Biologic markers of pain in the vulnerable infant

Hospitalized newborn infants experience pain that can have negative short- and long-term consequences and thus should be prevented and treated. National and international guidelines state that adequate pain management requires valid pain assessment. Nociceptive signals cause a cascade of physical and behavioral reactions that alone or in combination can be observed and used to assess the presence and intensity of pain.

Units that are caring for newborn infants must adopt sufficient pain assessment tools to cover the gestational ages and pain types that occurs in their setting. Pain assessment should be performed on a regular basis and any detection of pain should be acted on. Future research should focus on developing and validating pain assessment tools for specific situations.

Current literature lacks systematic data on acute perioperative pain management in neonates and mainly focuses only on procedural pain management. In the current review, the neurophysiological basis of neonatal pain perception and the role of different analgesic drugs and techniques in perioperative pain management in neonates are systematically reviewed. Intravenous opioids such as morphine or fentanyl as either intermittent bolus or continuous infusion remain the most common modality for the treatment of perioperative pain. Paracetamol has a promising role in decreasing opioid requirement. However, routine use of ketorolac or other nonsteroidal anti-inflammatory drugs is not usually recommended. Epidural analgesia is safe in experienced hands and provides several benefits over systemic opioids such as early extubation and early return of bowel function.

Premature infants spend much of their early days of life in an environment that is stressful and in many situations painful. Short and long term consequences of pain are not well documented, yet postulated to have a negative impact on stress-response systems and on deployment. To date there is insufficient evidence for the best methods to assess or to effectively treat their pain. Though a variety of uni- and multidimensional assessment tools are available, many lack sufficient psychometric testing, do not incorporate essential developmental cues to premature infants, and do not distinguish between acute and chronic pain. This review paper will discuss the etiology, sources, and manifestations of pain as well as the short and long term consequences of pain. The available assessment tools for pain in premature infants along with reliability and validity will also be presented.

Raising the possibility of fetal pain continues as a tactic to undermine support for abortion in the US and the UK. This paper examines anatomical and psychological developments in the fetus to assess the possibility of fetal pain. Neurobiological features that develop at 7, 18 and 26 weeks gestation suggest an experience of pain in utero. Pain, however, cannot be inferred from these features because they are not informative about the state of consciousness of the fetus and cannot account for the content of any presumed pain experience. We may be confident the fetus does not experience pain because unique in utero neuroinhibitors and a lack of psychological development maintain unconsciousness and prevent conscious pain experience. Before an infant can experience sensations and emotions, the elements of experience must have their own independent existence in the infant's mind. This is achieved after birth through discoveries made in action and in patterns of adjustment and interaction with a caregiver. Recommendations about anaesthetic practice with the fetus and the newborn or young infant should not focus on pain but on outcomes with obvious, and measurable, importance. In the case of an unwanted pregnancy, the health of the woman should guide anaesthetic practice. In the case of a wanted pregnancy, the survival and long-term health of both the woman and fetus should guide anaesthetic practice. In any case, current evidence does not support efforts to inform women of the potential for fetal pain. Any policy to mitigate fetal pain could expose women to inappropriate intervention, risk and distress.

La possibilité de la souffrance fœtale continue d'être utilisée comme tactique pour miner le soutien à l'avortement aux États-Unis et au Royaume-Uni. Cet article examine le développement anatomique et psychologique du fœtus pour évaluer la possibilité de douleur fœtale. Les caractéristiques neurobiologiques qui se développent à 7, 18 et 26 semaines de gestation suggèrent une expérience de la douleur in utero. Ces caractéristiques ne permettent cependant pas de prouver que cette douleur existe car elles ne rendent pas compte de l'état de conscience du fœtus ni du contenu d'une perception présumée de la douleur. Il semble assuré que le fœtus ne connaît pas la douleur car des neuro-inhibiteurs in utero uniques et un manque de développement psychologique maintiennent l'inconscience et évitent l'expérience consciente de la douleur. Pour qu'un nourrisson expérimente des sensations et des émotions, les éléments de l'expérience doivent avoir leur propre existence indépendante dans son esprit. Cela s'accomplit après la naissance par les découvertes faites dans l'action et les schémas d'ajustement et d'interaction avec la personne qui s'occupe de l'enfant. Les recommandations sur la pratique de l'anesthésie du fœtus et du nouveau-né ou du jeune nourrisson ne doivent pas se centrer sur la douleur, mais sur des résultats d'une importance évidente, et mesurable. Pour une grossesse non désirée, la santé de la femme doit guider la pratique de l'anesthésie. Pour une grossesse désirée, c'est la survie et la santé à long terme de la femme et du fœtus qui doivent la guider. Dans tous les cas, rien dans les données dont nous disposons n'indique qu'il faille informer les femmes de la possibilité de douleur fœtale. Toute politique destinée à soulager la douleur fœtale pourrait exposer les femmes à des interventions indues, des risques et des souffrances.

Incrementar la posibilidad de dolor fetal continúa siendo una táctica para debilitar el apoyo para el aborto en EE.UU. y el RU. En este artículo se examinan los desarrollos anatómicos y psicológicos del feto para determinar la posibilidad de dolor fetal. Las características neurobiológicas que se desarrollan a las 7, 18 y 26 semanas de gestación indican una experiencia de dolor in utero. No obstante, no se puede inferir dolor de estas características porque no informan sobre el estado de conocimiento del feto y no se les puede atribuir el contenido de una supuesta experiencia de dolor. Podemos estar seguros de que el feto no siente dolor porque los neuroinhibidores únicos in utero y la falta de desarrollo psicológico mantienen la inconsciencia e impiden una experiencia consciente de dolor. Antes que un recién nacido pueda experimentar sensaciones y emociones, los elementos de la experiencia deben tener su propia existencia independiente en su mente. Esto se logra después del nacimiento mediante descubrimientos realizados en acción y en patrones de ajuste e interacción con un cuidador. Las recomendaciones sobre la práctica anestésica con el feto y el recién nacido o bebé no deben centrarse en el dolor sino en los resultados con importancia obvia y mensurable. En el caso de un embarazo no deseado, la salud de la mujer debería guiar la práctica anestésica; en el de un embarazo deseado, ésta debería ser guiada por la supervivencia y salud a largo plazo de la mujer y el feto. En todo caso, la evidencia actual no corrobora los esfuerzos por informar a las mujeres del potencial de dolor fetal. Toda política para mitigar el dolor fetal podría exponer a las mujeres a una intervención inadecuada, riesgo y aflicción.