Gabapentin for pain, movement disorders, and irritability in neonates and infants

Commentary

Dr. Vanita Shukla 

Eric Williams Medical Sciences Complex, Trinidad and Tobago

Gabapentin, a structural analogue of GABA, targets multiple pathways involved in neuropathic pain and inflammation. It is commonly used to help peripheral neuropathic pain, dystonia and management of irritability in complex patients.

This study aimed to report one institution’s experience with gabapentin in a NICU setting. This was a retrospective study of infants admitted to the University of Virginia NICU between January 2015 and December 2017. Patients who were on gabapentin before admission and those transferred out of the NICU were excluded.

Age at start of gabapentin treatment, indication, initiation and discontinuation times, dosing and use of other neurosedative drugs were recorded. Mean daily pain scores were assessed using the Neonatal Pain, Agitation and Sedation Scale (N-PASS) – this was recorded 2 days prior to starting gabapentin and for the subsequent 28 days. Comparison of N-PASS scores before and after gabapentin treatment was analysed using a paired student’s t-test, with p<0.05 considered="" statistically="" significant="" p="">

Focusing on the patients with a neurological condition, 13 patients (out of 16) were included. These conditions included IVH (low and high grades), hydrocephalus (post haemorrhagic and congenital), HIE, cerebral infarct, venous sinus thrombosis, craniosynostosis and spinal cord injury.

Gabapentin was initiated (for pain, agitation and movement disorder) at doses ranging from 2.5-5 mg/kg/day, then increased every 3-5 days to effect, up to a maximum dose of 35 mg/kg/day. Infants reached their goal dose on average 26 days after initiation.

Ten infants were on multiple neurosedative medications at the start of gabapentin (benzodiazepines, opiates, alpha-adrenoreceptor antagonists). Of this patient subset, 1 died due to complex congenital heart disease. Gabapentin was stopped in another due to over-sedation on day 4. Of the remaining 8, a decrease in the mean number of neurosedative medications was observed (2.5/day -> 1.7/day). Gabapentin was associated with a decrease in N-PASS scores 14 days after starting treatment (p=0.003).

In summary, gabapentin was well-tolerated and was associated with lower pain scores and decreased need for multiple neurosedative medications 14 days after starting treatment.

Limitations of this study include the small sample size and retrospective design. An objective measurement tool was available for pain but not for agitation/irritability. Since this was a retrospective study, a direct causal relationship between gabapentin and reduced pain scores could not be inferred.

Despite these limitations, this study adds to the growing evidence (case series studies) that gabapentin is well tolerated and may help decrease pain scores and the need for multiple neurosedative medications in infants with a complex medical history.

Abstract

We aimed to report our institution’s experience with gabapentin therapy to manage agitation and pain in the neonatal intensive care unit (NICU) setting. This was a retrospective, single center study of NICU patients admitted between January 2015 and December 2017, who received gabapentin. Data on neonatal agitation, pain, Neonatal Pain, Agitation and Sedation Scale (N-PASS) scores, neurosedative medications, and adverse events were collected. Gabapentin was initiated in 16 patients at a corrected gestational age of 44 weeks (range 36.2–75wks) for agitation (n=9), pain (n=6), and movement disorders (n=1). A neurological diagnosis was present in 13 patients. Neonatal agitation, pain, and N-PASS scores and the need for other neurosedatives were significantly decreased 14 days after treatment initiation. Gabapentin is well tolerated in neonates and infants; it is associated with decreased pain scores and decreased need for multiple neurosedative medications 2 weeks after initiation.