Pain in the newborn, a possible new starting point

Abstract

Pain is not a subjective experience, it is, particularly in children, an emotional issue. The formation of the International Association for the Study of Pain (IASP) in 1973 injected some standards and objectivity into the subject which allowed investigators around the world to probe both the underlying scientific basis of pain and nociception (nociception being the noxious sensation per se with no regard to the emotional experience). At the same time therapeutic strategies for different clinical problems have been evaluated, putting pain management on a scientifically secure and more individually effective basis. Self report has been the 'gold standard' of pain measurement but even in co-operative adults this has inherent weaknesses/biases related to the person and their situation (both the feelings and the reporting of pain are context sensitive). In some clinical areas, subject report is clearly impossible e.g. the psychogeriatric population, the mentally retarded and in preverbal children. However, even in these groups, there are usually behavioural responses to acute pain that are reasonably interpretable by their caregivers.

The Effects of Early Pain Experience in Neonates on Pain Responses in Infancy and Childhood

“…Research on neonates and infants during acutely painful procedures has identitied consistent and reliable responses across three domains: behavioral, physiologic, and neurochemicai.l 4 l The responses to acute pain in neonates and infants are simi.lar to those observed in children and adults. They are generally short-lived and designed to be protective.…”

“…Persistent pain can occur in certain conditions that involve inflammation,l 4 l such as osteomyelitis and necrotizing enterocolitis. In addition, persistent pain may be iatrogenic and result ti·om repeated medical procedures (e.g.…”

Clinical validation of the Paediatric Pain Profile

“…(Schecter 1989). The criterion standard in pain assessment is 'self-report' (Craig 1997, McIntosh 1997 but for some groups of children, such as infants and those with severe cognitive or neurological impairment, it is their behaviour rather than their verbal report which has to be interpreted to determine whether they have pain (Anand and Craig 1996). While it is possible for many neurologically and cognitively impaired children and adults to use forms of self-report despite their impairments (Ferrell et al 1995, Parmelee 1996, Fanurik et al 1998, those unable to report their pain will remain dependent on their caregivers' observational skills.…”

Prevention and Management of Pain in the Neonate: An Update

“…27 The most commonly used assessment tools are listed in Table 1. [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] For each tool, the physiologic and behavioral indicators of pain are described, the population for which they have been validated are delineated, and unique aspects are listed. Whatever assessment tools are used, continual multidisciplinary training of staff in the recognition of neonatal pain and in the use of the chosen pain-assessment tools should be provided.…”