Saturday, June 10, 2006

Pain

The tiny baby was getting his PDA ligated, a surgery that involves making an incision around the side of the chest and tying or clipping off an open blood vessel that is very close to the heart. They were doing the surgery in a side room off the NICU, which is nice because then I could hang out in the room and keep an eye on things during the surgery. I was chatting with the anesthesiologist, who seemed a little nervous with this small of a baby, when he told me that he was using only one or two micrograms per kilogram of fentanyl as the anesthetic. I was appalled, because that is the dose of fentanyl we use for pain relief in the NICU. For anesthesia, you need about ten or more times that dose. In other words, this baby was having major surgery without real anesthesia.

This happened many years ago, in the early 1990's or late 1980's. Unfortunately, in the history of neonatology there have been many times when babies have been under anesthesized or not given adequate pain relief. It's a dark spot in our field, but fortunately now there is an increasing emphasis on pain relief. We're getting better at it, but there are still some problems.

The biggest problem with neonatal pain relief, as I see it, is that there are two opposing principles involved. One, we know that repetitive unrelieved pain is not good for babies and can lead to increased sensitivity to pain later in life. On the other hand, though, we know we shouldn't give treatments that have unknown effects on a baby's long term outcome. And there's the rub; we don't know what repetitive use of many of our analgesics does to the baby's developing brain. Does frequent stimulation of the opioid receptors in an immature brain change the formation of that brain and its pathways? It's hard to believe it doesn't, and not all of the data is reassuring.

One pain reliever used for newborns is sucrose, that is, sugar water. It's well established that a little bit of sucrose, combined with sucking on a pacifier, prior to a painful procedure offers pain relief. It probably works because the sweetness stimulates the release of the baby's own natural (endogenous) opiates. We're having a discussion now in our NICU whether we can use this routinely and frequently in premature babies, who can have hundreds of painful procedures like blood draws and IV starts done during their hospitalization. It sounds innocuous - hey, it's only sugar water - and some of the nurses want to be very liberal with it. But frankly, I'm a little leary of it; we don't have long term follow up information about what sucrose's repetitive use does to the immature brain. It may be only sugar water, but somehow it affects the brain - otherwise it wouldn't offer pain relief - and therefore, it seems, could affect brain development.

We could talk a long time about this topic, but this post is too long already. When in doubt, primum non nocere. First of all, do no harm.

21 Comments:

Blogger Kristina said...

Sorry if this duplicates, I'm getting errors.

Pacifier with sugar water =

Breast with breastmilk

Nature has it right and we are doing our best to catch up!

I know that in a NICU this isn't always (or even rarely) possible but what about having the mother pump breast milk and using her finger, or nursing the baby during pokes and whatnot? And when that isn't available, dipping the paci in her milk instead of sugar water- then there isn't a concern about what sugar will do to the baby long term.

As a mother myself I would be happy to provide some pumped milk/colostrum for a pain-paci if I knew it would help my baby.

WhenEVER possible, put those babies to their mothers breasts!

When my babes are born in a hospital I (much to the chagrin of the staff) insist that every procedure where my child might feel pain is done at my breast.

12:10 PM  
Blogger Dream Mom said...

I am so glad you wrote this post. Dear Son was born in 1991 and I remember reading the front page of our paper at that time where they talked about a new research study on infants. They said that the babies that received anesthesia during "open heart surgery" did better than the ones who didn't. I was appalled at the thought. They went on to explain the reasons for not using anesthesia, all of which escape me at this time, but the image never left my head.

As for the sugar water, I think you are correct to be conservative. Some of the best physicians I know always err on side of caution. I know one of the things that I like about Ped Neuro Doc was that he was always very conservative and until he could see that there was enough evidence to prove otherwise, he would always err to the side of caution. What I have learned by watching him and others like him, is that they are almost always right.

I too am always concerned with the effects of things on the brain and even on immature brains. I think we have a long way to go but thankfully, we are an awful long way from where we were fifteen to twenty years ago.

Really, really good post today Neonatal Doc.

1:00 PM  
Blogger SGA said...

I guess the question is, do you think the long term risk is such that it outweighs the short term benefits that have been shown? It's tough to tease out at times, that's for sure.

3:49 PM  
Anonymous Anonymous said...

Medicine is also now (finally) using sedation for spinal taps on children.
My son had one without sedation and it was horrifying!

5:22 PM  
Blogger Ex Utero said...

"primum non nocere"

Couldn't agree with you more NeoDoc. The problem here is I don't see a winner in this comparison. Probably just being ex utero is painful under 28 weeks gestation and pain also changes your neurodevelopment. So which is better, the potential for an opiod influence from sweeties or the influence or chronic pain?

I don't know the answer but I guess, since I don't know the answer to the neurodevelopment question, I have to fall back to the one of humaneness. Should we not err on the side of providing care that is as comfortable and painfree as possible, even to these essentially decorticate patients (decorticate in the sense that their cortex is not yet sufficiently mature to be functional yet)?

I think I have at least a couple of my toes across the line in the sweeties camp.

10:57 PM  
Blogger Flea said...

Anon 5:22,

Who's "Medicine"?

ND,

In defense of our predecessors, they would tell you they didn't use pain medicine because of their own absence of knowledge, or limited knowledge, of neonatal pain management.

And they were afraid of hurting small people with powerful medications.

They might not have believed that premies felt pain, but, in part at least they proceeded on the basis of primum non nocere.

best,

Flea

6:50 AM  
Blogger That Girl said...

Im trying to picture the faces of the staff if I insist on beastfeeding during a cardiac cath or open-heart surgery. Chagrin is not the word that comes to mind.

Much as it's fun to speculate without proof that breastmilk is an anethestic, Im all for the sugar as a distraction from the pain.

Maybe you have it the wrong way around - maybe the babies will come to relate overly sweet things with some unpleasant procedure.

I know that that is what happened with my son - although he likes naturally sweet things (squash), a bottle of karo/water mix will be rejected instantly.

11:51 AM  
Blogger neonataldoc said...

Thanks, everyone. Sga and ex utero, it is a tough issue with no clear winner. As long as we do our best and keep up with the issue, I think we can sleep at night, even if we come down on different sides. Flea, I appreciate your defense of our predecessors and agree to some extent. But it bugs me that some people actually believed neonates don't feel pain. All you have to do is look at them to know that they do.

And thanks, Dream mom, for the nice compliment.

3:58 PM  
Anonymous Anonymous said...

This subject is extremely close to my heart. Having said that, may i ask a question?

i have recently cared for a baby who was diagnosed uterally as hydrocephalas. Birth has revealed no cortex, not even a membrain. my education tells me that the pain signals travel to the brain - the cortex and thalamus. This baby has neither. How can it be that this baby obviously knew when we did blood draws and his circumcisian?

As for putting the baby to the breast for painful procedures, i wouldn't have a problem with that. i am presently studying 'touch' and find it fascinating. Our Country is the most deprived in the whole world. Moms of other cultures can be blindfolded and know their family members. The recent Laura/Whitney drama lets us know how severe this situation is in our Country. For our families sake - touch each other.

Apologies for the hijacks - is there a way we can have a section to ask questions that may coem up from time to time?

10:26 AM  
Anonymous Jen said...

Yikes, poor kiddo! I hope you intervened--I guess I'm not sure how much that's "allowed," but it just seems horrifying to me.
We do some bedside surgery in my ICU, and we crank up the sedation and pain medication--our pumps have an "anesthesia" setting to override the limits put on them otherwise.
And to anon, re sedation: I can't imagine doing an LP on a child without sedation! I had three last spring without sedation, and I found it horrible at 23.

9:31 PM  
Anonymous Anonymous said...

I clearly remember the days that PDA ligations were done with NO anesthesia whatsoever.... what were we thinking??! I'm now working in a large urban hospital in the Northwest, and we use "sweet-ease" regularly prior to all painful procedures. Of course if a baby is still NPO, sweet-ease is a "no-no".

2:24 PM  
Blogger adventures in disaster said...

I say go with the drugs....setting a baby up for a lifetime to chronic pain with no correctable source is a nightmare . The brain will be molded by pain in a terrible way..I prefer the babies brain be molded by pain relief.

3:45 AM  
Anonymous David said...

The idea that we could allow infants to be operated on without proper anesthetic is unconscionable to me. It is I believe, or should be, common sense that infants are able to feel pain, are aware of it, and are sensing, emotional, conscious, feeling beings who are aware of their surroundings. I do not know how, that one can look at an infant, who can laugh, smile, cry, who responds to different people in different ways, who can recognise its mother and other familiar persons, who can clearly respond to and sense pain, who is obviously aware and responsive to its environment, and assume that they do not deserve consideration and equally high concern for their comfort that should also be given to adults as well.

Recent evidence as well, has shown that infants do indeed experience real pain and are well aware of it, and in fact, due to the condition of the nuerological system at that point of development, that may in fact, may experience pain longer and more severely than an adult would. It is strongly supported that infants, even premature or ones still in the womb, have a nuerological system that allows for both consciousness and awareness and processing of the pain signals. At least, we should assume this is so, to give the child the benefit of the doubt, since the possibility is very real that they are conscious beings and aware of their surroundings and are susceptible to pain, we should not take the risk of possibly subjecting an infant to a painful procedure.

It is wrong to subject any conscious or sentient being to physical pain or suffering. It does not matter if they will remember it or not, or how primitive or advanced their stage of intellect is, all that matters is that there is a possibility that exists that may cause them to be able to experience this pain. Just because a conscious being is not at a high level of intellectual development, does not mean that it is more acceptable to subject them to pain and suffering.

There is evidence, furthermore that infants do in fact remember pain. There are studies comparing responses of infants, 6 months after circumcision, circumcised without anesthetic to infants circumcised with anesthetics. The infants who recieved the anesthetic demonstrated noticeably less pain response to the vaccination. Who knows how long these effects may last, and it is likely that memories of neonatal and early childhood events are retained in the subconsciousness, and if they are severely traumatic, have an effect on the person.

A very high priority concern of the medical profession, should be to assure the comfort of the patient and work to assure that they are not in severe pain. Administering anesthetics, should be of paramount importance. It is unacceptable to with-hold anesthetics or comfort assurance to allieviate or prevent severe pain for any reason at all, even if providing these things may place the life of the patient in increased risk, unless the patient perhaps is able to give, in sound mind and judgement, consent. Otherwise, we should assume that the patient would want to be protected from severe pain and not permit them to suffer. Pain can be a very serious matter and it is nothing to take lightly or regard as something which is acceptable to subject unconsenting persons to. It is increasingly realised that pain may lead to later psychological disorders, such as post traumatic stress disorder, and in fact, impair and cause altered nuerological development in infants. Withholding sugar or anesthetics may itself cause permenant rewiring of the infants brain, including greater susceptibility to pain, increased pain sensitivity later on in life.

You mention, "first do no harm", however, it is, at least in any civilised and decent society, that causing a person pain and suffering, is harmful to the person. Simply the fact of withholding pain relief needed to alleviate severe pain, from an inflicted procedure, is in itself causing harm to the person. Since it should be paramount to prevent pain, the importance of preventing severe pain should outweigh the risk of administering the pain relief. Again, with-holding the pain relief itself would be harmful to the infant, both in causing suffering but also on the development of a childs neurological system. The infant, is a person, a human being, with legal rights of its own, including not to be tortured and subjected to great suffering.

I believe a concern for humane treatment should previal, which includes doing whatever in our power to make sure that a person is comfortable and not in a great pain. It is inhumane, and unacceptable, to allow people to suffer and remain in pain and misery, and not administer relief to allow them to have a bearable existance.

As well, for patients who have some sort of injury, they as well should be offered pain relief if they are in severe pain. If a person has broken their arm for instance, they should be allowed to choose to be administered pain relief to avoid the trauma of setting.

Infants, children and adults alike, should have the same high standards of consideration for their comfort and it should be of paramount importance for all to alleviate and prevent severe pain with anesthetics. We should assume, that all persons, including infants, are able to experience pain and are aware of it, and that regardless of their intellect, deserve the same high regard for their comfort.

I am always shocked and horrified by our brutal, uncaring and sociopathic practice of ignoring the suffering of children and infants, as if somehow they are less human and less entitled to basic rights, or what should be basic rights, to have access to pain relief and be assured medical treatment that places top priority on assuring their comfort and relief from severe pain.

It seems, our society, tends to, horrifingly, subject infants to brutal, traumatic, and unbearable pain on a regular basis through the appalling practice of infant circumcision. It is of course wrong to perform such a traumatic and painful procedure on an infant without anesthetics, but as well, the practice itself is wrong, when it is done on a routine manner, that is not to treat any current or present medical condition. Since the infant cannot give consent to the practice of male genital mutilation, and since there is no current and present clinically verifiable medical condition that requires it, technically it is classified as a criminal assault and ought to already be illegal under our present laws. It is not only a removal of a "flap of skin", but a sexual, neurological, and sensory castration which can peremantly destroy, according to some accounts, 80% of a childs sensitivity, for life. It is basically robs a person of most their pleasure sensation experience, and there is no way for them to recover this devastating loss. Since this part of the body which is removed, is perhaps the most sensitive touch pleasure centre on the human body, removing it permenantly and drastically narrows the range of pleasure sensations a man will be able to experience. Who knows what sort of neurological and psychological effects are inflicted on the child by causing such pain and suffering on a part of their body of which one of its major functions is to provide pleasure and enjoyment, and permenantly destroying its sensitivity, replacing it with pain and scars. It is quite disturbing that FGM has been illegalised, when it is clear that MGM has devastating consequences for many men (including myself), and it is just as severe as many types of FGM. Clearly, boys deserve the same protection as girls. Are boys less human than girls, are they entitled to fewer human rights, are they less of a person than girls? This is part of the dehumanising nature of MGM that stomps on and ignores the rights of male children to not be mutilated and have a part of their body torn off and thrown away.

Again, the cruelty and barbarity that seems to be so pervasive in our medical establishment is shocking to me, and clearly there is a need for stronger laws to prevent children from being subjected to such dehumanising, traumatic, painful and harmful practices such as these, and to assure pain relief is administered properly.

4:26 PM  
Anonymous Anonymous said...

http://news.bbc.co.uk/1/hi/health/5190306.stm

2:15 PM  
Anonymous pain management emr said...

Great post about pain! I learned a lot here. Thanks for sharing this informative post.

-pia-

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