Pain in babies
Encyclopedia
Pain in babies, and whether babies feel pain, has been the subject of debate within the medical profession for centuries. Prior to the late nineteenth century it was generally considered that babies hurt more easily than adults. It was only in the last quarter of the 20th century that scientific techniques finally established babies definitely do experience pain – probably more than adults – and has developed reliable means of assessing and of treating it
.
and homeostatic
changes which result from untreated pain, including an increased requirement for oxygen
, accompanied by a reduction in the efficiency of gas exchange in the lungs. This combination can lead to inadequate oxygen supply, resulting in potential hypoxemia
. In addition, a rise in stomach acidity accompanies the stress reaction precipitated by pain, and there is a risk of aspirating this into the lungs, further endangering lung integrity and tissue oxygenation. In cases of acute, persistent pain, the metabolism becomes predominantly catabolic, causing reduced efficiency of the immune system
and a breakdown of proteins caused by the action of the stress hormone
s. In combination, healing of damaged or infected tissue may be impaired, and morbidity and mortality
increased.
The neuropsychological
effect on the bonding between mother and child, on later contact with health professionals, and on personal and social psychological well-being is difficult to quantify. Research suggests that babies exposed to pain in the neonatal period have more difficulty in these areas. Professionals working in the field of neonatal pain have speculated that adolescent aggression
and self-destructive behaviour
, including suicide
, may, in some cases, be attributed to the long term effects of untreated neonatal pain.
are capable of relaying information, albeit slower than would be the case with myelinated fibres. At birth a baby has developed the neural pathway
s for nociception
and for experiencing pain, but the pain responses are not an immature version of that of an adult. There are a number of differences in both nerve structure and in the quality and extent of nerve response which are considered to be pertinent to understanding neonatal pain.
The nerves of young babies respond more readily to noxious stimuli
, with a lower threshold to stimulation, than those of adults. A baby's threshold for sensitisation is also substantially decreased, whilst the process involves a much larger area of sensitisation with each trauma. The neural pathways that descend from the brain to the spinal cord are not well developed in the newborn, resulting in the ability of the central nervous system to inhibit nociception being more limited than in the adult.
There are also indication that the neonate's nervous system
may be much more active than that of an adult, in terms of transforming its connections and central nerve pathways in response to stimuli. The ongoing process of neural pathway development, involving both structural and chemical changes of the nervous system, have been shown to be affected by pain events, both in the short term and potentially into adult life.
The classical International Association for the Study of Pain
definition of pain as a subjective, emotional experience that is described in terms of tissue damage, depends on the sufferer being able to self-report pain, which is little use in diagnosing and treating pain in babies. More significant are non-verbal responses, of which there are two kinds: gross physical movements and physiological response measurements. The former are simple direct observation, while the latter requires specific equipment to monitor blood pressure
and stress hormone
levels.
The cry response is increasingly important, as researchers are now able to differentiate between different kinds of cry: classed as “hungry”, “angry”, and “fearful or in pain”. Interpretation is difficult, however, depending on the sensitivity of the listener, and varies significantly between observers.
Studies have sought additional, visible and easily definable indicators of pain. Combinations of crying with facial expression
s, posture
and movements, aided by physiological measurements, have been tested and found to be reliable indicators. A number of such observational scales have been published and verified
Described in 2000, the scale uses a measurement of five items, each rated as 0, 1, or 2 based on the following parameters:
Total score indicates how the baby should be managed according to the scale:
All observations, both movement and physiological, tend to decrease when pain is persistent, thus rendering the scale unreliable in acute or prolonged cases. In addition, hyperalgesia
and allodynia
, occur more quickly and more extensively in babies than in adults. Day to day changes in the response to a specific injury may therefore become unpredictable and variable.
, health professionals will take steps to reduce pain to a minimum, though in some circumstances it may be not be possible to remove all pain.
In case of illness, accident and post operative pain, a graded sequence of treatment is becoming established as standard practice. Research is making it easier and simpler to provide the necessary care, with a clearer understanding of the risks and possible side effect
s.
s, where the actions are performed both by female and male adults. Children who are able to verbalise pain report it to be an ineffective strategy and this is assumed to also be true of babies.
While the pain of a procedure may or may not be affected, the fear is visibly reduced. This works to ameliorate the negative effects of fear in health care situations. It is, therefore, considered good practice to involve parents or care-givers directly, having them present and in contact with the baby whenever possible before a minor painful procedure, such as the drawing of blood, or prior to giving a local anaesthetic injection.
, the use of a pacifier and the administration of sugar orally has been proven to reduce the signs of pain in babies. Electroencephalographic changes are reduced by sugar, but the mechanism for this remains unknown; it does not seem to be endorphin
mediated. As in comforting, it is unknown whether the physical pain is reduced, or whether it is the level of anxiety which is affected. However, the reduction in pain behaviour is assumed to be accompanied by a reduction in pain-related disorders, both immediate and longer term.
in the brains of newborns one second after the heel lance procedure. Sweet oral liquid moderately reduces the incidence and duration of crying caused by immunization injection in children between one and twelve months of age.
and “kangaroo care
” have been shown to reduce the response of babies to painful or distressful circumstances, while a comprehensive technique of nursing, called “developmental care”, has been developed for managing pre-term infants.
Local infiltration anaesthesia, the infiltration of anaesthetic agent directly into the skin and subcutaneous tissue where the painful procedure is to be undertaken, may be effectively used to reduce pain after a procedure under general anaesthesia
. To reduce the pain of the initial injection, a topical anaesthetic ointment may be applied.
Regional anaesthesia requires the injection of local anaesthetic around the nerve trunks
that supply a limb, or into the epidural space
surrounding the spinal cord
. It is used for pain relief after surgery, but requires special facilities for observation of the baby until the effect has worn out.
of dosage important. The potentially harmful side effects of analgesic drugs are the same for babies as they are for adults and are both well known and manageable.
There are three forms of analgesia suitable for the treatment of pain in babies: paracetamol
(acetaminophen), the non-steroidal anti-inflammatory drugs, and the opiate
s. Paracetamol is safe and effective if given in the correct dosage. The same is true of the non-steroidal anti-inflammatory drugs, such as ibuprofen
(aspirin
is seldom used). Of the opiates, morphine
and fentanyl are most often used in a hospital setting, while codeine
is effective for use at home.
to heart operations
were done with no anaesthesia or analgesia, other than muscle relaxation
for the surgery. The belief was that in babies the expression of pain was reflex
ive and, owing to the immaturity of the infant brain
, the pain could not really matter.
Cope considers it probable that the belief arose from misinterpretation of discoveries made in the new science of embryology
. Dr Paul Flechsig
equated the non-myelinisation of much of a baby’s nervous system
with an inability to function. In addition, the writings of Charles Darwin
expressed a belief that babies, animals, savages and the insane were incapable of experiencing pain.
It was generally believed that babies would not remember any pain that they happened to feel, and that lack of conscious memory
meant lack of long-term harm. Scientific studies on animals with various brain lesions
were interpreted as supporting the idea that the responses seen in babies were merely spinal reflex
es. Furthermore, the whole effort of relieving pain was considered futile since it was thought to be impossible to measure the child's pain.
This, coupled with a concern that use of opiate
s would lead to addiction, and the time and effort needed to provide adequate analgesia to the newborn, contributed to the medical profession's continued practice of not providing pain relief for babies.
A number of studies on the measurement of pain in young children, and on ways of reducing the injury response began, and publications on the hormonal and metabolic
responses of babies to pain stimuli began to appear, confirming that the provision of adequate anaesthesia and analgesia was better medicine on both humanitarian and physiological grounds.
It is now accepted that the neonate responds more extensively to pain than the adult does, and that exposure to severe pain, without adequate treatment, can have long-term consequences. Despite the difficulty of assessing how much pain a baby is experiencing, and the practical problem of prescribing the correct dosage or technique for treatment, modern medicine is firmly committed to improving the quality of pain relief for the very young.
The effective treatment of pain benefits the baby immediately, reduces some medium-term negative consequences, and likely prevents a number of adult psycho-physiological
problems.
Pain management
Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists,...
.
Effects
There are a number of metabolicMetabolism
Metabolism is the set of chemical reactions that happen in the cells of living organisms to sustain life. These processes allow organisms to grow and reproduce, maintain their structures, and respond to their environments. Metabolism is usually divided into two categories...
and homeostatic
Human homeostasis
Human homeostasis is derived from the Greek, homeo or "same", and stasis or "stable" and means remaining stable or remaining the same.The human body manages a multitude of highly complex interactions to maintain balance or return systems to functioning within a normal range...
changes which result from untreated pain, including an increased requirement for oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
, accompanied by a reduction in the efficiency of gas exchange in the lungs. This combination can lead to inadequate oxygen supply, resulting in potential hypoxemia
Hypoxemia
Hypoxemia is generally defined as decreased partial pressure of oxygen in blood, sometimes specifically as less than or causing hemoglobin oxygen saturation of less than 90%.-Distinction from anemia and hypoxia:...
. In addition, a rise in stomach acidity accompanies the stress reaction precipitated by pain, and there is a risk of aspirating this into the lungs, further endangering lung integrity and tissue oxygenation. In cases of acute, persistent pain, the metabolism becomes predominantly catabolic, causing reduced efficiency of the immune system
Immune system
An immune system is a system of biological structures and processes within an organism that protects against disease by identifying and killing pathogens and tumor cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own...
and a breakdown of proteins caused by the action of the stress hormone
Stress hormone
Stress hormones such as cortisol, GH and norepinephrine are released at periods of high stress. The hormone regulating system is known as the endocrine system...
s. In combination, healing of damaged or infected tissue may be impaired, and morbidity and mortality
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....
increased.
The neuropsychological
Neuropsychology
Neuropsychology studies the structure and function of the brain related to specific psychological processes and behaviors. The term neuropsychology has been applied to lesion studies in humans and animals. It has also been applied to efforts to record electrical activity from individual cells in...
effect on the bonding between mother and child, on later contact with health professionals, and on personal and social psychological well-being is difficult to quantify. Research suggests that babies exposed to pain in the neonatal period have more difficulty in these areas. Professionals working in the field of neonatal pain have speculated that adolescent aggression
Aggression
In psychology, as well as other social and behavioral sciences, aggression refers to behavior between members of the same species that is intended to cause humiliation, pain, or harm. Ferguson and Beaver defined aggressive behavior as "Behavior which is intended to increase the social dominance of...
and self-destructive behaviour
Self-destructive behaviour
In human context, self-destructive behaviour is a widely used phrase that conceptualises certain kinds of destructive acts as belonging to the self. It also has the property that it characterises certain kinds of self-inflicted acts as destructive...
, including suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
, may, in some cases, be attributed to the long term effects of untreated neonatal pain.
Pathophysiology
The present understanding of pain in babies is largely due to the recognition that the fetal and newborn unmyelinated nerve fibresNeuron
A neuron is an electrically excitable cell that processes and transmits information by electrical and chemical signaling. Chemical signaling occurs via synapses, specialized connections with other cells. Neurons connect to each other to form networks. Neurons are the core components of the nervous...
are capable of relaying information, albeit slower than would be the case with myelinated fibres. At birth a baby has developed the neural pathway
Neural pathway
A neural pathway, neural tract, or neural face, connects one part of the nervous system with another and usually consists of bundles of elongated, myelin-insulated neurons, known collectively as white matter...
s for nociception
Nociception
Nociception is defined as "the neural processes of encoding and processing noxious stimuli." It is the afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue...
and for experiencing pain, but the pain responses are not an immature version of that of an adult. There are a number of differences in both nerve structure and in the quality and extent of nerve response which are considered to be pertinent to understanding neonatal pain.
The nerves of young babies respond more readily to noxious stimuli
Stimulus (physiology)
In physiology, a stimulus is a detectable change in the internal or external environment. The ability of an organism or organ to respond to external stimuli is called sensitivity....
, with a lower threshold to stimulation, than those of adults. A baby's threshold for sensitisation is also substantially decreased, whilst the process involves a much larger area of sensitisation with each trauma. The neural pathways that descend from the brain to the spinal cord are not well developed in the newborn, resulting in the ability of the central nervous system to inhibit nociception being more limited than in the adult.
There are also indication that the neonate's nervous system
Nervous system
The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous...
may be much more active than that of an adult, in terms of transforming its connections and central nerve pathways in response to stimuli. The ongoing process of neural pathway development, involving both structural and chemical changes of the nervous system, have been shown to be affected by pain events, both in the short term and potentially into adult life.
Diagnosis
Some of the signs of pain in babies are obvious, requiring no special equipment or training. The baby is crying and irritable when awake, develops a disturbed sleep pattern, feeds poorly, and shows a fearful, distrustful reaction towards care-givers.The classical International Association for the Study of Pain
International Association for the Study of Pain
The International Association for the Study of Pain is an international professional organization promoting research, education and policies for the knowledge and management of pain. The IASP was founded in 1973, following the Seattle-Issaquah conference, under the leadership of John Bonica. Its...
definition of pain as a subjective, emotional experience that is described in terms of tissue damage, depends on the sufferer being able to self-report pain, which is little use in diagnosing and treating pain in babies. More significant are non-verbal responses, of which there are two kinds: gross physical movements and physiological response measurements. The former are simple direct observation, while the latter requires specific equipment to monitor blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
and stress hormone
Stress hormone
Stress hormones such as cortisol, GH and norepinephrine are released at periods of high stress. The hormone regulating system is known as the endocrine system...
levels.
The cry response is increasingly important, as researchers are now able to differentiate between different kinds of cry: classed as “hungry”, “angry”, and “fearful or in pain”. Interpretation is difficult, however, depending on the sensitivity of the listener, and varies significantly between observers.
Studies have sought additional, visible and easily definable indicators of pain. Combinations of crying with facial expression
Facial expression
A facial expression one or more motions or positions of the muscles in the skin. These movements convey the emotional state of the individual to observers. Facial expressions are a form of nonverbal communication. They are a primary means of conveying social information among humans, but also occur...
s, posture
Human position
Human positions refers to the different positions that the human body can take.There are several synonyms that refer to the human position, often used interchangeably, but having specific flavors....
and movements, aided by physiological measurements, have been tested and found to be reliable indicators. A number of such observational scales have been published and verified
Children and Infants’ Postoperative Pain Scale
The Children and Infants Postoperative Pain Scale (ChIPPS) is often used in the assessment of hospitalised babies. The scale requires no special measurements, and is therefore applicable across a wide range of circumstances.Described in 2000, the scale uses a measurement of five items, each rated as 0, 1, or 2 based on the following parameters:
| Item | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Crying | None | Moaning | Screaming |
| Facial expression | Relaxed smiling | Wry mouth | Grimacing |
| Posture of the trunk | Neutral | Variable | Rear up |
| Posture of the legs | Neutral | Kicking | Tightened |
| Motor restlessness | None | Moderate | Restless |
Total score indicates how the baby should be managed according to the scale:
- 0 - 3 No requirement for treating pain,
- 4 - 10 Progressively greater need for analgesia.
All observations, both movement and physiological, tend to decrease when pain is persistent, thus rendering the scale unreliable in acute or prolonged cases. In addition, hyperalgesia
Hyperalgesia
Hyperalgesia is an increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves. Temporary increased sensitivity to pain also occurs as part of sickness behavior, the evolved response to infection.-Types:...
and allodynia
Allodynia
Allodynia is a pain due to a stimulus which does not normally provoke pain. Temperature or physical stimuli can provoke allodynia, and it often occurs after injury to a site...
, occur more quickly and more extensively in babies than in adults. Day to day changes in the response to a specific injury may therefore become unpredictable and variable.
Treatment
Where the baby is to undergo some form of planned procedureMedical procedure
A medical procedure is a course of action intended to achieve a result in the care of persons with health problems.A medical procedure with the intention of determining, measuring or diagnosing a patient condition or parameter is also called a medical test...
, health professionals will take steps to reduce pain to a minimum, though in some circumstances it may be not be possible to remove all pain.
In case of illness, accident and post operative pain, a graded sequence of treatment is becoming established as standard practice. Research is making it easier and simpler to provide the necessary care, with a clearer understanding of the risks and possible side effect
Side effect
In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequences of the use of a drug.Occasionally, drugs are...
s.
Comforting
Touching, holding, stroking, keeping warm, talking and singing/music are ways in which adults have been comforting babies since the start of human history. This way of managing pain is shared with other primatePrimate
A primate is a mammal of the order Primates , which contains prosimians and simians. Primates arose from ancestors that lived in the trees of tropical forests; many primate characteristics represent adaptations to life in this challenging three-dimensional environment...
s, where the actions are performed both by female and male adults. Children who are able to verbalise pain report it to be an ineffective strategy and this is assumed to also be true of babies.
While the pain of a procedure may or may not be affected, the fear is visibly reduced. This works to ameliorate the negative effects of fear in health care situations. It is, therefore, considered good practice to involve parents or care-givers directly, having them present and in contact with the baby whenever possible before a minor painful procedure, such as the drawing of blood, or prior to giving a local anaesthetic injection.
Oral stimulation
BreastfeedingBreastfeeding
Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers breastfeed for six months or...
, the use of a pacifier and the administration of sugar orally has been proven to reduce the signs of pain in babies. Electroencephalographic changes are reduced by sugar, but the mechanism for this remains unknown; it does not seem to be endorphin
Endorphin
Endorphins are endogenous opioid peptides that function as neurotransmitters. They are produced by the pituitary gland and the hypothalamus in vertebrates during exercise, excitement, pain, consumption of spicy food, love and orgasm, and they resemble the opiates in their abilities to produce...
mediated. As in comforting, it is unknown whether the physical pain is reduced, or whether it is the level of anxiety which is affected. However, the reduction in pain behaviour is assumed to be accompanied by a reduction in pain-related disorders, both immediate and longer term.
Oral sugar
Sugar taken orally reduces the total crying time but not the duration of the first cry in newborns undergoing a painful procedure (a single lancing of the heel). It does not moderate the effect of pain on heart rate and a recent single study found that sugar did not significantly affect pain-related electrical activityEEG
EEG commonly refers to electroencephalography, a measurement of the electrical activity of the brain.EEG may also refer to:* Emperor Entertainment Group, a Hong Kong-based entertainment company...
in the brains of newborns one second after the heel lance procedure. Sweet oral liquid moderately reduces the incidence and duration of crying caused by immunization injection in children between one and twelve months of age.
Other techniques
Other "old fashioned" techniques are being tested with some success. “Facilitated tucking”, swaddlingSwaddling
Swaddling is an age-old practice of wrapping infants in swaddling cloths, blankets or similar cloth so that movement of the limbs is tightly restricted. Swaddling bands were often used to further restrict the infant...
and “kangaroo care
Kangaroo care
Kangaroo care is a technique practiced on newborn, usually preterm, infants wherein the infant is held, skin-to-skin, with an adult. Kangaroo care for pre-term infants may be restricted to a few hours per day, but if they are medically stable that time may be extended. Some parents may keep their...
” have been shown to reduce the response of babies to painful or distressful circumstances, while a comprehensive technique of nursing, called “developmental care”, has been developed for managing pre-term infants.
Local anaesthetics
A variety of topical anaesthetic creams have been developed, ranging from single agents with good skin penetration, to eutactic mixtures of agents and technologically modern formulations of lignocaine in microspheres. They are effective in suitable procedures, if correctly and timeously applied. Disadvantages are the slow onset of adequate anaesthesia, inadequate analgesia for larger procedures, and toxicity of absorbed medication.Local infiltration anaesthesia, the infiltration of anaesthetic agent directly into the skin and subcutaneous tissue where the painful procedure is to be undertaken, may be effectively used to reduce pain after a procedure under general anaesthesia
General anaesthesia
General anaesthesia is a state of unconsciousness and loss of protective reflexes resulting from the administration of one or more general anaesthetic agents...
. To reduce the pain of the initial injection, a topical anaesthetic ointment may be applied.
Regional anaesthesia requires the injection of local anaesthetic around the nerve trunks
Nerve plexus
A nerve plexus is a network of intersecting nerves. Except for the ventral rami of Th2-Th11 nerves, they combine sets of ventral rami of spinal nerves that serve the same area of the body into one large grouped nerve...
that supply a limb, or into the epidural space
Epidural space
In the spine, the epidural space is the outermost part of the spinal canal. It is the space within the canal lying outside the dura mater...
surrounding the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...
. It is used for pain relief after surgery, but requires special facilities for observation of the baby until the effect has worn out.
Analgesics
As the site of pain in babies is difficult to confirm, analgesics are often advised against until a proper diagnosis has been performed. For all analgesic drugs, the immaturity of the baby’s nervous system and metabolic pathways, the different way in which the drugs are distributed, and the reduced ability of the baby to excrete the drugs though the kidneys make the prescriptionMedical prescription
A prescription is a health-care program implemented by a physician or other medical practitioner in the form of instructions that govern the plan of care for an individual patient. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist or other therapist....
of dosage important. The potentially harmful side effects of analgesic drugs are the same for babies as they are for adults and are both well known and manageable.
There are three forms of analgesia suitable for the treatment of pain in babies: paracetamol
Paracetamol
Paracetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
(acetaminophen), the non-steroidal anti-inflammatory drugs, and the opiate
Opiate
In medicine, the term opiate describes any of the narcotic opioid alkaloids found as natural products in the opium poppy plant.-Overview:Opiates are so named because they are constituents or derivatives of constituents found in opium, which is processed from the latex sap of the opium poppy,...
s. Paracetamol is safe and effective if given in the correct dosage. The same is true of the non-steroidal anti-inflammatory drugs, such as ibuprofen
Ibuprofen
Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....
(aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
is seldom used). Of the opiates, morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
and fentanyl are most often used in a hospital setting, while codeine
Codeine
Codeine or 3-methylmorphine is an opiate used for its analgesic, antitussive, and antidiarrheal properties...
is effective for use at home.
Pre Late 19th Century
Before the late nineteenth century, babies were considered to be more sensitive to pain than adults. Doris Cope quotes paediatric surgeon Felix Würtz of Basel, writing in 1656:- If a new skin in old people be tender, what is it you think in a newborn Babe? Doth a small thing pain you so much on a finger, how painful is it then to a Child, which is tormented all the body over, which hath but a tender new grown flesh?
Late 19th Century
In the late nineteenth, and first half of the twentieth century, doctors were taught that babies did not experience pain, and were treating their young patients accordingly. From needle sticks to tonsillectomiesTonsillectomy
A tonsillectomy is a 3,000-year-old surgical procedure in which the tonsils are removed from either side of the throat. The procedure is performed in response to cases of repeated occurrence of acute tonsillitis or adenoiditis, obstructive sleep apnea, nasal airway obstruction, snoring, or...
to heart operations
Cardiac surgery
Cardiovascular surgery is surgery on the heart or great vessels performed by cardiac surgeons. Frequently, it is done to treat complications of ischemic heart disease , correct congenital heart disease, or treat valvular heart disease from various causes including endocarditis, rheumatic heart...
were done with no anaesthesia or analgesia, other than muscle relaxation
Muscle relaxant
A muscle relaxant is a drug which affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics...
for the surgery. The belief was that in babies the expression of pain was reflex
Reflex
A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc; this does not apply to casual uses of the term 'reflex'.-See also:...
ive and, owing to the immaturity of the infant brain
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
, the pain could not really matter.
Cope considers it probable that the belief arose from misinterpretation of discoveries made in the new science of embryology
Embryology
Embryology is a science which is about the development of an embryo from the fertilization of the ovum to the fetus stage...
. Dr Paul Flechsig
Paul Flechsig
Paul Emil Flechsig was a German neuroanatomist, psychiatrist and neuropathologist. He is mainly remembered today for his research of myelinogenesis.-Biography:...
equated the non-myelinisation of much of a baby’s nervous system
Nervous system
The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous...
with an inability to function. In addition, the writings of Charles Darwin
Charles Darwin
Charles Robert Darwin FRS was an English naturalist. He established that all species of life have descended over time from common ancestry, and proposed the scientific theory that this branching pattern of evolution resulted from a process that he called natural selection.He published his theory...
expressed a belief that babies, animals, savages and the insane were incapable of experiencing pain.
It was generally believed that babies would not remember any pain that they happened to feel, and that lack of conscious memory
Memory
In psychology, memory is an organism's ability to store, retain, and recall information and experiences. Traditional studies of memory began in the fields of philosophy, including techniques of artificially enhancing memory....
meant lack of long-term harm. Scientific studies on animals with various brain lesions
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
were interpreted as supporting the idea that the responses seen in babies were merely spinal reflex
Reflex
A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc; this does not apply to casual uses of the term 'reflex'.-See also:...
es. Furthermore, the whole effort of relieving pain was considered futile since it was thought to be impossible to measure the child's pain.
This, coupled with a concern that use of opiate
Opiate
In medicine, the term opiate describes any of the narcotic opioid alkaloids found as natural products in the opium poppy plant.-Overview:Opiates are so named because they are constituents or derivatives of constituents found in opium, which is processed from the latex sap of the opium poppy,...
s would lead to addiction, and the time and effort needed to provide adequate analgesia to the newborn, contributed to the medical profession's continued practice of not providing pain relief for babies.
Mid 1980's
In the United States, a major change in practice was brought about by events surrounding one operation. Infant Jeffrey Lawson underwent open heart surgery in 1985. His mother, Jill R. Lawson, subsequently discovered that he had been operated on without any anaesthesia, other than a muscle relaxant. She started a vigorous awareness campaign which created such a public, and medical, reaction that by 1987 medical opinion had come full circle.A number of studies on the measurement of pain in young children, and on ways of reducing the injury response began, and publications on the hormonal and metabolic
Metabolism
Metabolism is the set of chemical reactions that happen in the cells of living organisms to sustain life. These processes allow organisms to grow and reproduce, maintain their structures, and respond to their environments. Metabolism is usually divided into two categories...
responses of babies to pain stimuli began to appear, confirming that the provision of adequate anaesthesia and analgesia was better medicine on both humanitarian and physiological grounds.
It is now accepted that the neonate responds more extensively to pain than the adult does, and that exposure to severe pain, without adequate treatment, can have long-term consequences. Despite the difficulty of assessing how much pain a baby is experiencing, and the practical problem of prescribing the correct dosage or technique for treatment, modern medicine is firmly committed to improving the quality of pain relief for the very young.
The effective treatment of pain benefits the baby immediately, reduces some medium-term negative consequences, and likely prevents a number of adult psycho-physiological
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
problems.
External links
- Pain Journal of the IASPInternational Association for the Study of PainThe International Association for the Study of Pain is an international professional organization promoting research, education and policies for the knowledge and management of pain. The IASP was founded in 1973, following the Seattle-Issaquah conference, under the leadership of John Bonica. Its...