Paracetamol and Preterm Infants: a painless liaison?

Abstract

In the late 1980s there was a true turnabout on the important issue of neonatal pain. Then, Anand and co-workers [1, 2], published a trial on preterm infants randomly allocated to fentanyl with a muscle relaxant or muscle relaxant only during surgical patent ductus arteriosus (PDA) closure. This provided evidence, for the first time, that preterm infants have a capacity to feel pain from a very early age (24-26 weeks gestation) and that early repetitive pain gives rise to short-term and long-term consequences [3, 4]. Nowadays pain management has become an essential part of the standard of care in NICUs worldwide, and pain is considered ‘the fifth vital sign’. The degree of distress associated with the treatment of preterm infants is reflected by the, on average, 11.2 painful procedures per day at our NICU [5]. Studies from NICUs in other countries have shown a similar trend with 6 to 17.3 procedures per newborn per day [6-11]. It has been found also that neonates receive comparatively less pain medication than older children and adults in similar painful procedures [12]. Caregivers may be reluctant to prescribe analgesics to neonates for fear of adverse effects, drug tolerance and dependence [13]. Moreover, there are few dosing guidelines and pharmacokinetic data on common drugs for neonates of different gestational ages and birth weights. On top of this, more than 90% of the currently prescribed drugs to neonates are not licensed for or are used in an off-label manner in this age group — and pain medication is no exception.