Sunday, June 29, 2008

Pain Response in Preemies

"Methods commonly used by doctors to assess pain in infants may be underestimating the amount of pain they feel, according to a study by UCL researchers."


Kate K. said...

Their finding is hardly surprising. But I guess researchers have to come up with empirical proof of the obvious in order to justify changes to the practice of medicine.

Regarding this passage:
Dr Rebeccah Slater (UCL Biosciences) says: “Infants may appear to be pain free, but may, according to brain activity measurements, still be experiencing pain. It would be exciting to explore whether measures of brain activity could complement current methods for measuring pain in infants.”

Perhaps a better press release would have mentioned how this research will be used to minimize the pain in premature babies in the future rather than relishing in the idea that they’ll come up with new measures for detecting pain. I'm sure that this researcher is excited; this will contribute to another article on her vita. I would be more interested, however, in plans of action for preventing problems in brain development.

I suspect in 15-20 years the researchers will also conduct studies that use new methods to show that noise adversely affects preemie development even when the noise doesn't cause bradys or apnea spells. Again, it should be very obvious that noise around premature babies isn't good for them in the NICU (and also leads to behavioral and learning problems b/c of changes in brain development), but it will take millions of dollars and experts in the field to study what should be obvious before substantial changes are made in NICU practices.

Anonymous said...

Helen Harrison said...

This research is important, I think, because, although the pain of our children in the NICU may be obvious to some of us, it isn't to many of the docs. They do need this kind of empirical evidence.

I've heard so many neonatologists tell me "[Preemies] don't feel pain like you or I would..." (A look at some neo blogs indicates that this thinking continues.)

And, no, they don't feel pain like we would. Instead, I think the pain of preemies is worse, because these babies can't understand what is happening to them. It is merely random torture.

What also happens, is that the pain of early prematurity and NICU care changes the brains of our babies and makes them not process pain normally later in life.

It is also thought to lead to brain damage and autism, but that's another story.

We are just back from a stay in hospital, after our 29-weeker, Ed -- age 32 years -- developed pneumonia. We were admitted to the ER at UCSF and, because
Ed's heart was beating so rapidly -- 135 beats per minute, he was given an immediate EKG.

The docs quickly returned to Ed's bedside and informed us that the EKG showed our son was in the midst of a heart attack (Ed showed no signs of pain).

We all thought(in the absence of obvious chest pain) that the EKG must be mistaken. Then the blood work came in confirming damage to Ed's heart.

And through it all he showed no pain. Just as he showed no obvious pain when coming down with a hideous small bowel obstruction, or major intracranial pressure from shunt failure.

He either doesn't "feel" the pain in a normal way or, perhaps, he is just too frightened to acknowledge it, lest he be taken to the hospital and handed over to the doctors.

I guess all the unanesthetized surgery and other excruciating procedures that he endured in the neonatal period scrambled his pain signals or gave him new warning signals that are more compelling than pain.

Oh yes, and he is also autistic.

The CBS evening news with Katie Couric is apparently going to do something on the pain of premature infants and its life-long consequences tomorrow night.


Kristie McNealy said...


I hope Ed is doing OK. That must be pretty terrifying knowing that he doesn't seem to respond to such painful things.

The little differences our preemie has (at age 2) are heart breaking, because I know the NICU played a major part in how she relates to other people, and to pain and unusual stimuli. Just yesterday she came up behind me and wrapped her arms around me. It was literally the FIRST time she has ever hugged anyone, and Im pretty sure she did it from behind so I couldnt grab her back.

Take care,

Laura said...

okay, i will admit i haven't read the study yet. i bookmarked it for when i am not babysitting the brand new grandbaby...but i will offer from my own observations over the last (yegads! two decades that perhaps it is not necessarily how preemies feel pain but rather how they cope or handle pain. to some a screaming, writhing crying baby is obviously in pain and in some cases, they are, in others they just need to be picked up or nested or soothed with a binky. on the other hand a baby lying perfectly still and being quiet is often viewed as being "comfortable" yet often in a critical care setting a baby presenting like this could likely be in pain. i can only compare a baby presenting like this to when i broke my arm. it hurt like hell and i had no intention of moving it or my upper body under any circumstances because the pain was so great. in my nursing practice i try to look at subtleties like this. the neonate is trying to convey their pain level to me as their nurse. it is my job to look very closely and not always for the expected pain response.
i like what helen shared about her son too. i know my own ex-24 weeker son does seem to react to and cope with many stressors in ways the "normal" population does not, pain included.
okay, now off to read this link. thanks for passing it on.

Anonymous said...

Note the difference in response to this news item: Dr. Rebeccah Slater, who is close to the research, but removed from the bedside, minute-by-minute care of the infant; vs. Laura, who is talking about getting to know a baby and "reading her cues". The Slater response is the science of medicine; the Laura response is the ART of medicine/care. The Laura response will be very difficult to study as research, since it is often flying below the radar screen(as are the baby's pain signals). It is intuitive, the reading of body language and responding to body language.

This piece may seem obvious, but it is not the least obvious to me, how we can know, and how we can respond to a baby's pain/discomfort.

And by the way, this is really NOT a doctor issue, except that they are the ones prescribing pain meds. This is a nurse issue, since they are the ones at the bedside, getting to know the baby, attending minute by minute. It is the nurse who does the pain assessment--not the doc. In surgery, the anesthesiologist may also play a role . . . but in the day-to-day routine, it is the nurse who interprets pain, documents s/s of pain, "manages" pain. Why is it that nurses do not have a voice/use their voices about this issue and others that belong to them??!!??

Chris and Vic

Anonymous said...

Doctors not seeing pain as an issue for babies goes beyond preemies. Doctors still routinely do circumcisions without the use of any pain medication. It's horrible knowing that there is pain medicine that would numb the area prior to the procedure but doctors are too lazy or indifferent to order it.

Anonymous said...

Sorry to hear about Ed's heart attack. My prayers are with you and your family. Best wishes,

Anonymous said...

from Laura V.

OK, I haven't read the study. But it brings to mind a couple of things. When my son was born almost 20 years ago (how did we get so old???) I told the OB he could not circumcise him unless he used pain medicine. He thought I was silly.

Monday our daughter had an evaluation with a new OT. I told her how she recoiled from my touch for the first year. The OT said, "how much medical intervention did she have?"

Sometimes these common sense things seem so silly. I mean, do you think they cry when you poke them for the fun of it? My daughter was no dummy. It hurt and she learned that big hands hurt little girls.

Another common sense NG tube hold open the valve entering your stomach as it's formed. Of course, you're going to develop GERD. But that's another story.

Anonymous said...

Where are they STILL doing circumcisions without addressing pain???!!! Turn them in. It is unethical! Where I work, nurses "remind" doctors to let the penile bloc work for 5 minutes before they cut. There is a mechanism for reporting a doc who does not do this wait. This kind of think now has a name--it is part of the "time-out" that is supposed to happen before any procedure. The time-out serves many purposes, depending upon what procedure we are talking about--but there is/should be a time-out prior to the circumcision, to give the pain med a chance to take effect. Parents who suspect that their kids won't get their pain addressed should BE THERE, personally, to be sure their kids are not being "abused". Yup. You need to be there for the circ. Otherwise, no circ. IMO.
Chris and Vic

Anonymous said...

Chris & Vic,
We are in New Orleans area, when our son was born in 2002, the NICU nurses told me to have to doctor order pain medicine prior to the scheduled circumcision because routinely doctors do not. I had to talk to the doctor personally and told her to order the pain medicine or procedure wouldn't take place. She did but says that isn't protocal. Recently, a friend had a baby and same thing happened with a different doctor. So, in our area, it's not common. Such a shame but happens. I noticed the same thing with drawing blood in infants. Heel warmers help but some people are in such a rush, they don't give them time to work or say we don't do that here. People amaze me sometimes on their inability to have empathy for a child's pain. But it shouldn't surprise me, since a lot of adults don't even give children common courtsey. Have you ever noticed how adults expect children to move out of their way or run right into them like they don't matter?

Mom to Lilike, Locke & Anjeni said...

Lilike was a term 7 pounder baby and she did not cope very well at all with the iv changes and daily heel sticks for FBE while in the NNU. They used a dummy of there own to try to comfort her. We were told we could not use our own dummy for her. Lilike was screaming to much to take there dummies. While we had to watch her get pinned down as she screamed so loud and thrashed about the whole NNU could hear. They stuck her in her limbs to try to fin a new iv site at 5 days old for more antibiotics. But I blame the midwife Robin for that. Peter Marshall had ordered Lilike go upstairs that day then home with us. But the midwife took Lilike back down to NNU telling us sick babies don't belong upstairs. Neo doc said we might have to put an iv in ehr scalp to reduce iv attempts so she was not in pain. But we coudl also do thigh ijections that would be more painful then a scalp iv. But when we agreed to the scalp iv out of fear and guilt for Lilike. I came abck for the shaven bit of hair for her baby book and they had alreayd done the thigh injections. Dr Simons sent Lilike home at 9 days old. He got us to have the nurse we wanted Nikki who had been the 1st to care for Lilike on her 1st night to be the only nurse to care for her for her last 2 days in hospital. Nikki woild do the FBE heel sticks gently and not rushed that were required. She would put a bottle in Lilikes mouth of formula straight after the heel srick. The FBE heel sticks were to test Lilikes blood for infection. No infections were found. But they went by the testing of the white cell count.

Anonymous said...

Helen Harrison says: I think some specific quotes from the study in JAMA would be of interest.

From the July 2 issue of JAMA:

“Repeated invasive procedures occur routinely in neonates [a baby, from birth to four weeks] who require intensive care, causing pain at a time when it is developmentally unexpected. Neonates are more sensitive to pain than older infants, children, and adults, and this hypersensitivity is exacerbated in preterm neonates."

"Multiple lines of evidence suggest that repeated and prolonged pain exposure alters their subsequent pain processing, long-term development, and behavior. It is essential, therefore, to prevent or treat pain in neonates. Effective strategies to improve pain management in neonates require a better understanding of the epidemiology and management of procedural pain.”

During the study, neonates (average gestational age of 33 weeks ) experienced 60,969 first-attempt procedures, with 42,413 (69.6 percent) painful and 18,556 (30.4 percent) stressful procedures; and 11,546 supplemental attempts. Each neonate experienced a median of 75 painful procedures during the study period and 10 painful procedures per day of hospitalization.

Infants received analgesia for a median of 20 percent of the painful procedures performed during the study period.

Prematurity, parental presence during procedures, surgery, daytime performance of procedures (7 a.m. to 6 p.m.), and day of hospitalization (2-14 days) were associated with greater use of specific preprocedural analgesia. Mechanical ventilation and noninvasive ventilation were associated with less frequent use of analgesia.

“Advances in neonatal care in recent decades with increased survival of immature and sick neonates have led to an increased number of invasive procedures that may cause pain in these vulnerable neonates. The prevention of pain in critically ill neonates is not only an ethical obligation, but it also averts immediate and long-term adverse consequences,” the researchers write. “… strategies to reduce the number of procedures in neonates are needed urgently. The American Academy of Pediatrics recently emphasized the need to incorporate a principle of minimizing the number of painful disruptions in neonatal care protocols. Such strategies would aim at bundling interventions, eliminating unnecessary laboratory or radiographic procedures, using transcutaneous measurements when possible, and minimizing the number of procedures performed after failed attempts.”

“The knowledge that some vulnerable neonates underwent 153 tracheal aspirations or 95 heel sticks in a two-week period should elicit a thoughtful and relevant analysis on the necessity and the risk-benefit ratio of our clinical practices.”

(JAMA. 2008;300[1]:60-70. A

Anonymous said...

From Laura V.


Heel warmers are not used for pain control. They are used to get more blood to the area so that the blood comes out easier. I do know that ten years ago when our Katie was born they didn't give kids any pain meds for the sticks. They did, at that time, give tylenol for circumcisions. Most babies around here get the circumcision bell. They don't use pain meds for that.

ThePreemie Experiment said...

Tyler's circ was done without pain control. I am still upset about it. It's a long story, for another time.

I'll be posting more on pain control soon.

Thanks to everyone for their comments and thanks to Helen for reporting the research!!

Anonymous said...

Laura V.,
I know that heel warmers don't relieve pain. But when they are utilized properly, the blood flows out easy. Otherwise, they squeeze the heel to get the blood out. So, not only do they stick them but then double the pain by hurting them physically. It's a shame.

Anonymous said...

Laura V.,
I know that heel warmers don't relieve pain. But when they are utilized properly, the blood flows out easy. Otherwise, they squeeze the heel to get the blood out. So, not only do they stick them but then double the pain by hurting them physically. It's a shame.

mom to lilike, locke and anjeni said...

I remember the Rn who told me I could overheat Lilike by putting her in booties. Also was the one I saw aqueeze her foot during a FBE heel stick to get more blood out and Lilike was not happy!