Swedish study reveals gaps in pain management for preterm infants

By Dr. Chinta SidharthanReviewed by Lily Ramsey, LLMJan 29 2025

Swedish researchers emphasize the need for improved pain assessment in preemies.

Study: Pain in very preterm infants—prevalence, causes, assessment, and treatment. A nationwide cohort study. Image Credit: Ratchat/Shutterstock.com

A nationwide Swedish study published in the journal PAIN sheds light on the prevalence, causes, and treatment of pain in these vulnerable newborns. Using over four years of detailed data, the researchers highlighted gaps in care and suggested paths to better pain management.

Pain in infants

Each year, millions of preterm infants face unique challenges due to their early arrival. Among the most concerning is their vulnerability to pain, as their immature nervous systems amplify the risks associated with medical procedures.

Research shows that repeated pain exposure during critical developmental stages can disrupt brain development, potentially leading to long-term cognitive, psychological, and physical difficulties.

Current neonatal care focuses on reducing these risks, but assessing pain in preterm infants is particularly challenging. Their subtle pain responses can be difficult to interpret, often leading to underdiagnosis.

However, existing research on pain in newborns focuses predominantly on isolated procedures rather than providing a broader understanding of pain prevalence and treatment. Moreover, extremely preterm infants remain underrepresented in such studies. A better understanding of pain in infants is important for refining neonatal care and minimizing adverse outcomes for this vulnerable population.

The current study

To address this knowledge gap, this Swedish cohort study analyzed pain prevalence, causes, assessment, and treatment in very preterm infants born between 22 and 31 weeks of gestation.

The research utilized data from the Swedish Neonatal Quality Register, which encompassed 3,686 infants discharged from hospitals between January 2020 and June 2024, covering a total of 185,000 days of neonatal care.

The researchers focused on multiple dimensions of neonatal pain, including exposure to painful conditions and procedures, use of pain assessment tools, and pharmacological interventions. Pain assessment was documented daily by neonatal care staff based on observable behaviors and medical procedures.

The study analyzed potentially painful procedures such as respiratory support, ventilator treatment, tracheal intubation, surgical interventions, and skin punctures. Additionally, data on gestational age and postnatal age were used to identify trends in pain prevalence and management strategies. Infants were categorized into two-week gestational intervals to assess differences in pain experiences and treatment approaches.

Furthermore, the researchers examined the prevalence of pharmacological treatments, including topical, oral, intramuscular, and intravenous methods, and their association with gestational age.

The study aimed to visualize patterns of neonatal pain and identify gaps in clinical practices to improve outcomes. However, it did not determine the duration or severity of pain for each day reported, as caregivers only answered whether an infant had experienced pain within the last 24 hours.

Key findings

The research confirmed that preterm infants frequently experience pain. The study found that 90% of extremely preterm infants (born at 22–23 weeks) underwent painful procedures, with many requiring nearly daily painful interventions during the first month of life.

However, pain documentation was significantly lower, with only 45% of these infants reported to have experienced pain—suggesting challenges in recognizing and recording pain in neonatal care.

The researchers also observed that the smallest infants, despite undergoing the most painful procedures, had the lowest proportion of morphine treatment, raising concerns about possible undertreatment.

While healthcare professionals aim to minimize pain, the study findings suggest that current pain relief strategies may not be fully effective for the most vulnerable infants.

Pain assessment remains inconsistent. The study found that caregivers recorded pain assessments daily, but the specific scales used and their effectiveness in evaluating neonatal pain require improvement. The press release highlights the need for better rating scales and physiological techniques to ensure pain is recognized and treated appropriately.

Additionally, the findings revealed regional and temporal variations in pain management, with larger healthcare regions reporting higher pain prevalence and treatment rates.

The study emphasized the importance of tailored, gestational age-specific strategies to ensure effective pain management in preterm infants and mitigate the risks of long-term developmental impacts.

Conclusions

Overall, the study highlighted the widespread pain experienced by very preterm infants and the inconsistencies in pain assessment and treatment. Despite advancements in neonatal care, gaps remain in recognizing and managing pain effectively.

The findings call for standardized, gestational age-specific protocols to improve pain management and ultimately reduce the developmental and long-term health risks associated with untreated neonatal pain.