In this section
Definition of Terms
Procedural pain management & acute pain management
Post-operative and critically unwell pain management
Opioid Conversion (IV)
Conversion of IV Morphine to Oral Morphine
Weaning Opioids (IV & Oral)
Weaning IV Dexmedetomidine
Weaning Oral Morphine
Pain management in the acutely unwell neonate and/or post-operative period is not only humane; it is essential to minimise the endocrine, metabolic and neurologic responses to pain. It has been shown to significantly improve recovery time and healing and can prevent the development of chronic pain. However, exposure to opioids in the absence of pain may adversely impact the developing brain and neurodevelopmental outcomes. Judicious use of opioids in neonates is imperative and following a pain management algorithm has been shown to be effective in providing adequate pain management while minimising opioid exposure.
This guideline provides NICU clinicians with suggested pain and sedation management in the acutely unwell and/or post-operative neonate as a guide to individualise care. Each infant will respond to both pain and medications differently, clinical judgement, pain scores, gestational age, underlying diagnosis, previous exposure to opioids/sedatives and type of surgical procedure need to be considered in managing post-operative pain and sedation.
Pain management strategies will be focused on reducing (or minimising) pain during procedures and managing pain in critically unwell and/or post-operative neonates in the NICU.
Neonates being cared for in other wards/departments should refer to their local departmental guidelines and/or consult with the RCH Child Pain Management Service (CPMS) where appropriate.
All neonates receiving pharmacological pain relief should have continuous cardiorespiratory monitoring insitu with hourly (minimum) observations documented. Sedation nearly always precedes respiratory depression, therefore this is an important observation in non-intubated neonates (Management of the paediatric patient receiving opioids).
The RCH NICU uses the modified Pain Assessment Tool (mPAT) to assess pain in neonates. The frequency of pain assessment depends on how many hours post-operation a neonate is and how long they have been on opioids (Neonatal Pain Assessment Nursing Guideline).
It is important to consider the procedure or surgery that the infant is going to and/or has experienced when assessing pain. Infants vary in their experience of and response to pain. The below list and table are guides to painful procedures and surgeries that frequently occur in the NICU.
Painful procedures include:
Table 1: The categorisation of pain associated with procedures/surgery.
** Please consider the difficulty of the procedure/surgery and note that infants may experience and express pain differently. If an infant’s pain expression is more than expected, consider other factors for example, limb fractures, medical device placement or line
Long-term analgesic and sedative requirements:
For neonates who are ventilated, sedated, and requiring long-term analgesics and sedatives, it is important to consider the goals of care for each neonate, each day. While every neonate receives a sedation score (UMSS – University of Michigan Sedation Score) from 4 – unrousable to 0 – awake and alert, every shift as part of the ‘primary assessment’ flowsheet on EMR, it is important for the multidisciplinary team to consider the acceptable level of sedation for each neonate each day while they are in the acute phase of their postoperative journey. This determines if /when it is appropriate to start weaning analgesics and sedation to reduce the occurrence of opioid tolerance and iatrogenic opioid withdrawal.
The four basic principles underpinning pain management are:
1. Regular pain assessment and consideration of goals of patient care
2. Appropriate and timely medication administration
3. The use of multi-modal pain management techniques
4. Avoidance and careful management of side effects
All neonates should receive physical/psychological developmentally appropriate strategies during all painful procedures. Non-pharmacological strategies should be used in addition to pharmacological strategies. The neonate’s parents and families should be involved in these strategies during painful procedures, when
1. Skin to skin contact (Kangaroo care)
2. Breastfeeding (dependent on mother’s intention & neonate’s ability to breastfeed)
3. Non-nutritive sucking (Consent from parents to use a dummy/pacifier required)
4. Positioning and containment
5. Nesting and/or facilitated tucking)
7. Reduction of stimuli (light and sound)
8. Minimal handling
9. Voice or singing and music therapy
10. Cuddle, positive touch or movement
It is encouraged to use more than one neurodevelopmental strategy simultaneously, for example, non-nutritive sucking with swaddling and reduction of stimuli. More information on neurodevelopmental care strategies can be found on in the
Neurodevelopmental Care Learning Hero Package.
It is important to engage parents in neurodevelopmental care strategies during non-urgent ‘minor’ painful procedures, such as heel lances and venepuncture, as it enhances the benefits of these techniques for the neonate to have their parents and family present delivering this care (
COCOON Learning Package).
pain management & acute pain management
Oral sucrose is a safe and effective mild analgesic, which is effective in decreasing short-term pain and distress during minor procedures. (
Nursing Guideline: Sucrose (oral) for procedural pain management in infants)
Suggested opioid bolus ranges*:
*Higher doses may be required in opioid-tolerant patients and may be used with consultant approval
** Consider starting with smaller doses for opioid naïve patients.
Also consider chloral hydrate, clonidine and dexmedetomidine for procedures to provide sedation for agitated and distressed neonates. Remember to administer adequate pain relief in addition to sedatives. If no IV access, consider oral morphine and time to effectiveness prior to procedure.
and critically unwell pain management
Flowchart 1: Pain management in the Postoperative or Critically Unwell Neonate:
*Most neonates will have their pain well managed with morphine, paracetamol and clonidine. Midazolam use should be minimised due to its potentially harmful effects on neurodevelopment. If the complexity of the neonate’s condition requires midazolam, this should only be used with
It is important to continually assess the neonates mPAT scores and the goals of care for the neonate (i.e. the appropriate level of sedation) to consider weaning and de-escalating pain treatment to avoid tolerance and iatrogenic opioid withdrawal. The neonate’s goals of care should be clear to
the multidisciplinary team and the parents/families at the bedside to allow for appropriate patient care and advocacy.
For more information, please see the clonidine medication guideline (link coming soon)
Consider converting to fentanyl if morphine infusion reaches maximum dosage and remains ineffective.
Consider converting to hydromorphone and refer to CPMS if fentanyl infusion reaches maximum dosage and remains ineffective. Hydromorphone requires DUC approval.
Consider converting to dexmedetomidine if clonidine infusion reaches maximum dosage and remains ineffective. To reduce the risk of withdrawal, the use of dexmedetomidine is limited to 3-7 days. Dexmedetomidine requires DUC approval.
200 mcg of dexmedetomidine in 50mL of 0.9% NaCl
Increased up to 1.2 mcg/kg/hr with consultant approval
Dexmedetomidine may also be used as a weaning agent to facilitate the reduction of opioids to aid with a more timely extubation in chronic, long-term patients, as dexmedetomidine does not effect respiratory drive.
of IV Morphine to Oral Morphine
Opioids (IV & Oral)
As the neonates mPAT scores reduce and the neonate is recovering from their acute deterioration and/or surgery, analgesia and sedation should be weaned as aligned with the neonate’s long term care goals. This should be clearly communicated with the multidisciplinary team and parents/families
and documented in the progress notes in EMR.
The neonate should have regular neonatal abstinence scores (or Finnegan’s scores) as per the departmental guideline and resources (
Neonatal abstinence scoring). Ensure the neonate has clonidine and/or paracetamol prescribed while weaning opioid analgesia. If prescribed regular clonidine, this should be weaned last.
Halve the infusion. If haemodynamically stable after
2 hours, wean by 0.1 micrograms/kg/hr every 4-6 hours.
Iatrogenic opioid withdrawal is different to neonatal abstinence syndrome. The following information pertains to weaning from opioids administered during a neonates NICU journey. The regime to wean oral morphine for a neonate with neonatal abstinence syndrome is different. For information on neonatal abstinence
syndrome, please refer to the Butterfly departmental guideline
When weaning from oral morphine reduce the dosage by 10–20% of the dose that the patient was receiving when weaning commenced e.g. if the starting dose was 500 micrograms when weaning commenced wean by 50 – 100 microgram increments (the same amount each time rather than weaning each individual dose 10-20%).
Clonidine requires weaning if used for more than 5 days (after the opioid/ benzodiazepine weaning is complete) to avoid side effects, such as rebound hypertension. The clonidine dose should be weaned by about 50% each day for 2 to 3 days (reflecting an average
half-life of 17 hours in neonates) before ceasing the drug. Watch for tachycardia, hypertension, sweating, agitation, but remember these may also be opioid withdrawal symptoms.
Liver Disease Dosing Adjustment Recommendations
The evidence table for this guideline can be viewed here.
Please remember to read the disclaimer.The development of this nursing guideline was coordinated by Bianca Devsam, Clinical Nurse Specialist, Butterfly Ward, Neonatal Intensive Care Unit, approved by the Nursing Clinical Effectiveness Committee. Published December 2021.