Pain and Stress in the Neonatal Unit

Managing pain and stress is the ethical responsibility of everybody who works in the neonatal unit.

“All pain is stress, but not all stress is pain.” Mary Coughlin

Pain and Stress

Pain and stress are ongoing experiences to babies admitted to the neonatal unit. Carbajal (2018) reported an infant in ITU experiences up to 16 painful procedures everyday. These early pain experiences influence both immediate and long term outcomes and can lead to structural and functional alterations in brain development. However, despite an improved understanding in pain and stress and the consequences with short – and long-term morbidity, pain continues to be inconsistently assessed and managed (American Academy of Pediatrics, 2016)

Arguably, the best pain management strategy is prevention, but this is not always possible. There are several methods available in the NICU to minimise the level of pain of neonates. These include the use of pain assessment tools, pharmacological interventions and non-pharmacological interventions.

Non-pharmacological intervention

Non-pharmacological interventions are cost effective, practical schemes that can be easily integrated into care (Cignacco et al. 2007). Four systematic reviews have focussed on non –pharmacological strategies to manage neonatal pain. Johnson et al. (2014) concluded that skin-to-skin contact is effective in managing neonatal pain as measured both physiologically and behaviourally. Stevens et al. (2016) concluded that sucrose was effective for reducing procedural pain from a heel lance, for both preterm and term infants. Shah et al. (2012) stated that breastfeeding or breastmilk should be used to alleviate pain in neonates undergoing a single painful procedure. Riddell et al. (2015) stated there was evidence to support the use of different non-pharmacological interventions during invasive medical procedures, in particular non-nutritive sucking, swaddling/tucking and rocking/holding.

Although, non-pharmacological interventions are often recommended as the first choice to alleviate pain in the NICU (Campbell-Yeo et al. 2011), there remains a significant gap between the available knowledge and clinical practice (Carbajlet al. 2008). Understanding Baby behaviour

In order to recognise when a baby is feeling comfortable or distressed, we need to understand what each baby is saying to us. Using the principles of newborn behavioural observations (Nugent et al 2007) it is possible to understand the individualised infant responses to each care interaction.

Examples of signs that a baby is in discomfort include changes in heart rate, colour or breathing rate, yawning, hiccoughs, square mouth, nasolabial fold, eye squeeze, brow bulged, flattened, broadened nose, taut tongue, fisting, finger splaying, arched back, toes and fingers spread out, thrusting arms and legs into the air, loss of tone, looking away.

Examples of signs that a baby is comfortable even stable colour and breathing, flexed tucked posture with hands near face or mouth, clearly identifiable state.

There is always something you can do to help manage a baby’s pain or discomfort. Remember interactions are always easier with two people.

You Can do something to help 

  • Parental Presence: More effective than oral sucrose or sucking (Bellieni, 2008)
  • Collaboration: 2 people whenever possible
  • Timing: time the procedure to avoid cluster cares and to support baby’s sleep (Holsti, 2005)
  • Pacing: Respond to the baby’s motor, behavioural and autonomic cues.
  • Support the infants sensory development: create a calm healing environment, always talk first, then touch, then move
  • Sucking: colostrum or sucrose on pacifier
  • Skin to skin (oxytocin release, familiar odours, mothers voice)
  • Breastfeeding (No negative association with mother, Phillips 2005)
  • Bedding and positioning support to support flexion, comfort and alignment 
  • Hand Hugs and opportunities to hold on


Campbell-Yeo, M., Fernandes, A. and Johnston C. (2011). Procedural pain managementfor neonates using non-pharmacological strategies: part 2: mother-driveninterventions. Advanced Neonatal Care, 11(5), pp 312–318.

Carbajl, R., Rousset, A., Danan, C., Coquery, S., Nolent, P., Ducrocq, S., Saizou, C.,Lapilonne, A., Granier, M., Durand, P., Lencien, R., Coursol, A., Hubert, P., de SaintBlanquat, L., Boelle, P., Annequin, D., Cimerman, P., Anand, K. and Breart, D. (2008),Epidemiology and treatment of painful procedures in neonates in intensive care units.Journal of American Medical Association, 300 (1), pp. 60-70.

Cignacco, E., Hamers, JP., Stoffel, L., van Lingen, RA., Gessler, P., McDougall, J., and NelleM (2007). The efficacy of nonpharmacological interventions in the management ofprocedural pain in preterm and term neonates. A systematic literature review.European Journal Pain, 11(2), pp. 139-52.

Coughlin, M. (2016). Trauma-Informed Care in the NICU Evidenced Based PracticeGuidelines for Neonatal Clinicians, New York: Springers Publishing Company.

Nugent K, Keefer C, Minear S, Johnson L and Blanchard Y (2007) Understandingnewborn behaviour and early relationships: The Newborn Behavioural Observations(NB)) systems handbook.

Riddell, P., Racine, N., Gennis, H., Turcotte, K., Uman, L., Horton, R., Ahola, Kohut,Hillgrove, Stuart J., Stevens, B. and Lisi, D. (2015), Non-pharmacological management ofinfant and young child procedural pain. Cochrane Database Systematic Reviews, 2, (12).

Shah, P., Herbozo, C., Aliwalas, L. and Shah, V. (2012), Breastfeeding or breast milk forprocedural pain in neonates. Cochrane Database Systematic Reviews, 12, (12)

Stevens, B., Yamada, J., Ohlsson, A., Haliburton ,S. andShorkey, A. (2016). Sucrose foranalgesia in newborn infants undergoing painful procedures, Cochrane DatabaseSystematic Reviews, 16 (7)

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