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Infant pain management: a developmental neurobiological approach

Nature Clinical Practice Neurology volume 5, pages 35–50 (2009)Cite this article

Abstract

Infant pain is a clinical reality. Effective pain management in infants requires a specialist approach—analgesic protocols that have been designed for older children cannot simply be scaled down for CNS pain pathways and analgesic targets that are in a state of developmental transition. Here, we discuss the particular challenges that are presented by an immature CNS for the detection and treatment of pain. We show how the application of neurophysiological and neuropharmacological approaches can help to overcome the problems inherent in measuring and treating pain in infants, and how research data in these areas can be used to devise age-appropriate methods of assessing pain as well as strategies for pain relief. The evidence that untreated pain in infancy results in long-term adverse consequences is presented, thereby emphasizing the need for a longer term view of infant pain management.

Key Points

  • Neonatal and infant pain management is largely based on clinical experience and extrapolation of data from older age-groups; improvements in perioperative analgesia are being increasingly made on the basis of evidence-based recommendations, but further research is required to establish the most effective analgesic protocols in early life, particularly for management of procedural pain and sedation in ventilated neonates in intensive care

  • A considerable challenge to infant pain management is presented by the fact that maturation of CNS pain pathways and postnatal changes in neural processing have a major impact on infant pain sensation and behavior and sensitivity to analgesia

  • Measurement of pain with observational tools in preverbal infants requires informed analysis, as interpretation of the data depends upon the maturational stage of pain behavior

  • Neurophysiological analysis of developing pain pathways can provide important insights into pain measurement in infants and provide new knowledge about persistent inflammatory and neuropathic pain states in infancy

  • Postnatal changes in the expression, distribution and function of transmitters and receptors required for analgesic action have a major impact on the pharmacodynamic profile of analgesics, and understanding these processes can inform and improve the design of future clinical trials

  • The fact that neural pathways are still undergoing maturation in early life means that tissue injury can alter the normal course of development, leading to long-term changes in somatosensory processing and pain sensitivity; laboratory studies give an increased understanding of the factors that trigger these changes and how to prevent them

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Figure 1: Key sites of developmental transition in infant pain pathways.
Figure 2: Methods of assessing infant pain.
Figure 3: The long-term impact of infant pain.

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Acknowledgements

The authors would like to acknowledge research funding from the Medical Research Council, the Wellcome Trust, and the International Association for the Study of Pain.

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Authors and Affiliations

  1. M Fitzgerald is Professor of Developmental Neurobiology in the Department of Neuroscience, Physiology and Pharmacology, University College London, and SM Walker is a Senior Clinical Lecturer and Consultant in Paediatric Anaesthesia and Pain Medicine at the UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, UK.,

    Maria Fitzgerald & Suellen M Walker

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  1. Maria Fitzgerald
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Correspondence to Maria Fitzgerald.

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Fitzgerald, M., Walker, S. Infant pain management: a developmental neurobiological approach. Nat Rev Neurol 5, 35–50 (2009). https://doi.org/10.1038/ncpneuro0984

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