Pain in babies

Do babies and children before they can speak or express feelings hurt in the same way as adults hurt? Do they hurt more easily, or do they feel less pain? Up until the last 30 years medicine seems to have been unable to make up its mind about this. Doctors followed whatever the prevailing expert opinion was, and until the late nineteenth century it was generally considered that babies hurt more easily than adults. Then the opinion changed, and until the mid 1970s doctors “knew” that babies do not feel much pain. For much of the history of modern scientific medicine children and babies were therefore denied the benefits of the steadily improving medical techniques of treating pain. Fortunately for the linguistically challenged young human, having nothing but a fierce cry with which to convey hurt, science has in the last quarter of the 20th century established beyond reasonable doubt that neonates and babies definitely do experience pain – probably more than adults.

This article sets out to review the main difficulties involved in assessing and treating pain in children. It aims to dispell those social, medical, and scientific myths and fallacies which have caused whole generations of children to suffer unnecessarily, and to help in empowering caregivers to approach the hurting child with more confidence.

However could we think babies don’t hurt?

Before the late nineteenth century babies were considered to be more sensitive to pain than adults. That this should be so was patently obvious, by virtue of everyday observations and logic. The baby had a thinner skin, and an adult knows that the thin skin of a healing wound is more sensitive than the thick skin on a finger. Doris Cope quotes from The Children's Book, by Felix Wurtz, published in 1656, to illustate this logic: "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?" The ease with which an apparently trifling hurt can set off a piteous crying spell in the young child had made its impression on Mr Wurtz, and set him a-wondering, as it has turned out, on the right path.

But then the whole idea did a turn-about. Suddenly, in the late nineteenth and first half of the twentieth century, doctors were being taught that babies did not experience pain, and they were treating their young patients according to this unproven idea. From needle sticks to tonsillectomies to heart operations were done with no analgesia or even anaesthesia, other than muscle relaxation for the surgery.

When one realises that a horse lover is prepared to put his beloved mount “out of its misery” when it sustains an incurable injury, this callous attitude of humans towards their young seems inexplicable. Doris Cope thinks it possible that this was a result of a scientific misinterpretation of the findings of the new science of embryology – which considered that the non-myelinisation of much of a baby’s nervous system indicated that it did not yet function – taken together with the writings of Charles Darwin in his book The Expression of Emotions in Man and Animal (1872), that babies (as well as “animals, savages and the insane”) were incapable of experiencing pain. Whatever the real cause for the myth was, doctors were taught that in babies the expression of “pain is merely reflexive and … owing to the immaturity of the infant brain, the pain could not really matter.” At the same time there was the unscientific belief that use of opiates would lead to addiction, 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 reflexes. Furthermore, the whole effort of relieving pain was considered futile since it was thought to be impossible to measure the child's pain. No doubt the perceived risk of opiates, and the time and effort needed to provide adequate analgesia to the newborn, contributed to the doctor clinging to the doctrine of “carry on regardless of the crying”, rather than worrying about the ethics of not providing pain relief.. The “sensible and safe” approach was therefore to get on with the job and ignore the child’s crying.

While there were always doctors who treated young patients’ pain at face value, the revolution towards studying and treating pain in babies gained momentum in the 1980s. Publications on the hormonal and metabolic responses of babies to noxious stimuli began to appear, in the face of which the arguments about an “inadequate” cerebral response to pain could not be sustained. Studies on the measurement of pain in young children, as well as ways of reducing the injury response began to be done. The medical opinion about the significance of pain in the neonate has come a full circle. We now know that the very young respond more extensively to pain than the adult does, and that exposure to severe pain, without adequate treatment, can have long-term consequences. Recent writers have even suggested that inadequate treatment of painful events in the newborn may be related to violence and self-mutilation, even suicide, in later life. In spite of the difficulty of assessing how much pain a baby has, and the problem of finding the correct dosage or technique for treating a feeling which can be gauged but indirectly, modern medicine is firmly committed to improving the quality of pain relief for the very young. Science is catching up with what the caring mother has always known about her child, by the tone of her offspring’s cry.

The developmental neurobiology of pain

Ethically, one cannot take biopsies of babies’ nerves or brain tissue in order to study the neuronal anatomy and chemistry. If it were to become practical to turn the powerful tools of functional neuro-imaging to use in the study of neonates, it may well mean a second revolution in our understanding of pain in the newborn, but this has not yet been done. The reader has therefore to interpret this section in the light of the fact that beliefs about the development of the nociceptive component of the human nervous system frequently are deduced from findings in animal models of neonatal nociception.

One of the critical scientific events which lead to the present improved understanding of pain in the newborn was the realisation that the fetal and newborn unmyelinated nerve fibres are quite capable of relaying information, albeit slower than would be the case with myelinated fibres. The dictum that “babies don’t feel pain because their nerve pathways are not yet completely myelinated” originated in the nineteenth century, but was eventually, almost a century later, shown by experiment in animal models to be false.

At birth a human has developed the neural pathways for pain perception, but the pain responses of a newborn baby is not simply a miniaturised or 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 responses which are considered to be pertinent to understanding neonatal pain.

For one, the nerves of young babies respond more readily to noxious stimuli (lower threshold to stimulation), than those of adults. Secondly, their threshold for sensitisation is also decreased. Sensitisation refers to to the phenomenon that a spinal neuron which senses a noxious event activates connections to adjacent neurons in the spine, increasing their sensitivity to noxious stimuli. In practice this means that an area of hypersensitivity to stimulation develops in the normal (unharmed, or not infected) tissue around a site of injury. This happens in adults and babies, but in babies this occurs more quickly and the sensitised area is larger than in an adult, for the same initial stimulus. A third factor which deserves mention is the fact that the pathways that descend from the brain to the spinal cord are not well developed in the newborn, so that the ability to reduce pain via central brain mechanisms is limited. Finally, the distribution of certain pain receptors is different in the newborn, compared to the adult. Specifically, the sensitivity to morphine and some anaesthetics seems to be quite different, and this is explained by the difference in the neuronal receptors for the specific drugs. For all these known reasons, and probably many which still need to be discovered, a noxious event which appears minor to adults (for instance, an intramuscular injection) can have unexpectedly widespread effects in the nervous sytem; it is sensed more intensely and potentially more diffusely than it would be in the adult.

As important as the basic increased sensitivity, it is important that the neonate's nervous system seems much more active than that of an adult in transforming its connections and central nerve pathways in response to stimuli. This reshaping - also called plasticity - involves both structural and chemical changes of the nervous system. It has been shown to occur in response to noxious events in the short term, and there are indications that such changes, once established, can persist until adult life. What precisely this implies for later childhood and adult life is as yet unclear, but the present feeling is that this potential for long term harm is yet another reason for working towards more effective management of neonatal pain.

Why treat pain?

If it made no difference to a person whether he or she experienced repeated and severe pain as a baby, then it would be a senseless exercise for the care-givers to look for ways of relieving such pain. What is known about the pain response and the effects of pain on the baby, both immediate and long term, argues strongly for the view that the effective treatment of pain benefits the patient now, reduces some medium-term negative consequences, and likely prevents a number of adult psycho-physiological problems.

Some of the immediate effects of pain are obvious to the observer, 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. These all have implications for the future well-being of the child, not least because the relationship between care-givers and neonate may suffer, with the necessary caring and tenderness being replaced by mutual irritation.

What the observer may not notice, however, is the number of metabolic and homeostatic changes that are caused by untreated pain. The neonate in pain develops an increased requirement for oxygen, while at the same time the gas exchange between air and blood in the lungs becomes less efficient. The combination can lead to inadequate oxygen supply to the cells. The damage that hypoxemia does to cells is well known, and may be permanent, but in the neonate it may be impossible to quantify. Another unseen disadvantage is the rise in stomach acidity that accompanies the stress reaction precipitated by the pain. The sick neonate, in pain, is at risk of aspirating this acid into the lungs, further endangering lung integrity and tissue oxygenation.

The undesirable effects of pain go further. For the duration of the period of persistent pain (for instance after an operation), or of repeated episodes of acute pain (for instance from the procedures in an intensive care unit), the metabolism becomes prdominantly catabolic, that is, the baby is not building up its own protein and tissues, but breaking them down through the action of the stress hormones. This same pain and stress response reduces the efficiency of the immune system. Taken together with the reduced oxygen available, it would not be surprising if healing of damaged or infected tissue is impaired, and morbidity and mortality increased. This has been shown to be true in trials of analgesia in newborns with pain.

The neuropsychological effect of untreated pain 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, but research indicates that babies exposed to pain in the neonatal period have more difficulties in all these areas of function, to their detriment as older children and adults. Professionals working in the field of neonatal pain have even speculated that adolescent aggression and self-destructive behaviour – including suicide – may in some cases be caused by untreated neonatal pain and stress.(Anand wrote about the suicide behaviour in adolescents -> Reference somewhere?)

Diagnosis

The problem of assessing pain in the child – factors different from adult. Nociceptive activity vs emotional response. Problem if latter is used as criterion.

Pain assessment

the problem of no language dependence

Ways of trying to get past these difficulties

observations, forms, scales, pictures. Reliability – can one treat on these results?

Treatment

Decisions about when to treat - Specific ways of treating - difference from adults - dosage implications. Parents/family/caregiver education

Pharmacologic treatment

”Placeboid”

pacifier +- sucrose, coddling, etc.

Analgesics

Paracetamol and NSAIDs Opiates

Topical, local and regional anaesthesia

What is topical / local / regional? How does it work? What are the risks / benefits?

Physical treatments

That relieve pain That cause pain (see also specific conditions)

Environment

A place of rest and peace vs a place of conflict

Psychological

Parents and caregivers. The babies intuition. Truth and trust. Confidence and love.

Specific conditions

This may be redone by way of complexity of treatment (as opposed to by condition) graded from coddling to GA.

It may then be included in the previous section on treatments, e.g. : "Local anesthetic infiltration is xxxx etc. It is useful for managing the pain of xyz (procedure or painful event), and has the advantages of abc".

On the other hand, a person looking for what one does for a condition may prefer the treatment-by-condition order of things. Or maybe just do the one as a discussion, and the "condition>form of analgesia" as a list or table.

Bloods and IVs; Diagnostic procedures; Postoperative; Trauma, including burns; Cancer; Sickling; AIDS.