Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of
pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess
acute pain, few methods are available to assess
chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of
pain and agitation in the preterm infant, with concerns emerging over the adverse effects of
analgesia and
sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat
pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures.
Sucrose may be utilized judiciously as an adjunctive
therapy for minor painful procedures. Rapidly acting
opioids (
fentanyl or
remifentanil) form the backbone of
analgesia for moderately painful procedures. Chronic sedation during invasive
mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose
morphine infusion may be utilized cautiously and
dexmedetomidine infusion may be considered as an emerging adjunct.