as “wind-up phenomenon”) may persist after the procedure, causing routine handling and caregiving to be perceived as painful due to heightened activity in nociceptive pathways. Allow infant to fully recover from painful stimulus before resuming caregiving. · Handling in preparation for painful procedures can also heighten pain responses by increasing activity in nociceptive pathways. Decreased physiologic pain responses were noted when containment and/or swaddling were used to maintain flexion and allow hand to mouth for self comforting during procedures. Animal studies have shown that the effects of repetitive pain are lessened by the nurturing presence of the mother animal. Helping to provide containment during uncomfortable procedures is an ideal opportunity for parent participation. The parent’s presence is reassuring to the infant, and the parent is able to actively contribute to their infant’s comfort. What can we do in the NICU? Both non-pharmacologic (“comfort measures”) and pharmacologic therapies should be used to control and prevent pain. An additive or synergistic effect is seen when these strategies are combined. · Comfort measures are indicated for all minor or moderately stressful procedures · Add pharmacologic agents to comfort measures whenever moderate or severe pain is anticipated The following comfort measures are known to minimize pain and stress, while maximizing an infant’s regulatory and coping abilities: · Provide containment with hands (facilitated tuck or “hand hugs”), Dandleroos/wraps or standard swaddling. Maintain flexion and allow hand to mouth for self-comforting. Containment may reduce pain by providing gentle stimulation across proprioceptive and tactile sensory systems · Skin-to-skin contact significantly diminishes pain responses during and after heel sticks for preterm and term infants · Nonnutritive sucking (NNS) during painful procedures is thought to activate nonopioid pathways, but the pain-relieving effects of NNS stop as soon as the sucking stops Most common symptoms of pain Additional responses to pain ◦Tachycardia ◦Tachypnea ◦Elevated blood pressure ◦Crying ◦Body movements ◦Facial expression ◦Brow bulge ◦Brows drawn together ◦Eyes squeezed shut ◦Raised cheeks ◦ Desaturations and/or cyanosis ◦ Pallor ◦ Flushing ◦ Muscle tremors ◦ Hypertonic ◦ Hypotonic ◦ Sleep/wake cycles changes ◦More wakeful or lethargic ◦ Fussy, irritable, listlessness ◦ Feeding difficulties NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 17 · A systematic review found that breastfeeding and breast milk reduced pain responses. If available, use breastfeeding to minimize procedural pain · Sucrose is effective in reducing pain responses, especially when combined with sucking (i.e. dipped pacifier) and other comfort measures. It should be applied to the tip of the tongue (where sweet receptors lie) two minutes before a painful procedure. The two minute interval is thought to coincide with the endogenous opioid release triggered by the sweet taste. Refer to SMC Sucrose Analgesia for our parameters for use of sucrose Use nonopioid analgesics, such as acetaminophen, for short-term management of mild to moderate pain. Acetaminophen works by inhibiting prostaglandin formation, and provides mild analgesia as well as some antipyretic and anti-inflammatory benefits. When used in conjunction with opiates, there is an additive effect that may allow lower doses of both medications to be used. Since acetaminophen is metabolized by the liver, care must be taken to avoid overdosing. In addition to comfort measures, add pharmacologic agents such as opioids for moderate or severe procedural, post-operative, or disease related pain. Analgesics such as fentanyl and morphine work by binding with receptors to block the transmission of pain messages. Opioids are indicated for pain control, but extended use for ventilation or sedation is not recommended due to lack of long-term outcome data. Manage procedural pain by using standardized best-practice guidelines: NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 18 Neuro-protective Best Practice Guidelines Part 5: Optimizing Nutrition Goal is to provide the best nutritional support available, and to support a positive infant-driven breast or bottle feeding experience Background: Preterm birth interrupts the third trimester, when protein and fat stores accumulate. Early parental nutrition is essential to minimize catabolism for these infants, and to support them until enteral feedings can be established. Ideally, glucose should be infusing within 30-60 minutes after birth to meet the brain’s energy demands. Protein is vital for growth and prevention of poor neurodevelopmental outcomes. Intralipids prevent essential fatty acid deficiency and contribute to myelination. There is compelling evidence to support breastfeeding as the optimal form of infant feeding. Since breast milk is the most well tolerated substrate for preterm infants, it allows full enteral feedings to be reached more quickly, and reduces the need for prolonged use of parenteral nutrition. The risk of necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and sepsis are reduced when breast milk is used rather than