Types of neonatal procedures requiring pain control

Simple procedures associated with mild pain
Nonpharmacologic measures* plus Sucrose	Example procedures Heelstick Finger stick Venipuncture Intramuscular or subcutaneous injection Venous catheterization Nasogastric tube insertion Bladder catheterization Dressing change Tape removal Removal of intravenous catheter Bladder compression Tracheal extubation
Simple procedures associated with moderate pain
Nonpharmacologic measures plus Sucrose plus Topical anesthetic plus (if needed) +/– Short-acting opioid (low-dose fentanyl)	Example procedures Arterial puncture Arterial or venous line placement Lumbar puncture Retinopathy of prematurity (ROP) assessment^¶ Lumbar puncture Obtaining intraosseous access Umbilical catheterization
More complex procedures^Δ
Nonpharmacologic measures plus Sucrose plus Local/topical anesthesia plus Acetaminophen plus (if needed) +/– Opioids	Example procedures Central line placement Peripheral insertion of central catheter (PICC line placement) Chest tube placement Circumcision Suprapubic bladder aspiration Tracheal intubation
Prolonged pain/discomfort
Nonpharmacologic measures* plus Sucrose plus Intermittent doses of opioid analgesic or sedatives plus (if needed) For severe agitation, can add low-dose continuous infusions of midazolam or dexmedetomidine	Example scenarios Mechanical ventilation Chest tube in place Arterial or central venous line in place Meningitis Necrotizing enterocolitis
Chronic pain
Nonpharmacologic measures plus Sucrose plus Opioid infusions or Ketamine can also be used to treat associated hyperalgesia	Example conditions Epidermolysis bullosa
Post-operative pain
Nonpharmacologic measures plus Acetaminophen plus Opioid therapy – Intermittent doses and/or continuous infusion

This table summarizes our suggested approach to treatment of pain in neonates. For each category of pain or painful procedure, the possible measures for pain control are listed. Each procedure may not require all of the suggested measures. Clinicians should make decisions based on the clinical status of their patient. For instance, tracheal intubation is in the "invasive procedures" section, but local/topical anesthesia would not be indicated, as the skin is not broken during this procedure. This table is not meant to represent a comprehensive list of all possible pain control measures for neonates. Refer to Lexicomp and UpToDate's topics on neonatal pain for additional details, including a discussion of the evidence supporting our approach.

* Nonpharmacologic measures include breastfeeding, non-nutritive sucking, swaddling or facilitated tucking, skin-to-skin contact, and sensorial saturation.

¶ ROP assessment – There are currently no guidelines for ROP assessment. We use deep sedation with short-acting drugs like ketamine and remifentanil, or low dose fentanyl infusion for this procedure.

Δ More complex procedures are those that not only cause significant pain, but also require that the neonate remain as still as possible.

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