AAP Updates Recommendations for Management of Procedural Pain in Neonates

Summary and Comment |
January 25, 2016

AAP Updates Recommendations for Management of Procedural Pain in Neonates

  1. Martin T. Stein, MD

Limiting neonatal procedures, objective assessment of pain, and judicious use of pain management are highlighted in the policy statement.

  1. Martin T. Stein, MD

Pain during neonatal procedures is inconsistently assessed and often inadequately treated. In addition to ethical reasons for pain alleviation, research has shown that repeated painful stimuli early in life are associated with physiologic instability, dysregulation of stress response systems, and abnormal neurodevelopment. Based on recent evidence, the American Academy of Pediatrics has updated its recommendations for the prevention and management of procedural pain in neonates.

Among the recommendations:

  • Hospitals and clinics that provide neonatal care should have written guidelines for pain prevention (including minimizing the number of painful procedures) and treatment.

  • Validated neonatal pain assessment tools should be used before, during, and after painful procedures.

  • Nonpharmacological strategies are recommended for short-term mild to moderately painful procedures such as heel lance and intravenous catheter insertion. Strategies include swaddling/facilitated tucking, nonnutritive sucking, breast feeding, massage, and skin-to-skin care.

  • Oral sucrose or glucose is safe and effective with mild to moderately painful procedures (e.g., immunizations) either alone or with nonnutritive sucking and swaddling.

  • Pharmacologic treatments (e.g., opioids and benzodiazepines) may be used with more painful procedures, after balancing benefits and side effects. Topical anesthetic agents (tetracaine gel and EMLA) decrease pain during venipuncture and insertion of venous and arterial lines. Evidence is insufficient to recommend methadone, ketamine, or propofol, or to recommend routine use of opioids in mechanically ventilated infants.

  • Pain management is recommended for circumcision and nonemergency intubation.


Limited attention to neonatal pain occurred until about 20 years ago. Pediatricians who care for neonates should be familiar with pain-reducing strategies reviewed in the policy statement.

Editor Disclosures at Time of Publication

  • Disclosures for Martin T. Stein, MD at time of publication Consultant / Advisory board Pearson Neuroscience Advisory Board Speaker’s bureau American Academy of Pediatrics Royalties Elsevier, Inc. Editorial boards Journal of Developmental and Behavioral Pediatrics


Reader Comments (1)

Sanford D'Esopo

I have been unable to find any response by CDC, NIH, AAP, or other major organization regarding the 1995 findings of Danish researcher Morten Frisch. In a study of 340,000 boys, he found a 46% higher incidence of ASD in those circumcised at birth or in early childhood. Hyperactivity incidence was also higher. In view of the seriousness of these afflictions, I am confused that there seem to be no immediate concern.

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