Perioperative pain management for preterm babies, infants and toddlers

Perioperative pain management in children should follow the same basic principles that apply to adults. As in the case of the latter, pain treatment should comply with the stepwise approach described as the 'pain ladder' by the World Health Organization (WHO) using such established methods as patient-controlled analgesia. It can be assumed that regional anaesthesia provides the same beneficial effects in children as in adults. Furthermore, regional techniques can be used to minimize the amounts of systemic sedatives or analgesics applied, which are all suspected of having neurotoxic side effects. The only aspect which can limit the usage of adult concepts either for measuring or treating pain, may be a restricted ability to communicate with younger children. In addition, age-related duration of action and side-effect profiles need to be taken into account. Very often, it is possible to provide adequate pain treatment using the same drugs as in adults. The only group of patients to which these rules do not apply are the newborn and premature babies. Due to the significant immaturity of their pain reception suppressing systems, less satisfactory action of opioids can be observed, while at the same time respiratory depression at sub therapeutic dosages may occur. As a result, it may be impossible to achieve adequate pain relief while preserving spontaneous breathing when using opioids. In addition, this group of patients has significantly delayed metabolism due to the immaturity of enzyme systems. A solution to this dilemma can often be found in the use of regional anaesthesia, and the prevention of pain whenever possible.