Urgent need to assess and treat babies suffering from chronic pain
Reported June 30, 2009
TORONTO – Signs that an infant is experiencing chronic pain may be going unrecognized by doctors and other caregivers in hospitals due to a lack of consensus on what constitutes chronic pain in babies, according to a study led by a researcher at York University with collaborators from the Hospital for Sick Children, Womens College Hospital, Bloorview Research Institute, Toronto General Hospital and the University of Toronto.
The study, appearing online in The Journal of Pain, conducted in-depth interviews with 45 master clinicians at university-affiliated hospitals with a median of 17 years experience to determine the best way to define and assess chronic pain in hospitalized infants, some born as young as 23 weeks gestation.
Despite the lack of any formal training or guidelines about how to assess and treat it, the clinicians overwhelmingly agreed that infants are capable of experiencing chronic pain a new development in the field since there is currently no formal definition of chronic pain in infants, said lead author Rebecca Pillai Riddell, a psychology professor at Yorks Faculty of Health.
“One of the only ways to identify chronic pain in adults is to ask a person. There are often no clinical markers for chronic pain; there is no blood test, for example, Pillai R iddell said. With these ill infants who cant verbalize their experience and who often have low energy reserves after being in pain for long periods of time, we have to rely on different cues than have been established in response to acute pain, such as a needle stick.”
The clinicians agreed that reactions such as the inability to settle, social withdrawal, constant grimacing, tense body, extreme or indifferent reactions to acute pain and problems with sleep and feeding, may indicate chronic pain.
But they were evenly split about whether long periods of persistent pain from repetitive exposure to painful procedures, such as needles – which may be the case for extremely premature infants – should be considered chronic pain.
It is important to parse the difference between prolonged pain that results from time-limited procedures such as surgeries and continuing pain that results from disorders such as short gut syndrome, said Pillai Riddell, noting that there are different approaches to treating different kinds of pain.
Would you want to keep a baby that you keep poking with a needle, for example, on a constant morphine drip? No, I would rather see them being treated pre-emptively with an analgesic before each painful procedure and afterwards if needed. But I would want to see a baby with short gut syndrome, where I think the pain is pretty constant, on a more steady pain management regime.
There is an urgent need to define chronic pain in infants so that clinicians can use proper and consistent measurements to assess and treat the pain, and help alleviate their prolonged suffering, regardless of the cause, Pillai Riddell said.
I suspect that, just as an adult would, babies initially have a strong reaction to painful procedures but they eventually shut down and become conditioned to the fact that even if they cry, they still get the pain from the IV or the surgery or the underlying disease.
This is really a serious gap in our system. Infants who may be in the most pain may be among the least reactive. Doctors or nurses may be interpreting that lack of response as the baby not being in pain, when it could be opposite.
Chronic Pain in Hospitalized Infants: Health Professionals Perspectives can be found online at The Journal of Pain website.