Pain management for necrotizing enterocolitis: getting the balance right

Abstract

Background: Adequate pain management for preterm born neonates suffering from the extremely painful disease necrotizing enterocolitis (NEC) is essential, since neonatal exposure to pain is related to negative short-term and long-term consequences. The aim of this study was to describe the current pain management and its effectiveness in NEC patients.

Methods: In this single-center, retrospective study, neonates (gestational age < 32 weeks and/or birth weight < 1500 g) with NEC Bell's stage II or III were included. Information on pain (based on COMFORTneo and NRS scores) and analgesic therapy was collected and analyzed for the acute disease period.

Results: Of 79 patients included, 74 (94%) received intravenous analgesic therapy: most commonly morphine, fentanyl, and acetaminophen. The median COMFORTneo score was 11 (IQR 10-11), however, 49 patients had at least one COMFORTneo score ≥ 14 indicating pain. Nineteen patients had persistent high pain scores ≥ 14 with a median duration of 7.2 h (IQR 2.8-14.0).

Conclusions: This study showed that despite analgesic therapy, most NEC patients showed signs of pain, and in some, pain persisted for several hours. It suggests that current analgesic therapy frequently failed to prevent pain and existing pain was often insufficiently treated. This supports the urgent need for individualized pain management guidelines for NEC patients.

Impact: This study is unique in reporting on pain management in neonates suffering from necrotizing enterocolitis (NEC) during the full acute disease period. Despite analgesic therapy, the majority of NEC patients experience pain, and in some patients, pain persists for several hours. These findings highlight the need for improvement of neonatal pain management in NEC patients, including better pain monitoring and guidelines for individualized analgesic therapy. Improved pain management guidelines may help to prevent short-term and long-term consequences of neonatal exposure to pain, as well as excessive exposure to opioids.

Fig. 1. Boxplot depicting the longitudinal evolution of COMFORTneo score.

The number of patients remaining in the cohort is indicated below the day. The distribution of COMFORTneo scores is rather constant over time, with an acceptable median COMFORTneo score but also frequent high scores.

Fig. 2. Boxplot depicting the longitudinal evolution of COMFORTneo score in medically and surgically treated patients.

The number of patients remaining is indicated below the day. Surgically treated patients had more high COMFORTneo scores and these high scores occurred over a longer period.

Fig. 3. Scatter plots of the daily cumulative dose of morphine, fentanyl, acetaminophen, and midazolam over time with a superimposed smooth regression line and the corresponding standard error bounds.

The percentage of the cohort receiving the analgesic is indicated below the day. a Morphine is mainly used during the first five days, with the daily cumulative dose peaking at day 3. b Fentanyl is used more frequently after the first week, representing a switch from morphine to fentanyl. c Acetaminophen use is initially low, but increases over the first week. d Midazolam use is common among patients with a very long disease period.

Fig. 4. Overview of the longitudinal evolution of COMFORTneo scores and continuous and intermittent doses of analgesics of patient A.

The COMFORTneo score is shown on the left y-axis and the dose is shown on the right x axis. The colored symbols represent the COMFORTneo scores, with red symbols indicating high scores, green symbols indicating acceptable scores, and orange symbols indicating low scores. The black lines indicate continuously administered analgosedatives and the different black symbols indicate intermittently administered analgosedatives. Patient A exhibits persistent high scores, persistent low scores, and recurrent high scores.