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Preventing Infant Pain

When my first son was circumcised without any anesthetic almost 20 years ago, he cried with shattering intensity for a few moments, then stuffed his fist into his mouth and calmed down. Though he was only 3 days old, his pediatrician told us that "he already has good coping mechanisms. He knew how to handle the pain."

Two and a half years later, with my second son  -- premature, 7 days old, and recently released from the hospital  -- the procedure was overwhelming. My husband and I were assured that he'd recovered enough from his first few days' experience of monitors, stomach tubes, and blood tests in the intensive-care unit, and that he could easily handle a mere cut to the foreskin. I was surprised no anesthetic was used, but instead of questioning this, I waited outside the pediatrician's office, assuming that the doctor knew best.

When I heard the shrieks from behind the closed door, I realized that I had made a major mistake. My son had already been disconnected from me during his three days in an incubator and was distressed by so many medical procedures. I was sure that this pain was the last straw.

Following his circumcision, my son cried constantly, and every disturbance, from diaper changing to burping, seemed too much for him to handle. It was several months before he showed any improvement.

When Glenda Grunzweig's daughter, Katy, was born severely jaundiced, she was subjected to blood tests repeatedly for the first two weeks of her life, along with a procedure in which a needle was inserted into her kidney. "The doctor asked me to hold her arms down while he put the needle in. He told me to trust him, but he gave no anesthetic," Grunzweig recalls. "I'm convinced that from then on Katy associated being held with pain. We failed to establish a nursing pattern, and we both became depressed for the next few months.

"Katy's 11 years old now," Grunzweig adds, "but still fearful of medical situations and overly worried about her physical safety."

Diana Reynolds Roome received the 2000 C. Everett Koop Award for medical journalism. She lives in Mountain View, CA.

The Power of Pain

Until recently, injections and circumcisions were routinely performed without anesthesia, and many doctors dismissed parents' concerns that acute or chronic pain might affect a child's personality or hinder his recovery from an illness. But researchers are discovering that the pain young children  -- especially infants  -- experience can have immediate, as well as lasting, effects. "The nervous system isn't fully developed in infants, and acute or chronic pain can cause temporary or permanent psychological, hormonal, chemical, and cellular changes in the body," says Donna Wong, Ph.D., co-creator of the Wong-Baker FACES Pain Rating Scale, a graphics tool created in 1983 that is used worldwide to help children ages 3 and older identify their own discomfort levels. Some of the results of the changes Wong refers to are easily measured, such as fluctuations in the heart rate or breathing; psychological or metabolic changes may be less obvious.

If pain has such profound effects on the body, why then doesn't every baby who's circumcised without anesthesia lapse into a depression, the way my son did? "What's minor for one patient can be catastrophic for another," says Sandy Sentivany-Collins, R.N., M.S., an advanced practice nurse in pediatric pain management at Lucile Salter Packard Children's Hospital, in Stanford, CA. "Age, gender, culture, physiological makeup, position in the family, and how parents cope with pain, fear, and anxiety all play a part."

The Power of Pain

Until recently, injections and circumcisions were routinely performed without anesthesia, and many doctors dismissed parents' concerns that acute or chronic pain might affect a child's personality or hinder his recovery from an illness. But researchers are discovering that the pain young children  -- especially infants  -- experience can have immediate, as well as lasting, effects. "The nervous system isn't fully developed in infants, and acute or chronic pain can cause temporary or permanent psychological, hormonal, chemical, and cellular changes in the body," says Donna Wong, Ph.D., co-creator of the Wong-Baker FACES Pain Rating Scale, a graphics tool created in 1983 that is used worldwide to help children ages 3 and older identify their own discomfort levels. Some of the results of the changes Wong refers to are easily measured, such as fluctuations in the heart rate or breathing; psychological or metabolic changes may be less obvious.

If pain has such profound effects on the body, why then doesn't every baby who's circumcised without anesthesia lapse into a depression, the way my son did? "What's minor for one patient can be catastrophic for another," says Sandy Sentivany-Collins, R.N., M.S., an advanced practice nurse in pediatric pain management at Lucile Salter Packard Children's Hospital, in Stanford, CA. "Age, gender, culture, physiological makeup, position in the family, and how parents cope with pain, fear, and anxiety all play a part."

Is My Baby in Pain?

Whatever doctors may say, parents know when their child's in pain. In fact, a recent study published in the Archives of Pediatrics & Adolescent Medicine found that parents' estimations of babies' pain from photographs of facial expressions were often more accurate than those of health care professionals.

In addition to parental instinct, pain scales  -- a list of characteristics used by doctors to identify pain  -- can help determine the level of discomfort your child is experiencing. Some pain scales measure signs that can only be verified by health care professionals, such as heart rate or blood pressure, but most include equally important behavioral indicators.

Deciding what type of therapy or medication is appropriate for your child's pain is up to the pediatrician or medical team treating her. But since children don't always express discomfort, parents can help doctors assess it by looking for the following cues.

 

  1. Facial expression Facial expression is one of the most obvious  -- and most important  -- measures of infant pain. Expressions that we associate with pain are the same ones that doctors use: a bulging forehead with a furrowed brow; eyes squeezed shut; broadened nose; taut, cupped tongue; and mouth open in a tense, rectangular shape. In instances of chronic pain, however, there may not be facial cues.

  2. Body language Movements such as thrashing, ear-pulling, or rolling the head from side to side can offer clues about pain. More subtle signs include muscular rigidity or a refusal to move a body part. "Extremes of body tone, either very active or very passive, can also indicate discomfort," explains Sentivany-Collins.

  3. Cries Crying can be deceptive because it's one of the only ways that babies can communicate their needs. A child may appear to be in pain when she is only stressed by events. This can easily happen in a NICU, note experts. At the same time, babies who are in pain can become lethargic or expressionless rather than crying fiercely, according to a recent study that found nurses could gauge chronic pain better from assessing its clinical likelihood than from the babies' behavior. Responses can be especially subtle when pain has continued for a long time, so if a baby stops reacting, it's important not to assume that the pain has gone away or that he has grown accustomed to it. Pain is especially easy to overlook in preemies because they are less likely to show signs of it, though they may in fact experience pain more acutely than older children, according to a report recently published in Pediatrics.

  4. Changing sleep patterns If your baby's regular pattern of sleep has suddenly changed, it may be a sign that she's in pain, according to Sentivany-Collins. Regular, deep sleep promotes tissue repair and strengthens the psychological defenses your baby needs to cope with pain. If pain is interfering with a child's sleep, a doctor may prescribe medications such as acetaminophen or ibuprofen to help.

  5. Skin color An infant who is reacting to sudden pain will often turn red as he cries vigorously. In extreme situations, unusual pallor can indicate shock or an overload of pain.

  6. Heart and breathing rates "Remember, pain causes a physiological stress response that can be measured," says Wong. As parents are the ones who know what is normal for their child, they should never hesitate to talk to their pediatrician or hospital staff and ask that a pain scale be used if they think their child is suffering, she adds. "Parents should expect adequate pain control, and doctors should do what they can to meet those expectations."

     

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