Procedural sedation is an option for more lengthy, difficult or intrusive therapies. However, this procedure should be implemented with rigorous cardiovascular and respiratory monitoring by caretakers.

Neonatal Pain Management

There are some important physiologic differences in the neonatal population to be aware of when addressing pain and considering sedation. Most analgesics (including opiates and local anesthetics) are conjugated in the liver. Newborns are often still developing the necessary enzymes for drug metabolism for up to the first six months of life.²⁶ Newborns also have a higher total percentage of water contributing to body weight (less fat) than older children and adults, therefore water soluble drugs will have a greater volume of distribution in the neonatal body. The ventilatory response to hypoxemia and hypercarbia in the newborn, particularly in the premature infant, is diminished²⁷ so there is potential to blunt this response with benzodiazepine and opiates.

Topical anesthetics may be administered to the neonatal population. However, care should be taken not to allow prolonged exposure to the agents and to use appropriate dosing to prevent systemic toxicity.

In addition to showing efficacy of topical agents, literature has demonstrated that sucrose decreases the pain response in neonates in the following procedures: heel lance, venipuncture, ophthalmologic exam, bladder catheterization, nasogastric tube insertion, and subcutaneous injections.²⁸

Sucrose solutions are most valuable about two minutes prior to the start of the painful procedure in neonates less than six months old. Oral sucrose is more efficacious in the younger neonate. Sucrose also may be more effective when administered with a pacifier.³⁰

Encouraging maternal involvement is also helpful if a provider anticipates a painful procedure for a neonate.

One study has shown that breastfeeding or breast milk is better than placebo, positioning or no intervention, and may even have a similar effect compared to the use of sucrose solution.³¹

Child Life Specialists

Child life specialists are trained professionals who offer support for children and families, to help them cope with injuries and illness. There are currently 111 children’s hospitals within larger hospital systems that provide at least one full-time registered child life specialist in the emergency department. There are at least 40 children’s hospitals in systems that do not provide a full time registered child life specialist in the ED.³²

Possessing a strong background in child development and family systems, child life specialists are an invaluable part of the emergency department team.