Fetal Pain—Reply

Abstract

To the Editor:We have a number of concerns about the Clinical Review of fetal pain by Dr Lee and colleagues. 1 First and foremost, none of the authors appear to routinely provide care for premature infants, including the administration of analgesia and anesthesia. Providing clinical care to pregnant patients does not make a caregiver an expert on fetal or neonatal pain, and a clinician with expertise in this area should have been included.While this was intended to be a current and comprehensive literature review of articles relating to pain, anesthesia, and analgesia in fetuses younger than 30 weeks' gestational age as well as articles specifically addressing fetal pain and nociception, many relevant articles and an entire textbook devoted to this topic were not cited. [2][3][4] We routinely provide care for premature infants, many of whom are as young as 24 weeks' gestation. We regularly administer anesthesia and analgesia to these premature infants for painful interventions and surgery, even though this article would suggest that might be unnecessary. We also routinely provide anesthesia and analgesia to fetuses as early as 19 weeks' gestation undergoing certain interventions and surgery. Pediatric anesthesiologists are often faced with a patient population who may not have the ability to convey thoughts and desires, including the presence of pain. We must then look for indirect measures of pain, such as stress responses; physiologic alterations in heart rate and blood pressure; and, at times, facial grimacing, crying, and withdrawal. Even though these infants cannot verbally express that they feel discomfort, most practitioners in the medical community would not withhold analgesia or anesthesia if the same procedure would require this treatment in an older patient.Although the article reviews neuroanatomical development, the gestational ages the authors cite can be argued. Definitive gestational dates are not known because of ethical challenges in fetal research. As such, the data discussed in this article should be viewed as gestational age ranges, not precise dates of gestational development.We do not know for certain whether a fetus has the capacity to feel pain prior to 29 weeks' gestation. We as clinicians should focus on methods to deliver effective fetal analgesia safely while minimizing maternal risk. As stated by Glover and Fisk, 5 "We don't know; better to err on the safe side from mid-gestation." Financial Disclosures: None reported. 1. Lee SJ, Ralston HJP, Drey EA, Partridge JC, Rosen MA. Fetal pain: a systematic multidisciplinary review of the evidence. JAMA. 2005;294:947-954. 2. Myers LB, Bulich LA, eds. Anesthesia for Fetal Intervention and Surgery. Lewiston, NY: BC Decker Inc; 2005. 3. Fenton KN, Heinemann MK, Hickey PR, Klautz RJ, Liddicoat JR, Hanley FL. Inhibition of the fetal stress response improves cardiac output and gas exchange after fetal cardiac bypass. J Thorac Cardiovasc Surg. 1994;107:1416-1422. Gitau R, Fisk NM, Teixeira JM, Cameron A, Glover V. Fetal hypothalamicpituitary-adrena...