CONCLUSION

Studies relevant to nociception and its consequences in the very young have proliferated in recent years and the above review can only survey a rapidly evolving field. Despite the promise of continued scientific advances, certain fundamental questions lie outside the realm of clinical investigation per se. For example, questions regarding quality of life are often posed for the adult patient with pain, for example due to cancer. In those settings, the patient's verbal description are heavily weighted, as are his or her functional abilities as a family member and productive individual within society. Defining quality of life in normal neonates, particularly in premature, is infinitely more difficult given their inability to express or otherwise convey experiences and emotions. Furthermore, "purposeful activity" is a concept that is irrelevant to the neonatal setting.

Despite these difficulties, one must take into account the neonate's potential to grow and develop, to overcome handicaps, and to experience life to a degree far greater than in the adult. To foster optimum development, stress during the perioperative period or prolonged intensive care should be minimized.³ The recognition of highly developed nociceptive systems, and evidence of clinical, physiologic, and psychologic sequellae of inadequately treated pain in neonates and children, mandate that aggressive treatment of pain is central to such care. In the future, knowledge of nociceptive mechanisms and their ontogeny in the human undoubtedly will be exploited to apply novel treatments of pain in context-dependent manner. As this occurs, the present perspective that pain and suffering are inevitable results of each child's illness will have to be abandoned.

ACKNOWLEDGEMENTS

Partial Support for this article was provided by Shriners Hospitals for Crippled Children and NINCDS grant PO 1-23357 (to Dr. Carr), and the Children's Hospital Medical Center Anesthesia Foundation (to Dr. Anand).

REFERENCES

3. Als H, Lawhon G, Brown E, et al: Individualized behavioral and envirornmental care for the very low birthweight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and developmental outcome. Pediatrics 78:1123, 1986.

Department of Medicine
The Children's Hospital
300 Longwood Avenue
Boston MA 02115

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*Clinical Fellow in Pediatrics and Research Fellow in Anesthesia, Harvard Medical School and The Children's Hospital, Boston, Massachusetts.
†Associate Professor of Anesthesia, Harvard Medical School; Co-Director, Anesthesia Pain Unit Staff Physician, Massachusetts General Hospital and Shriners Burns Institute, Boston, Massachusetts.