| Infantile traumas

New research assesses newborns' physical pain

Crying is the language of infants. Regardless of place or time, parents have faced the puzzling task of discovering the reasons behind their child’s tears. Most often, babies cry because they are hungry, cold, or tired, but sometimes they’ll cry because they are in pain.

Perhaps surprisingly, infants undergo numerous painful procedures. For starters, birth can be quite a traumatic and painful experience in itself. Additionally, doctors give all newborns a heel stick – a procedure that draws blood sample from the heel sometime during their first 72 hours of life. Afterward, the doctor decides what other kinds of pinches and pokes the infant will endure from vitamin K injections to punctures in veins. Premature infants generally experience between one and twelve painful events a day, according to Celeste Johnston, a professor and researcher at McGill’s School of Nursing. While anesthesia is commonly used in major pediatric surgeries, a great deal of medical literature suggests a lack of local anesthetic use in minor surgical procedures. For example, one study found that while adults receive local anesthetics for spinal taps, newborns rarely ever do.

These and other issues concerning pediatric pain were addressed at the 13th World Congress on Pain that took place in Montreal this past August. Many researchers from the conference, including Johnston, are currently looking at ways to manage and, in some cases, prevent babies’ many unnecessarily painful experiences.

A few telltale signs distinguish a baby’s bawl of pain from other cries, explained Johnston: the baby grimaces with eyes squeezed shut and mouth open (this universal “pain face” was recorded by Darwin well over a century ago), and lets out a harsh high-pitched and shrill cry while pulling in his or her limbs close to the body, growing tense and tight. Less visibly, the baby’s oxygen decreases and their heart rate increases simultaneously.

Though significant, these signals do not tell us much about the pain’s intensity or duration. While an adult can verbally self-report on these features using a scale of one to ten, an infant must be assessed differently. Remarkably, there are currently about 40 forms of pediatric pain evaluations, yet most are based on a few basic criteria: facial expressions, heart rate changes, oxygen saturation, and crying. Pediatricians assign numerical scores to each category to sum up a total pain rating. The most common forms of child pain assessment are the FLACC (Face, Legs, Activity, Cry, and Consolability) scale for children and infants and the PIPP (Premature Infant Pain Profile) for premature newborns.

New research on brain activity in infants will hopefully become another valuable pain assessment tool. Various brain imaging studies focus on whether pain signals generated by stimuli reach the somatosensory cortex, the part of the brain responsible for perceiving bodily sensation in infants and pre-term neonates. According to Johnston, the most comprehensive way to assess pain in infants would be to zero in on “a combination of behaviours and physiological changes and brain activity.”

Though many painful procedures continue to take place, babies all over the world are in luck. Recent research findings and clinical studies have proven numerous successful techniques to ease infant suffering that are neither costly nor require a visit to the pediatrician. I guess Mary Poppins knew it all along – “just a spoonful of sugar” can do wonders. Anything sweet with about 24 per cent sucrose will release pleasurable endorphins that distract from the feeling of pain, explained Johnston. The best method is dipping a pacifier into something sweet; released endorphins combine with serotonin released from the sucking action. However, there are limits to the benefits of sucrose. As Julie Brouillard of the Acute Pain Service Department at the Montreal Children’s Hospital described, it only works for mild pain or pain occurring during a short period of time.

The “sweet taste” technique can be combined with another method to calm a baby in pain commonly called Kangaroo Care, when a mother holds her naked baby against her bare chest and wraps around them both something warm like a blanket (fathers may use this technique as well, but the results for pain reduction are not as successful). Breast-feeding a baby with the same skin-to-skin contact can have similar pain-reducing effects during stressful immunization or intravenous medical procedures, said Johnston.

Brouillard explained that it’s also a good idea for parents to prepare children going through procedural pain so the pain does not come as a suprise. However, too much information about an upcoming surgery or other medical procedure can make a child overly anxious.

When administering shots or conducting operations on infants and young children, doctors are faced with the ethical considerations of balancing the risk of administering medication with the child’s level of pain. Infant pain only became of medical interest in the 1980s, leading to a set of guidelines for the treatment of procedural pain, a measure jointly established by the American and Canadian Pediatric Societies. The code includes many of the aforementioned techniques as well as the obligation for doctors and researchers to present all treatments available to the parents of infants, even when they may personally disagree with the use of drugs.

In fact, there are lasting negative effects in ignoring or reducing infant anesthetic use. Infants whose first few years of life are characterized by painful events and lack of care may suffer long-term consequences. Johnston, whose research on neonatal care relates directly with this malady, says that infants may develop a “learned helplessness” similar to adult depression. They do not respond vigorously to stimuli, even painful ones, and typically have a low energy level. These babies often grow up with altered pain processing abilities. While their pain threshold is higher than most children’s, they tend to experience very painful events with a higher intensity and lower tolerance.

Simple measures taken by parents can easily prevent these ramifications. Being aware of a baby’s cry and holding them close can make all the difference. Even distracting a child by telling a story or singing a song during a painful procedure will help, said Johnston, significantly more so than empty words of solace such as “Its going to be okay.”

Now more than ever, with studies like Johnston’s and conferences addressing the topic of pediatric pain, crying infants are being given a voice.