Discovering Pain in Newborn Infants

Pharmacologic Analgesia and Sedation in Neonates

Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.

The Effect of Endotracheal Suctioning Using the Four-handed Care on Physiological Criteria and Behavioral Responses of the Preterm Infants: Randomized Crossover Clinical Trial

Introduction: Endotracheal suctioning is one of the procedures that can cause pain and stress for infants admitted to neonatal intensive care units (NICUs). Pain and stress can be manifested with physiological and behavioral responses. This study is a crossover randomized clinical trial design that aimed to investigate the effect of endotracheal suctioning, using four-handed care on the physiological criteria and behavioral responses of preterm infants. Methods: In this study, 40 infants were randomly divided into two groups of 20, one group was first suctioned by the routine method (two hands) and then with the four-handed method. The other group was first suctioned by the four-handed method and then with the routine one. The ALPS-Neo (Astrid Lindgren Children’s Hospital Pain Scale Neonates) was used to evaluate pain and stress in infants. One camera recorded facial expressions and body movements, and physiological data were recorded from the monitor simultaneously. Results: Repeated measures analysis of variance (ANOVA) showed no statistically significant difference in changes in arterial saturation, heart rate and behavioral response scores between the two methods, but there was a significant difference in the mean heart rate of infants during and two minutes after suctioning in four-handed method using independent t test. Data were analyzed using SPSS version 13. Conclusion: Four-handed suctioning method can prevent an increase in the heart rate during and two minutes after suctioning, but it does not seem to affect behavioral responses and oxygen saturation of the infants. Since one of the symptoms of pain and stress in infants is the change of vital signs, especially the heart rate, we recommend four-handed method for suctioning of endotracheal tube.

Fetal Pain in the First Trimester

Fetal pain perception has important implications for fetal surgery, as well as for abortion. Current neuroscientific evidence indicates the possibility of fetal pain perception during the first trimester (<14 weeks gestation). Evidence for this conclusion is based on the following findings: (1) the neural pathways for pain perception via the cortical subplate are present as early as 12 weeks gestation, and via the thalamus as early as 7–8 weeks gestation; (2) the cortex is not necessary for pain to be experienced; (3) consciousness is mediated by subcortical structures, such as the thalamus and brainstem, which begin to develop during the first trimester; (4) the neurochemicals in utero do not cause fetal unconsciousness; and (5) the use of fetal analgesia suppresses the hormonal, physiologic, and behavioral responses to pain, avoiding the potential for both short- and long-term sequelae. As the medical evidence has shifted in acknowledging fetal pain perception prior to viability, there has been a gradual change in the fetal pain debate, from disputing the existence of fetal pain to debating the significance of fetal pain. The presence of fetal pain creates tension in the practice of medicine with respect to beneficence and nonmaleficence.

[175 years of anesthesia and narcosis-Towards a "human right to unconsciousness"]

The Ether Day, a key moment in the history of mankind, commemorates its 175th anniversary on 16 October 2021. On that day the dentist William T. G. Morton successfully gave the first public ether anesthesia in Boston. From then on it was possible to save people from pain with justifiable risk and at the same time to protect them from psychological damage by inducing unconsciousness. The German philosopher Peter Sloterdijk, one of the most renowned and effective philosophers of our times, deduced that from then on humans, to some extent, had a right to unconsciousness when in psychophysical distress. This postulate unfolded from his concept of "anthropotechnics" developed around 1997, meaning the idea of treating human nature as an object of possible improvements. According to Sloterdijk, in favorable cases a synthesis of man and technology can result in a significant improvement of human capabilities in the sense of "enhancement", i.e. an increase, an improvement or even an expansion of intellectual, physical or psychological possibilities, as it were in a transgression of the human (so-called transhumanism). Man should go into vertical tension, i.e. strive for higher aims and exploit his inherent potential, he should not dwell in the horizontal. This is not meant as an appeal but as an imperative: "You must change your life!". In this context modern anesthesia may prove helpful: be operated on by others in order to undergo an enhancement. Or, in its most extreme form, the operation in the "auto-operational curved space", a person can even operate on himself as has been dramatically demonstrated by Rogozov, a young Russian physician and trainee surgeon who successfully performed a self-appendectomy under local anesthesia at the Novolazarevskaya Antarctic Station in 1961; however, the implementation of this idea is a long way off. On the one hand, many countries lack qualified personnel in sufficiently large numbers to perform even vital operations with patients under anesthesia. On the other hand, over the decades it has become clear that anesthesia is obviously beneficial for mankind in that it offers relief from pain and psychological stress but that it can also often show its dark side: substance abuse, use of anesthetics in torture and in executions. In addition, the role of anesthetics in resuscitation, palliative care, and allaying executions is unclear or controversial. Finally, the necessary formal legal steps to acknowledge a "human right to unconsciousness" have not yet been implemented.

Historical roots of pain management in infants: A bibliometric analysis using reference publication year spectroscopy

Retrospective evaluations of the historical role of previously published research are often fraught with subjective bias and misrepresentation, which leads to contested scientific claims. This paper investigates the historical roots of infant pain management using novel quantitative methods to identify the published literature and evaluate its relative importance. A bibliometric analysis named “reference publication year spectroscopy” (RPYS), was performed using the program CitedReferencesExplorer (CRExplorer) to avoid the subjectivity associated with comparative evaluations of individual research studies. Web of Science (WoS) search queries on infant‐related synonyms, pain‐related synonyms, and analgesia or anesthesia‐related synonyms were combined using the Boolean operator “AND,” to identify all publications related to pain management in infants. The RPYS analyses were based on 8697 papers in our publication set containing the citations for 86268 references. Selected cited publications were associated with peak citation years in 1951, 1954, 1957, 1965, 1987, 1990, 1997, 1999, and 2000. Subsequent analyses suggested that research on infant pain management made rapid progress during 1982‐1992. Landmark publications were defined as those belonging to the top 10% of the most frequently referenced publications for longer than 25 years. Through this analysis, we identified and ranked 24 landmark publications to illustrate the historical background and early research on infant pain management. From the first‐ever application of RPYS (an objective, reproducible approach to study the early history of any scholarly activity) to pain research, infant pain management appears rooted in the scientific rationale for neonatal pain perception, randomized trials of opioid anesthesia/analgesia, and studies describing the facial expressions and crying activity following heel‐lance procedures in newborns.