The New England Journal of Medicine, Volume 317, Issue 21: Pages 1347-1348, 19 November 1987.
It has generally been assumed that the ability of a child to feel pain increases with age and that neonates may not perceive pain or may perceive it only minimally. Assumed by whom? Certainly not by those who have observed their increasing heart and respiratory rates and profuse sweating to heel sticks or circumcision. And finally not by those who have seen babies gasp for every breath as they die from incurable lung disease.
Why then has surgery in neonates been conducted without anesthesia? Is this barbarism, as some have suggested?1-3 Is it indifference to the plight of those too young to respond verbally, or is there another explanation? First, one must ask whether such operations are as common as has been thought. Probably not. The increased rate of anesthesia in the past few years has decreased their number dramatically. But why have needle sticks and circumcisions been routinely done without any thought of the pain incurred by the infant? More important, why are heel sticks, venipunctures, intubations, chest-tube insertions, and suctioning routinely done without much consideration of the physiologic or possible psychologic damage to the neonate?
The reason these procedures are done without anesthesia is not barbarism. One must remember that neonatalogy, and perhaps neonatal anesthesiology specifically, are relatively new fields. Many sick neonates who are surviving through intensive care and surgery today would not have lived 20 years ago. In our preoccupation with survival and improved outcome, relatively little attention was paid to pain and its control. It was not indifference or lack or concern but a lack of awareness and a fixed but unfocused outlook that led to this situation.
In this issue of the Journal, the excellent review by Anand and Hickey on the biologic aspects of pain and its effects in the human neonate and fetus helps to explain this situation.4 Among the 201 references cited, approximately 20 articles appeared in journals that neonatologists read with reasonable frequency. Most of these articles deal with plasma opioids, apnea, the use of local anesthesia in circumcisions, or the response of the infant to environmental stress. A few more of the 201 would probably have been available to anesthesiologists, particularly those who read the European literature. Unless a neonatalogist had made a concerted effort to study the topic of pain, a subject that has not until now been in the forefront of concern in neonatal care, he or she would not have had easy access to most of the information in the Anand study. Making this information accessible represents an important contribution.
Good often comes from bad. In fact, change has already begun in neonatal intensive care units. More attention is being channeled into improving the environment by decreasing the intensity of the lighting,5 lowering noise levels, using more physiologic positioning of infants, limiting painful procedures, allowing more time for uninterrupted sleep, comforting infants after painful intervention, administering fentanyl when an infant is paralized with pancuronium, and using analgesics in postoperative patients. At Children's Hospital National Medical Center in Washington, where criticism from parents helped to bring questions about pain to the fore, anesthesia is now being used in virtually all neonatal surgery.
Safe anesthetic drugs for newborns now exist. The two most commonly used are the narcotic fentanyl and lidocaine, which is locally infiltrated into the skin used as a nerve block. Fentanyl is a potent analgesic whose precise method of action is unknown. It has been shown to block nocioceptive stimuli, to maintain hemodynamic stability, and to prevent the biochemistry and endocrine stresses of surgery that may be harmful to the newborn.6-8 In dose-response studies, Yaster has shown that the effects of a 12.5 mu-g of fentanyl per kilogram of body weight given in a bolus can last for 120 minutes of surgery before supplementation is needed.9 Local infiltration of the skin or nerve block with lidocaine is effective, although intravenous injection should be avoided. There should be very little reason to perform cutdowns, chest-tube insertions, or circumcisions without using this agent.
Neonatalogists need to continue to observe infants to recognize stress responses to pain and to treat them appropriately. We also need to urge our colleagues to see that infants receive analgesia and anesthesia. We must listen to and be honest with parents who at times have overwhelming fear about the pain their infants may be feeling.
Recently, the Committee on the Fetus and Newborn, the Committee on Drugs, the Section on Anesthesiology, and the Section on Surgery of the American Academy of Pediatrics stated that local and systemic anesthetic agents are now available and relatively safe in neonates. The Anand and Hickey study marshals the empirical evidence justifying the use of these drugs. The observations cited in this review should dispel the now outmoded notion that newborns are insensitive to or immune from pain. Consequently any decision to withhold anesthetic agents ought not to be based on the infant's age or perceived degree of cortical maturity; it should be based on the same criteria used in older patients.10
There will necessarily be occasional unavoidable noxious stimuli in the neonatal intensive care unit. We must not attempt to provide such as stress-free experience in that setting that there is unchecked use of analgesia. But the evidence that nociceptive activity constitutes a physiologic stress in newborns is so overwhelming that physicians can no longer act as if infants were indifferent to pain. Neonatalogists, anesthesiologists, and surgeons must join with parents to guarantee that the best is done for newborns and to ensure that they are kept as free of pain as possible.
Children's Hospital, National Medical Center, Washington, DC 20010
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