Newborns do feel pain (quick, tell the doctor)

This is an article which appears to conflate several disjoint issues into a single article. I say conflate: they have been forced together with a crowbar.

The issues are:

  1. There are some who claim infants do not feel pain. Most of this seems to come from those who promote non-medical infant circumcision.
  2. There are good reasons not to use general anaesthesia on neonates, some of which are discussed below.
  3. Premature babies may require surgery, and the risks of anaesthesia are much higher in these infants because their brains are at an earlier stage of development.
  4. WDDTY is vehemently opposed to the use of “painful procedures” on infants. By “painful procedures” they mean, of course, vaccinations.

The result is a diatribe that is unusually unhinged even for WDDTY.

This will astonish nobody except doctors: babies feel pain as much as adults, and perhaps even more so. Yet, not believing this simple fact, doctors perform surgery on newborns without using any pain relievers.

Why would they do that, I wonder? First, you might want to read Wikipedia’s overview of pain in babiesW. It starts:

Pain in babies, and whether babies feel pain, has been the subject of debate within the medical profession for centuries. Prior to the late nineteenth century it was generally considered that babies hurt more easily than adults. It was only in the last quarter of the 20th century that scientific techniques finally established babies definitely do experience pain – probably more than adults – and has developed reliable means of assessing and of treating it.

That’s a reality-based overview. Nobody in the medical and scientific community disputes that babies feel pain.

Mohel performing bris
Surgery performed on an infant without anaesthesia. There is a reason these people are not wearing scrubs.

So who performs surgery on newborns without pain relief?

Probably the single most common surgical procedure performed on infants without anaesthesia is  not actually done by doctors. It is a religious, not a medical practice.

And when you start looking into it, you find that a good deal of the myth-spinning about babies and the ability to feel pain, is from this religious standpoint.

Here’s a mohel arguing his case:

Simply put, we don’t really know but this is a very controversial area. There is clearly some discomfort. Many studies have been done to try to ascertain how much pain the baby feels. These studies, however, reflect the clinical experience of hospital circumcisions, not traditional brisses that were done by mohels. There are other reasons why the baby will cry such as when his diaper comes off and he is exposed, and when he is held down.

I believe the reason that this question is asked with such increasing frequency is because of the non-traditional circumcision techniques that are used today by doctors or non-traditional mohels. A circumcision can take up to a half an hour or longer when performed by a doctor or in the hospital. In a traditional bris, the entire ceremony takes about fifteen minutes. The “bris” part takes about thirty to forty seconds.

I am sure doctors have a view on why it takes longer to perform surgery in a hospital. There are, after all, regulations, especially around infection control procedures. We wouldn’t want the baby getting a fatal dose of herpes or anything.

The practice—which was common up to the 1980s, and to this day 60 per cent of babies still receive no pain medication before having surgery—is based on the belief that the newborn child has not developed the neural pathways that transmit signals of pain.

Really? It is actually very hard to find credible sources to support this claim. Most of the sources discussing medical denial of pain in babies, are very obviously partisan – see, for example, “Babies don’t feel pain: a century of denial in medicine” by David B. Chamberlain.

It’s clear that the debate, such as it is, has often crystalised over the vexed issue of non-medical infant circumcision.

It’s equally clear that anaesthesia in infants is currently routine. Specialist centres like Great Ormond Street train paediatric anaesthetists. The Association of Paediatric Anaesthetists of Great Britain and Ireland has a position paper on infant anaesthesia. It’s pretty clear that some of the controversy is manufactured by chemophobes and the anti-medicine brigade.

There are good reasons to think long and hard before using general anaesthesia on infants, but at least some of this discussion is in the context of non-invasive procedures such as MRI scans for cardiac abnormality.

But a study from Oxford University has finally overturned the theory. Researchers used an MRI scanner to monitor the brains of 10 newborns and 10 healthy adults while they poked the participants on the bottom of their feet with a rod. It was like being poked with a pencil, the researchers said, and was not so painful that it would wake up the babies.

This is, frankly, bollocks.

The study has not “finally overturned” the theory, because it is no longer prevalent, if it ever was, and because the study itself doesn’t make any such claim: it is primarily looking into whether babies feel pain the same way as adults:

fMRI reveals neural activity overlap between adult and infant pain

Limited understanding of infant pain has led to its lack of recognition in clinical practice. While the network of brain regions that encode the affective and sensory aspects of adult pain are well described, the brain structures involved in infant nociceptive processing are completely unknown, meaning we cannot infer anything about the nature of the infant pain experience. Using fMRI we identified the network of brain regions that are active following acute noxious stimulation in newborn infants, and compared the activity to that observed in adults. Significant infant brain activity was observed in 18 of the 20 active adult brain regions but not in the infant amygdala or orbitofrontal cortex. Brain regions that encode sensory and affective components of pain are active in infants, suggesting that the infant pain experience closely resembles that seen in adults. This highlights the importance of developing effective pain management strategies in this vulnerable population.

See where it says that the old theory that infants don’t feel pain has been overturned? Me neither.

I’d highlight one passage in particular (emphasis added):

Consequently, infants have received poor pain management, exemplified during the 1980s by surgery being routinely performed using neuromuscular blocks without provision of adequate analgesia.

It looks to me very much as if WDDTY has read this as meaning that surgery was (note past tense) performed without anaesthesia, but anaesthesia and analgesia are very different: anaesthesia is a temporary state of unconsciousness, analgesia is pain relief.

In this case the operations were carried out using neuromuscular blocks but the source does not mention whether nerve blocks were also used.

There are some excellent references cited in the paper including a 1987 paper which gives a much less simplistic reading of the development of understanding of infant pain response. I know, a medical paper giving a nuanced view that is at odds with WDDTY’s strident generalisations, nobody expected that, did they?

But despite being asleep, the babies’ brains experienced the same pain responses as the adults. The same areas of the brain could be seen to be responding, the researchers said. In fact, the babies’ brains had the same response to a weak poke as the adults did to a poke that was four times as great, suggesting the babies were more sensitive to pain.

Er, no, that’s not actually true. The responses were similar but there are two areas of the brain that showed greatly less response in babies than in adults.

Significant infant brain activity was observed in 18 of the 20 active adult brain regions but not in the infant amygdala or orbitofrontal cortex.

So the paper definitely refutes WDDTY’s claim that the responses are the same.

“Thousands of babies across the UK undergo painful procedures every day but there are often no local pain management guidelines to help clinicians. Our study suggests that not only do babies experience pain but they may be more sensitive to it than adults,” said research team leader Dr Rebeccah Slater.

No pain management guidelines does not equate to no pain management. This is made abundantly clear in the paper. What the paper’s authors are saying is that the understanding of neonatal analgaesia is very limited, an argument for which they provide good evidence,

Newborns experience an average of 11 painful procedures in the first days of life, and yet 60 per cent are not given any pain medication, a 2014 survey discovered. Back in the 1980s, medication was never given before a surgical procedure on a newborn.

Newborns experience an average of 11 painful procedures in the first days of life, eh?

The original says:

Indeed, a recent review of neonatal pain management practice in intensive care highlighted that although infants experience an average of 11 painful procedures per day, 60% of the population did not receive any pharmacological analgesia.

Can you see how a study of a paediatric intensive care practice might not be representative of the population as a whole? You really can’t draw much from this sentence on its own, as the “painful procedures” will include things like blood draws, and the lack of pharmacological anaesthesia does not rule out any anaesthesia at all. Should babies be given pain drugs before cannulas are fitted?

The source for the claim is cited:

Objective: To study whether new pharmacological and nonpharmacological guidelines lowered numbers of painful procedures in neonates and changed the amount and frequency of analgesic therapy as compared to the results of our previous study in 2001.

Conclusions: The mean number of painful procedures per NICU patient per day declined. Nonpharmacological pain- or stress-reducing strategies like NIDCAP and sucrose were fully embedded in our pain management. As further reduction of the number of painful procedures is unlikely, we should apply more nonpharmacological interventions and explore newer pharmacological agents.

See where it argues for more use of anaesthesia? It doesn’t.

WDDTY is over three decades out of date with its anti-medicine rhetoric resulting in a piece which is alarmist, misleading and irrelevant – as usual – but which will also, unusually, be well known to be wrong by a significant number of its readers.

 

 

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