Overview of procedural analgesia in neonates

Type of procedure	Suggested multimodal pain management regimen	Additional comments
Simple procedures associated with mild pain Examples: Heel lance or finger stick Venipuncture or peripheral IV catheter insertion IM or SubQ injection NG tube insertion Bladder catheterization Dressing change/tape removal	Both of the following: Nonpharmacologic measures (eg, skin-to-skin contact, non-nutritive sucking)^* Oral sucrose	A topical anesthetic (eg, EMLA) can also be used for some procedures in this category (eg, IV catheter insertion, IM or SubQ injection)^¶ but not others (eg, NG tube insertion, bladder catheterization, dressing change). EMLA is not routinely used for heel lance since it appears to be ineffective in this setting.
Simple procedures associated with moderate pain Examples: LP Peripheral arterial puncture or catheterization Umbilical venous or arterial catheterization Intraosseous cannulation	All of the following: Nonpharmacologic measures (eg, skin-to-skin contact, non-nutritive sucking)^* Oral sucrose Topical anesthetic (eg, EMLA), if appropriate^¶	In our experience, the combination of these 3 measures usually permits successful completion of the procedure. Rarely, neonates who do not achieve adequate analgesia from these measures may require a low-dose short-acting opioid (eg, fentanyl, sufentanil). Opioids should be used with caution in nonintubated patients.
More complex procedures^Δ Examples: Percutaneous CVC placement PICC placement Chest tube placement	All of the following: Nonpharmacologic measures (eg, non-nutritive sucking, facilitated tucking)^* Topical and/or local anesthesia (eg, EMLA and/or lidocaine)^¶ Acetaminophen Short-acting sedative/analgesic (eg, ketamine, fentanyl, sufentanil), if needed	We prefer short-acting over longer-acting opioids in this setting because these procedures are usually brief. Opioids should be used with caution in nonintubated patients. Using a local anesthetic and acetaminophen reduces the amount of opioid required.
Specific procedures
Circumcision^◊	All of the following: Nonpharmacologic measures (eg, non-nutritive sucking, facilitated tucking)^* Oral sucrose Local anesthesia (eg, ring block or dorsal penile nerve block) Acetaminophen for postprocedure pain control	Local or topical analgesia is routinely provided for neonatal circumcision since it reduces procedural pain with minimal risk.
ROP examination	All of the following: Nonpharmacologic measures (eg, non-nutritive sucking, facilitated tucking)^* Oral sucrose A topical anesthetic (eg, proparacaine), depending on the preference of the ophthalmologist	The interventions listed are generally sufficient for routine screening or follow-up examination. Additional analgesia/sedation is required when ROP treatment is administered during the procedure (eg, laser therapy or anti-VEGF injection). We use a short-acting agent (eg, ketamine, fentanyl, sufentanil) for this purpose. Opioids should be used with caution in nonintubated patients.
Elective endotracheal intubation	Options include: Ketamine (preferred agent at the author's institution) or Short-acting opioid (eg, fentanyl, sufentanil, remifentanil)	The combination of an opioid plus a benzodiazepine (eg, midazolam) is another alternative; however, this does not appear to improve intubation success rates compared with an opioid alone.

This table summarizes our suggested approach to procedural pain management in neonates. Suggested interventions for common neonatal procedures are summarized here; this is not intended to be a comprehensive list. The guidance in this table represents the general approach. Optimally, the pain management plan should be tailored to the individual neonate. Refer to UpToDate topics on neonatal pain for additional details, including a discussion of the evidence supporting our approach.

CVC: central venous catheter; EMLA: eutectic mixture of local anesthetics; IM: intramuscular; IV: intravenous; LP: lumbar puncture; NG: nasogastric; PICC: peripherally inserted central catheter; ROP: retinopathy of prematurity; SubQ: subcutaneous; VEGF: vascular endothelial growth factor.

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

¶ Topical anesthetics should not be applied on open wounds or lacerations. Repeated or frequent doses should be avoided as this increases the risk for systemic absorption and toxicity.

Δ These procedures not only cause moderate pain, but also require that the neonate remain relatively still during the procedure.

◊ Refer to separate UpToDate content on neonatal circumcision for a detailed discussion of pain management for the procedure.

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Overview of procedural analgesia in neonates