Minimizing Pain and Stress in the NICU



Pain and Stress in the NICU

Babies in the Neonatal Intensive Care often experience multiple painful procedures during routine care. Things such as blood work, IV insertion, suctioning, feeding tube placement, ventilator tubes, tape removal, and even diaper changes all lead to increased stress in premature babies. Exposure to environmental stimuli such as bright lights, monitors, loud noises, and voices all affect the preemie’s ability to self regulate.


Pain Receptor Development:

  • Pain receptors are first present around the tissue of the mouth at approximately 7 weeks gestation.
  • Pain receptors then form in the face, the palms of the hands, and the soles of the feet by the 11th week of gestation.
  • By the 15th week of gestation the trunk and proximal parts of the arms and legs will have developed pain receptors.
  • Circuits of neurons that link the receptors to the brain can be found as early as 6-13 weeks gestation.
  • Pain receptors are present across the entire body by 20 weeks gestation.
  • Between 20-30 weeks gestation the highest density of pain receptors develop in the baby. These “neuronal bursts” appear like electrical activity making the baby five times as sensitive to touch than any term newborn or child. These bursts prep the brain for complex activities and metal processing that lead to the development of sensory responses.
  • Babies cannot differentiate between pain and touch until after 35 weeks gestation because the pain receptors are not fully developed.
  • Premature babies have not developed the mechanisms needed to modulate and tone down pain because pain-dampening development occurs around 40 weeks gestation.

In adults, tactile sensations such as touching, rubbing, hugging, or piercing, jabbing, and pinching all correspond with distinguishable and precise arrangements of brain activity. In contrast, the premature brain lacks this neurological organization, making it very difficult for them to distinguish between painful stimuli and simple touch.


Pain Relief in the NICU

A variety of pain relief techniques have been shown to effectively reduce pain from minor procedures in neonates in the Neonatal Intensive Care. Including the use of oral glucose, (sugar water)non-nutritive sucking, Kangaroo Care, facilitated tucking, swaddling, decreasing environmental stimulation, promoting sleep, and paying close attention to behavioral cues.


In a stressful or painful situation: a baby born prematurely may attempt to gain some control by stiffening their muscles. They may arch their head, neck, and trunk. They may lift their shoulders, make fists with their hands, stiffen their legs, and point their toes.


As a parent, what can you do to help your preemie with pain control?

You can help your baby by following their cues.

Look for facial signs, body language, as well as a change in their vital signs such as a drop or rise in their heart rate or breathing pattern. These may indicate your baby is feeling some discomfort or stress.

Your baby may find comfort with a grasp of their hand or by holding your baby in a special way called "tucking".  Cup your baby's head with one hand and bottom with your other. This will help your baby stay organized and content.

Ask about Kangaroo Care. Holding your baby skin-to-skin can help sleep better, grow better, and even eat better. It also helps you to bond with your infant. Kangaroo Care has also been shown to help mothers produce more breast milk.


Reducing Stress While Promoting Growth and Development


It’s important to remember that preterm babies are not just smaller versions of full term babies. They have very specific psychological and physiological developmental needs.


Muscle Tone: Full term babies are typically born with strong, developed muscle tone and are able to curl up into a comfortable flexed position with their arms and legs tucked into their body.


Babies born prematurely often have less tone and are unable to bend their arms and legs independently, their movements are often jittery or jerky, and they tend to keep their arms and legs straight. Because premature babies have less muscle bulk they are typically “hypotonic”, meaning their muscles are floppy or loose. It is difficult for a premature baby to stay in a flexed (or bent) position. Instead you may notice your preemie may lie in a frog-like position. It’s hard for premature babies to keep their hand close to their mouths in a flexed and organized position because of their lack of muscle strength and tone. You may notice your baby hold their arms out at the side, rather than tucked in and midline.

If, over time, a preterm baby maintains these positions, it can affect their tone, balance, and motor development.

Proper positioning and holding techniques used while your baby is in the NICU can help to prevent some of the problems associated with decreased muscle tone and posture due to prematurity.


Before Birth:

The uterus provided the perfect environment for promoting proper muscle tone and development.

Your baby was able to:

  • Move within the secure boundaries, bouncing and pushing of the walls of the uterus with the ability to return to a flexed and midline resting posture.
  • Have protected sleep in a quiet dark environment away from painful external stimuli.
  • Flex their arms and legs, keeping their knees and elbows tucked to midline, their head tucked forward with a curved spine.


When a baby is born prematurely their position and posture are both affected. Preemies have a tendency to have:

  • Arms and legs that flop to the sides, leading to muscle imbalance.
  • Weak or little muscle tone and development.
  • Stress and feelings of unsafety by gravity and the lack of boundaries.



Babies born at or before 24 weeks gestation have very little muscle strength and tone. These extreme preemies tend to lay flat and stretched with their feet positioned in an upward direction.

Babies born between 27 and 29 weeks gestation have some flexion to the knee, but no tone in upper extremities. Their muscle tone continues to be very floppy and weak. These preemies need support to gain full alignment and musculoskeletal development.

Premature babies born between 31-34 weeks gestation typically show some flexor tone in the upper extremities and their muscle tone is increasing in the lower extremities, but they will need proper alignment and nesting support to continue to develop their muscles, tone, and strength.

Babies 36 weeks to term gestation keep their arms and legs in a flexed position and attempt to pull their body midline with hands and arms tucked in and resting at or near their mouth.


Promoting motor development through positioning

As a Parent, what can you do to help your preemie with positioning?

Flexion- Help to keep your baby in a flexed or curled up position. Encourage this position when your baby is sleeping, nested in the incubator, when you are transitioning your baby out of the incubator to skin-to-skin, or when you are holding your baby close to your chest. This will help to keep your baby supported midline, with hands tucked close to the body. Your baby will feel comforted and less stressed in a flexed and supported position.

Midline- Help your baby keep their head in the middle, facing forward and to bring their hands toward the middle of the body. Keeping the head in the midline, hands to mouth, and legs up into flexion will help your baby strengthen and develop their muscles and tone.




Provide your baby with support by:

  • Keeping their chin tucked towards their chest to support their head.
  • Bringing your baby’s arms forward and their hands to their mouth.
  • Bringing your baby’s legs together to support the hips.
  • Keeping your baby’s knees flexed to support alignment.


The Importance of Positioning in the NICU:

  • Provides the building blocks necessary for growth and development.
  • Helps the baby to self regulate and organize their behavior, decreasing stress and helping them to feel safe and secure.
  • Help conserve body heat and reduce energy expenditure, allowing the baby to grow and develop to their fullest potential.
  • Improves sleep quality.



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