Pain relief during pregnancy and breastfeeding

The Royal College of Obstetricians & Gynaecologists has published Antenatal and postnatal analgesia (Scientific Impact Paper No. 59)

This Scientific Impact Paper reviews existing evidence-based guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) and European Medicines Agency (EMA) on the use of painkillers during and after pregnancy, as well as during breastfeeding.

The findings reflect current NHS guidance on the use of medical pain relief options in pregnancy and during breastfeeding. The paper also recommends that women try non-medical treatments first, such as adequate rest, hot and cold compresses, massage, acupuncture, physiotherapy, relaxation and exercise.

Before taking any medicine when pregnant or breastfeeding, a woman should ask for advice from her obstetrician, midwife or GP. If a pain relief drug is needed, the lowest effective dose should be taken for the shortest possible time. If possible, all drugs should be avoided during the first trimester (up to 12 weeks of pregnancy), but some will need to be continued to prevent harm to the woman.

Full document: Bisson DL, Newell SD, Laxton C, on behalf of the Royal College of Obstetricians and Gynaecologists | Antenatal and Postnatal Analgesia |Scientific Impact Paper No. 59 | BJOG | 2018

Additional link: RCOG press release

Better pain relief for women in labour

NIHR | October 2018 | Better pain relief for women in labour

An NIHR-funded study is the first large trial of its kind to compare  intravenous remifentanil (administered via a patient-controlled delivery device) with intramuscular pethidine for women requesting opioid pain relief in labour.  This trial aimed to address an evidence gap identified in a 2017 Cochrane Review, that compared remifentanil with other methods and found mostly low-quality and inconsistent evidence, particularly around maternal and neonatal safety outcomes. Until this review, no large trials had compared remifentanil with intramuscular pethidine or looked at conversion to epidural as the main outcome. 


Pethididine is given to a quarter of a million women each year in the UK, it can make mothers feel sleepy or nauseated and also crosses the placenta making babies sleepy and occasionally causing dangerous depression of breathing.  Pethidine not always very effective, and many women need a subsequent epidural. Although opioid drugs can cause maternal sedation and depression of the baby’s breathing but this trial found no difference in adverse maternal or neonatal outcomes between drugs.


Women in labour who were given remifentanil rather than pethidine, had less need for further pain relief. Almost one-fifth (19%) of women given remifentanil received a subsequent epidural compared with a little over two-fifths (41%) given pethidine. Remifentanil was given intravenously, using a patient-controlled delivery device, and pethidine given by intramuscular injection.

One caution is the potential for subjective bias. A quarter of women allocated to pethidine who converted to epidural requested this before they had even received the drug. Nevertheless, this study could pave the way for patient-controlled remifentanil to have more widespread use in the UK.  (Source: NIHR)

Read the full signal at NIHR 


Mindfulness Meditation for Pediatric Chronic Pain

Waelde, L.C. et al (2017) Children. 4, 32.

Despite advances in psychological interventions for pediatric chronic pain, there has been little research examining mindfulness meditation for these conditions. This study presents data from a pilot clinical trial of a six-week manualized mindfulness meditation intervention offered to 20 adolescents aged 13–17 years.

Mindfulness meditation shows promise as a feasible and acceptable intervention for youth with chronic pain. Future research should optimize intervention components and determine treatment efficacy

The full article is available to download here

Parents’ reactions can lessen or worsen pain for injured kids

New research (yet to be published) has looked at family coping and distress during a dressing change following a burn injury in kids | The Conversation


The 18-month study observed 92 families during their young child’s (one to six years) first burn dressing change at a Brisbane hospital.

Parents who reported they were more anxious or distressed were less able to support their child during the procedure. This decreased the child’s ability to cope and increased the child’s distress, which was measured by their ability to be distracted by toys and conversation, compared to crying or screaming during the dressing change.

Ratings of child anxiety and pain during the dressing change were also greater for children of parents who were less able to support their child during the dressing change.

Read the full blog post by  Erin Brown & Justin Kenardy here

Low Back Pain in Children and Adolescents

Moreno, M. (2017) JAMA Pediatrics. 171(3):312

Image source: H – – J – Flickr // CC BY-NC-ND 2.0

Low back pain is often thought of as an adult condition. However, it is relatively common as children grow older.

At 7 years of age, about 1% of children will have experienced low back pain; at 10 years of age, about 6% of children will have experienced low back pain; and at 14 to 16 years of age, about 18% of adolescents will have experienced low back pain.

Unfortunately, having low back pain as a child or adolescent is a significant risk factor for having low back pain as an adult.

Read the full article here

Childhood & adolescent risk and prognostic factors for musculoskeletal pain

Huguet, A. et al. (2016) Pain. 157(12) pp. 2640–2656

B0007029 Skeleton
Image source: Tim Ellis – Wellcome Images // CC BY-NC-ND 4.0

A variety of factors may be involved in the development and course of musculoskeletal (MSK) pain.

We undertook a systematic review with meta-analysis to synthesize and evaluate the quality of evidence about childhood and adolescent factors associated with onset and persistence of MSK pain, and its related disability.

No study was identified that examined prognostic factors for MSK pain–related disability. High-quality evidence suggests that low socioeconomic status is a risk factor for onset of MSK pain in studies exploring long-term follow-up. Moderate-quality evidence suggests that negative emotional symptoms and regularly smoking in childhood or adolescence may be associated with later MSK pain. However, moderate-quality evidence also suggests that high body mass index, taller height, and having joint hypermobility are not risk factors for onset of MSK pain. We found other risk and prognostic factors explored were associated with low or very low quality of evidence.

Additional well-conducted primary studies are needed to increase confidence in the available evidence, and to explore new childhood risk and prognostic factors for MSK pain.

Read the full abstract here

Intrapartum care for healthy women and babies

NICE has updated its clinical guideline Intrapartum care for healthy women and babies (CG190). This guideline covers the care of healthy women and their babies during labour and immediately after the birth.  NICE has reviewed the evidence on the effectiveness of midwife-led continuity models and other models of care and deleted a recommendation about team midwifery.

This guideline includes recommendations on:nice-logo

  • choosing place of birth
  • the latent first stage of labour
  • initial and ongoing assessment
  • transfer of care
  • pain relief and monitoring during labour
  • care in the first, second and third stages of labour
  • care of the baby and woman after the birth