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Three Part Question

[For neonates with acutely painful injury] are [parenteral opiates as safe and effective as paracetamol] for [alleviating pain]

Clinical Scenario

A 4-week-old term baby is brought into your DGH ED by his mother. He is crying inconsolably, and examination reveals a swollen and deformed right femur. Xrays confirm a midshaft fracture. You want to alleviate his pain and discuss strong analgesia. The ED nurses tell you that opiates are unsafe in his age group and state that paracetamol is the only option. You wonder about the evidence for this.

Search Strategy

Medline 1966 to 12/2013, EMBASE 1980 to 12/2013 and CINAHL 1980 to 12/2013 using the OVID interface.
Duplicate filtered:[(exp NEWBORN/ OR exp INFANT/ OR NEONATE) AND (EXP MORPHINE/ OR exp PARACETAMOL) AND (EXP INJURY/ OR trauma.ti,ab OR exp FRACTURE/) AND exp PAIN/]

Search Outcome

Search revealed 382 results. No papers which address management of severe or traumatic pain in neonates. One paper was found considering the use of morphine analgesia in children following major surgery.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Howard et al 2010 United Kingdom	10,079 children (510 neonates) following major surgery at Tertiary Paediatric Hospital receiving Nurse controlled analgesia (NCA) with morphine (continuous infusion with boluses titrated against pain scoring).	Prospective cohort study	Effectiveness of analgesia, frequency of Serious Adverse effects, satisfaction ratings.	Nurse controlled analgesia using boluses of IV morphine for breakthrough pain over continuous infusion for post operative pain is safe and effective. Overall incidence of Serious Adverse Effects was 0.4%. Risk of SAE for neonates was significantly higher (2.4%). Satisfaction ratings were good or very good for 98%.

Comment(s)

It is recognised that insufficient pain management in the infant period has deleterious effects in the long term. No papers were found which consider management of traumatic pain in neonates with either paracetamol or opiate analgesia. Evidence exists for the use, safety and efficacy of opiates in postoperative management of neonates and in the Neonatal Intensive Care setting. There is an increased risk of serious adverse effects, in particular respiratory depression, in the neonatal population. It is necessary for practitioners administering opiates in this context to receive appropriate training in administration techniques and patient monitoring.

Clinical Bottom Line

Intraveneous opiates may be administered to neonates with caution and appropriate monitoring.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Howard RF, Lloyd-Thomas A, Thomas M, Williams DG, Saul R, Bruce E, Peters J Nurse-controlled analgesia (NCA) following major surgery in 10000 patients in a childrens' hospital Pediatric Anesthesia 2010; 20:126-134