positioning aids is required before
discharge.
• Supine positioning should be initiated at
least 2 weeks before discharge.
Positioning Guidelines
• AAP Recommendations
– Supine position is the preferred
sleeping position during infancy
– Avoid use of soft/loose bedding or
objects (pillows, comforters, sheepskin,
stuffed toys)
– Avoid use of waterbeds, sofas, or soft
mattresses as a bed
– Avoid bed sharing or co-sleeping even
with siblings
– Avoid overheating by too many clothes &
overly warm bedroom temperature
Feedings
• Key Concept: recognizing the difference
between a successful feeding (volume &
duration of feeding) & a successful
feeder (infant competence &
enjoyment).
• Within this context lies the difference
between task-oriented or procedural
feedings & a developmental feeding.
Feedings
• Developmental Feeding (Ancona, et
al.,1998) involves 3 concepts:
– Physiologic, motor, & state behavioral
assessment before, during, & after
feeding
– Individualized feeding approach based
on specific infant cues
– Fostering parent competence,
confidence, & enjoyment while feeding
the infant
Feedings
• Transition to oral feedings
– Support sleep/wake behavioral
organization
– Provide proper positioning to promote
neuromuscular control & postural
alignment for suck, swallow, & breathing
(prevent hyperextended neck or trunk &
shoulder retraction)
– Protect against oral aversion
Feedings
• Transition to oral feedings
– Provide pleasurable oral experiences
– Offer opportunities to smell breast milk
or formula
– Offer a pacifier for pleasure & not just
for comfort during care or painful
procedures
Feedings
• Feeding readiness behaviors
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–
–
Medical status
Energy for feeding
Capable of quiet, alert state behavior
Gag response with orogastric tube
insertion
– Rooting & sucking behaviors
– Functional sucking reflex
Feedings
• Nonnutritive Sucking: meta-analysis of
NNS literature which reviewed 13
randomized controlled trials
demonstrated a significant effect on
length of hospital stay.
• Nutritive sucking
– Requires greater coordination of
suck-swallow-breathe sequence
Feedings
• Nutritive Sucking
– To encourage as normal a suck-swallow
pattern as possible while infant
maintains physiologic stability
– very important to hold nipple as still as
possible and allow infant to pace the
feeding.
– Allow rest between suck bursts.
– Manage environmental distractions so
infant can focus on feeding.
Feedings
• Nutritive Sucking
– Monitor infant for fatigue; forced
feeding after an infant is tired can
cause
• Prolonged feeding duration
• Poor weight gain
• Bradycardia
• Incoordination during the feeding
• Aspiration
• Deglutition apnea
• Desaturations
• Oral aversion & defensiveness
Feedings
• Nutritive Sucking
– Intervene with infants who become
fatigued by oral feeding
• Stop oral feeding when infant tired
• Continue feeding by NG or OG tube to
provide adequate intake
• Decrease number of oral feedings per
day or feeding duration for each feed
• If feeding fatigue persists, develop
plan for further evaluation and
change in plan of care
Feedings
• Maturation & Coordination
– Significant correlation between
maturity of the infant’s sucking ability &
post conceptual age.
– Neurobehavioral maturation is a
developmental sequence that supports
feeding progression/abilities.
– Coordination of suck, swallow, &
respiration is seen by 34 weeks PCA.
– Milk flow volume is related to nipple hole
size.
Feedings
• Maturation & Coordination
– Restricted milk flow facilitates oral
feeding in preterm infants allowing rest
between suck & swallow. Rapid flow may
overwhelm preterm infants.
– Changing nipples frequently may affect
feeding organization & adaptation;
identifying an appropriate nipple & using
it regularly as long as an infant is
successfully feeding may be more
supportive
Feedings
• Studies (Arvedson et al, 1994; Comrie &
Helm, 1997) have shown that ~94% of
aspiration in infants and children evaluated
by video fluoroscopy is “silent.”
• Feeding success is directly related to an
infant’s ability to maintain physiologic
stability, a flexed posture, and an alert
state while feeding.
Feedings
• Infants provided 5 minutes of NNS
prior to feeding demonstrate more
alert & quiet awake states during
feeding than those who do not receive
the intervention
• NNS infants also demonstrate higher
O2 saturations before & after feedings.
Feedings
• Ross & Browne (2002) suggest that oral
cheek & jaw support remove the infant’s
own ability to pace the feeding & also
increased milk volume; both experiences
may lead to negative feedback during a
feeding increasing oral aversion &
defensiveness.
Feedings
• Pacing supports feeding success by
allowing breathing breaks to slow sucking
or successive swallowing & allowing
adequate breathing opportunity for
infants who are having difficulty with
stability during a feeding. Pacing is
achieved by tilting the bottle slightly so
that the milk drains out of the nipple &
does not continue to flow. This is
preferred to removing the bottle from the
mouth which may result in difficulty
reestablishing the latch onto the nipple.
Feedings
• Assessment
– Physiologic assessment (HR, respiratory
pattern, color, oxygenation, vigor, stable
digestion)
• Maintenance of physiologic stability
during oral feeding
• Choking or gagging during feeding
• Apnea or bradycardia
• O2 Sats & WOB
• Signs of fatigue
• Weight gain with adequate caloric
intake
Feedings
• Motor assessment
– General tone & posture
– Changes in muscle tone, posture, &
movements with handling
– Maturity of sucking
– Coordination of suck/swallow/breathing
– Control of milk bolus
Feedings
• Assessment
– Behavioral state assessment
• Timing, duration, & quality of arousal
• Sensitivity to environment &/or
stimulation
• Response to touch, handling, &
position changes
• Interest in feeding by facial
expression or stress
Feedings
– Endurance
• Volume taken
• Time frame for feeding
• Vigor during feeding
Feedings
• Assessment
– Evaluation of a successful feeding
• Physiologic & behavioral cost of
feeding is minimal (vital signs
maintained with good oxygenation,
stable/relaxed muscle tone,
predominant state is quiet, alert & is
interested)
• Little or no recovery time for physical
or behavioral return to baseline.
• Energy & vigor maintained during
feeding.
Feedings
• Evaluation of a successful feeding
• Infant participates in feeding with
interest, energy, & enjoyment.
• Adequate intake by mouth &/or
mouth/gavage.
• Adequate weight gains.
• Tolerance of feedings observed by
minimal residuals, soft abdomen,
audible bowel sounds, and regular
elimination.
Feeding Facilitation Techniques
• Provide NNS & milk odors during gavage
feedings.
• Avoid trial po feeds after stressful events
• Allow adequate time for rest after care
and before feeds
• Provide feeds on semi-demand or demand
basis depending on unit practices.
• Choose firmer nipples with slower flow
rather than premie nipple that may result
in rapid milk flow that may overwhelm
infant
Feeding Facilitation Techniques
• Be prepared to focus on infant and the
feeding with ongoing observation and
adaptation.
• Gently arouse infant to alert state; may
use NNS prior to feeding
• Swaddle in gentle flexion with hands
midline toward face
• Support positioning infant with infant
cradled close to body semi-upright or
upright position with neck in neutral to
slightly flexed position
Feeding Facilitation Techniques
• Continually observe physiologic, behavioral,
& oral-motor functioning, careful to
respond appropriately to subtle cues when
needed to modify or terminate feeding
• Provide breathing/rest periods for infants
who need assistance with pacing
• Provide gentle jaw/cheek support
discriminately for problems with latching
onto nipple, weak seal, or loss of milk bolus
Feeding Facilitation Techniques
• Use “developmental burping” on shoulder
with postural support & gentle back
rubbing in an upward motion to stimulate
burp; avoid sitting infant upright &
leaning infant forward or patting the
back because this is an unstable position
with tactile stimulation that is often
disorganizing for the preterm infant.
• Recognize the infant’s limits and when to
stop the feeding (fatigue, aversion, etc.)
Feeding Facilitation Techniques
• Gavage remainder of feeding as needed
based on infant cues
– Reduce energy expenditure
– Promote a positive feeding
experience & minimize feeding
aversion
– Schedule plenty of undisturbed rest
between feedings
Feeding Facilitation Techniques
– Evaluate feeding tolerance (abdominal
exam, stools, emesis, bowel sounds,
residuals, interest in feeding, vigor
during feeding, etc..)
– Document volume, duration of
feeding, feeding behaviors
(autonomic, state, & motor) &
interventions required.
Breastfeeding
• Provide skin-to skin holding or kangaroo
care
• Provide privacy and comfort to mother
& infant
• Provide easy access to pumping
equipment & breast milk storage.
• Provide easy access to lactation
consultants.
Breastfeeding
• Provide training in proper breastfeeding
positions
– Cradle-classic holding position
– Clutch-infant’s body rests across
mother’s chest or is tucked (football
style ) underneath her arm
– Infant position- comfortable alignment,
gentle flexion of extremities, & slight
extension of neck for full jaw excursion;
well supported flexion & containment
Breastfeeding
• Share feeding readiness cues and teach
mother to assess for signs of stability and
stress
• Allow plenty of time for feeding: Avoid
rushing or appearing hurried
• The most common problem with
breastfeeding with preterm infant is
maintaining secure attachment to nipple
and areola so may need to use silicone
nipple shields.
Breastfeeding
• Assist mother with evaluating
successful feeding with objective
rather than subjective measures.
• Prompt evaluation & correction of
inadequate positioning or latch-on is
recommended to facilitate successful
breastfeeding.
Pain
International Association for the Study
of Pain
• “unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage” (1979)
• Implies that pain is subjective & must
be learned through experience and
expressed verbally
Pain
Verbal Communication and self-reports
are considered the
Gold Standard
for pain assessment
Pain
HOWEVER….
Infants are not capable of verbally
communicating pain!!!
THEREFORE…
Other means of pain assessment MUST
be utilized with infants!!
Most Commonly Used Pain
Assessment Tools
• CRIES (crying, requires oxygen
saturation, increased vital signs,
expression, sleepless)-originally designed
to assess post-op pain in infants 32-60
weeks gestation; now useful for pain
assessment in all preterm and term infants
• Scores range 0-10
Most Commonly Used Pain
Assessment Tools
• PIPP (Premature Infant Pain Profile)
uses 2 physiologic indicators (heart
rate & O2 saturation) & 3 facial
indicators (brow bulge, eye squeeze, &
nasolabial furrow)
• Originally used to measure procedural
pain; now used for routine pain
assessment in all preterm and term
infants
Most Commonly Used Pain
Assessment Tools
• N-PASS (Neonatal Pain Agitation &
Sedation Scale) – scores based on
assessment of cry/irritability, behavior
state, facial expression, tone, & vital
signs
• Scores adjusted for gestational age
• Incorporates separate scoring system
for assessment of level of sedation
Most Commonly Used pain
Assessment Tools
• NIPS (Neonatal Infant Pain Scale)originally used for procedural pain but
now used to assess all pain in preterm
and term infants
• Assesses pain based on facial
expression, cry, breathing patterns,
muscle tone in arms and legs, * state of
arousal
Pain Assessment
• Become familiar with and utilize pain
assessment tool and treatment plan
used by your facility
• Not all tools have guidelines for
treatment
• In general, scores in the mid-range are
indicative of moderate to severe pain &
pharmacologic treatment is warranted
Physiology of Pain
• Peripheral Nervous System
• Spinal Cord
• Centers at the Supraspinal/Integrative
level, includes the thalamus and the
cerebral cortex
Peripheral Nervous System
• Fully mature & functional by 20 weeks
gestation
• Two types of neuronal afferent fibers:
A-delta fibers (rapid- conducting fibers
that transmit sharp pain) & C-fibers
(slow-conducting fibers associated with
aching, burning, & poorly localized pain)
Peripheral Nervous System
• Number of pain receptors is equal to or
greater than those in an adult
• Tissue injury activates pain receptors that
send pain impulses to the spinal cord &
CNS
• Releases chemicals that increase
sensitivity to painful stimuli causing
decreased pain threshold that can last for
days to weeks
Peripheral Nervous System
• Dendritic spouting & hyperinnervation
causes hypersensitivity and lowered
pain threshold that can last into
adulthood!
Spinal Cord
• Weak linkage between the PNS and the
spinal cord result in prolonged or no pain
response during the 1st week of life
• Pain impulses travels to the spinal column
via efferent neurons, cross over to the
opposite side of the brain to the thalamus
which then relays incoming pain messages
to the dorsal horn producing a reflex
withdrawal
• Preterm infants have limited ability to
modulate pain
Supraspinal/Integrative Level
• Cerebral cortex has full supply of neurons
by 20 weeks gestation & is functionally
mature by 22 weeks gestation
• Germinal matrix is highly vascular until
~28 weeks gestation & is vulnerable to
hemorrhage due to increased intracranial
pressure with pain
Supraspinal/Integrative Level
• Neonates can differentiate touch as
early as 27 weeks gestation
• Infant can perceive, react to and
remember pain as early as 30 weeks
gestation
Nonpharmacologic Pain
Management
• Prevention: minimize pain & stress
• Behavioral measures:
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Facilitated tucking
Blanket swaddling
Pacifier
Non-nutritive nursing
Breast feeding
Sucrose (remains controversial)
Pharmacologic Pain Management
• Used with moderate, severe, or prolonged
pain assessed or anticipated
• IV opioids- most commonly used analgesic
– Spinal Cord- impairs/inhibits
transmission of the pain impulse from
the periphery to the CNS
Pharmacologic Pain Management
• IV opioids
– Basal Ganglia- activates a descending
inhibitory system
– Limbic system- alters emotional
response to pain, making it more
tolerable
Pharmacologic Pain Management
• Longer dosing intervals may be needed due
to longer elimination and delayed clearance
• Higher plasma concentration necessitate
longer monitoring of patient after
medication is discontinued
• Significantly higher doses nay be needed
to achieve analgesia due to immature
neural pathways
Pharmacologic Pain Management
• Fentanyl
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Bolus: 1-4mcg/kg q2-4 hours
Infusion: 1=5mcg/kg/hr
Onset of action is immediate
Adverse reactions; respiratory
depression, chest wall rigidity,
hypotension, tolerance & dependence,
urinary retention
Pharmacologic Pain Management
• Morphine
– Bolus: 0.05-0.2mg/kg/dose IV, IM, or
subcutaneously as needed, usually q4hrs
– Infusion: loading dose of 0.1-0.15mg/kg
IV over 1 hour followed by continuous
infusion of 0.01-0.02mg/kg/hr
Pharmacologic Pain Management
• Morphine
– Onset of action begins within a few
minutes and peaks at 20 minutes
– Adverse reactions- respiratory
depression, hypotension, bradycardia,
transient hypertonia, ileus, delayed
gastric emptying, urinary retention,
seizures, tolerance & dependence
Pharmacologic Pain Management
• Nonopioid Analgesics
– Acetaminophen: nonsteroidal antiinflammatory drug used for short-term
mild to moderate pain
– Lidocaine/Prilocaine (EMLA cream):
mixture of local anesthetics, lidocaine, &
prilocaine used topically for pain relief
during procedures
• Adverse reactionmethemoglobinemia, redness,
blanching
Pharmacologic Pain Management
• Liposomal lidocaine cream (LMX 4%)– Topical anesthetic with faster onset of
action than EMLA and without side
effect of methemoglobinemia
– Neuromuscular blocking agents• Chemical paralysis for severely ill
neonate
• Masks signs of pain & agitation
• Should use in conjunction with
analgesia &/or sedatives
Pharmacologic Pain Management
– Sedatives
• Suppresses behavioral expression
of pain
• No analgesic effect
References
Kenner, C. & Lott, J. W. (2007).
Comprehensive Neonatal Care: An
Interdisciplinary Approach (4th Edition).
Saunders Elseiver: St. Louis.
Tappero, E.P. & Honeyfield, M.E. (2003).
Physical Assessment of the Newborn (3rd
Edition). NICU Ink: Santa Rosa). Pp. 174181.
References
Verklan, M.T. & Walden. M. (2004). Core
Curriculum for Neonatal Intensive Care
Nursing (3rd Ed). Elseiver Saunders:
St. Louis.