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Pain relief in infants after major surgery: A descriptive study
Pain Relief in Infants After Major Surgery: A Descriptive
Study
By Gunnel Elander, Tor Lindberg, and Birgitta Quarnstriim Lund, Sweden and Ume$ @Twenty subjects (nurses or parents) were interviewed concerning postoperative pain and pain relief in infants. Details of postoperative analgesics given were obtained from hospital records of 32 infants, aged 0 to 12 months, who had undergone major surgery, and routines for postoperative pain relief in infants were investigated at four Swedish hospitals where major surgery is performed on infants. Although both nurses and parents were foundto be able to recognize postoperative pain reactions in infants, attitudes to pain relief were not uniform. In principle, postoperative pain relief is given “as required,” although both dosage and intervals between doses are arbitrary. Copyright 8 1991 by W.B. Saunders Company INDEX WORDS:
Pain, postoperative
relief, infants.
I
T HAS BEEN ASSUMED that newborn infants feel no pain, and that perception of pain increases with age. One reason for this belief was the neurological immaturity of infants, pain being thought to be dependent on the degree of myelination present in the nervous system-the less the myelination, the less the perception of pain. However, pain is now known to be transmitted both by the lightly myelinated A delta fibers and by the unmyelinated C fibers, and there is no doubt that infants do indeed feel pain, and react both spontaneously and vigorously to painful stimuli.lm5 Due to their rapid development and individual differences in their response to painful stimuli, the assessment of pain in infants is difficult. Somatic response to pain, for instance, from being diffuse in the first month of life evolves to become more specific to the pain source between 3 and 10 months of age. Anticipatory fear of pain begins to appear around 6 months of age.6 Little attention has been paid to postoperative pain in infants despite the fact that it constitutes a very real problem with regard to providing adequate care. When prescribed at all, postoperative pain relief is given “as necessary”; whereas this might be satisfactory in adults or where the patient is capable of
Sweden
communicating a need of relief, the infant is wholly dependent on the judgement of others. In turn, such judgement is dependent on a number of factors, eg, on someone actually being present to observe the infant in the first place, on that person’s capacity for recognizing the infant’s signals of distress, and on their attitudes toward pain and its relief. The aims of this study were to ascertain (1) how infants behave in response to pain following surgery; (2) what attitudes parents and nurses may have toward pain relief; and (3) the type and amount of analgesics routinely administered to infants following major operations. MATERIALS AND METHODS
Interviews Twenty subjects (either nurses or parents) connected with two surgical wards at one of the four Swedish hospitals where major surgery is performed on infants were selected to be interviewed regarding pain in infants and its relief. The nurses were recruited by posting lists in the two wards, on which nurses willing to be interviewed could put their names; this procedure was adopted with a view to recruiting people both interested and experienced in the topic. Parents to be interviewed were selected by the head nurse, who was asked to approach parents of infants who had undergone major surgery (eg, kidney, gastrointestinal, or heart operations), but who were otherwise healthy. Shortly before such an infant was due for discharge, its parents were given a written resume outlining the aims of the study and the form the interview would take. None of the parents thus approached declined to participate. The interviews, which took place in the autumn of 1987 and the spring of 1988 and were tape-recorded, consisted of more or less informal conversation or discussion. Transcriptions of the taperecordings were analyzed with a view to answering the question of how to recognize when an infant is in pain and requiring analgesics for relief.
Questionnaire To obtain data on routines practiced in Sweden in 1988, a questionnaire comprising items regarding standard practice visa-vis postoperative pain relief in infants was sent to the four national hospitals where major surgery is performed on infants.
Examination of Hospital Records From the Care Research Unit, University of Lund, Lund, Sweden and the Department of Pediatrics, University of Umei;, Umei, Sweden. Date accepted: February 7,1990. Address reprint requests to Gunnel Elander, DMSc, Care Research Unit, Box 5116,220 05 Lund, Sweden. Copyright o 1991 by W. B. Saunders Company 0022-3468/91/2602-0002$03.0oQI0
128
To obtain details of analgesics administered to infants at the hospital where the interviews were done, a scrutiny was made of the hospital records of all infants born after January 1, 1986 who had undergone major surgery during 1987 (n = 32) any cases of postoperative complications being exciuded. The details noted were age, weight, type of surgery, type of anesthetic used, type and amount of analgesics given, the time(s) at which they were given, and any comments by nurses before or afterward.
Journalofkdiatric
Surgery, Vol26, No 2 (February), 1991: pp 128-131
POSTOPERATIVE
129
PAIN RELIEF TO INFANTS
RESULTS
Interviews
Analysis of professional and parental opinions of the infants’ postoperative experience and behavior, obtained in interviews at the hospital, enabled two main issues to be identified-recognition that an infant is in pain, and attitudes to and treatment of pain in infants. Recognition of Pain
Cues or symptoms described by nurses or parents as pain reactions of the infants are given in Table 1. None of the cues listed in Table 1 were predominantly mentioned by nurses or by parents. Several of those interviewed emphasized that although they knew when an infant was in pain, it was not always easy to pinpoint how this pain was expressed-“It is just something you feel, because the baby seems to radiate anxiety and restlessness.” However, all those interviewed were able to describe some symptoms of pain, and there was no hesitation in distinguishing between the expression of pain and signs of hunger or other distress. Attitudes to Pain Relief
Statements concerning the recognition and treatment of pain in infants by nurses are summarized in Table 2, and those by parents in Table 3. Synthesis of Questionnaire Answers
Analgesics are prescribed for pain relief as necessary at all four hospitals, and continuously at none. At one hospital physicians alone decide the need of pain relief; at another physicians, nurses, and parents decide; and at the two remaining hospitals nurses and physicians make the decision. At all four hospitals, nonnarcotic analgesics are tried first. Table 1. Symptoms of Pain Described by Nurses and Parents Tense muscles Tense body Legs bent “upward” “Pain face” Unsteady gaze Gaze full of agony Face of anxiety Crying Special crying Sound asleep and suddenly start to crawl around Head turns from side to side Scratch the sheet Kick the legs Difficult to calm down Totally uninterested in the environment
Data Collected From Hospital Records
In Table 4 is summarized the administration of analgesics (narcotic v nonnarcotic) among all 32 infants during the first 72 hours after surgery. The infants varied in age from 1 day to 12 months. Narcotic analgesics (ketogan or pethidine) were given by injection, and nonnarcotic analgesics (acetaminophen) were given as suppositories. Of the nine infants in the 2.5 to 5.5-kg weight group, seven received no pain relief whatsoever (Table 4). Of these seven, one, a day-old neonate, was observed to be apathetic and gavage was necessary for 6 days; another day-old neonate, whose heart rate fluctuated between 50 and 250 beats/min, received no pain relief until the fourth day after surgery, and an entry-“pain affect?“-was made in the record by a nurse; and yet another newborn, who was given a tranquilizer (diazepam) on the first day after surgery but no analgesic for the first 4 days, also had an irregular heart rate and the same entry (“pain affect?“) was made in the record. Occasionally, comments on the effect of analgesics were entered in the record; in one case a 6-month-old infant was given 60 mg of acetaminophen the night after surgery, but although this was without effect and the infant noted as “inconsolable,” no additional analgesic was given until 4 hours had elapsed. As can be seen from Table 5, ketogan dosages varied widely, as did the intervals between doses. DISCUSSION
The findings of this study raise three main issues. First, infants are in pain after major surgery and both nurse and parent participants asserted that they could recognize when infants were in pain; they also declared themselves able to distinguish symptoms of pain from signs of hunger or other distress. Second, despite general agreement as to the recognition of pain in infants, opinion differed among the nurses and parents interviewed as to whether analgesics should be given to infants. Finally, both the answers to the questionnaire and the examination of hospital records showed the prescription or administration of analgesics to be inconsistent with regard to type (ie, narcotic v nonnarcotic), dosage, relation of dosage to body weight, number of doses given, and intervals between doses. There are several explanations for these findings, as we shall consider in the following sections. General Attitudes to Infant Sensitivity to Pain
Not long ago it was generally assumed that infants feel no pain, and certain types of surgery such as
130
ELANDER, LINDBERG, AND OUARNSTR6M
Table 2. Nurses’ Statement 0 “The baby was crying and was given acetaminophen.
on Pain Relief to Infants
Since it did not help, it was agreed on that pain was not the cause of the problem.”
l
“His behavior did not change, but since acetaminophen had been given we knew that he was no longer in pain.”
l
‘We are told to be generous with acetaminophen,
l
“The infants are given very potent drugs for various reasons, but to increase the dosage for pain relief is considered dangerous.”
l
“The parents are very brave and keep telling us that we can postpone pain relief to the infant.”
l
“If we give morphine they can develop addiction.”
l
“There are no general rules, we always start by giving the least potent medicine. If that does not help, something else is tried.”
l
“When the father came to visit he complained about all the medicine that the infant had received. He considered crying in infants to be
l
“We do not follow a schedule, if we did, we might give pain relief to an infant who did not need it.”
l
“Usually the parents are in favor of pain relief, but sometimes they disagree to the infant receiving medicine.”
l
“Pain relief is never regularly given to infants and if the parents are not aware of the infant’s pain, they do not ask for analgesics.
but if we were, we would exceed the general prescription.“
normal behavior.”
I do
not
understand that pain relief is not prescribed. To adults, pain relief is given as prevention, why not to infants? The prescription is to administer pain relief according to demands. Of course infants are in pain after major surgery, and if one or two babies are not, I don’t think they will be hurt by an extra dose of acetaminophen.”
circumcision are still performed without anestethics.’ An analysis of 40 published reports has shown that 77% of neonates undergoing surgical ligation of patent ductus arteriosis received either muscle relaxants alone or only intermittent nitrous oxide.7 Opinion continues to differ as to whether neonates and young infants can feel pain, and according to Hatch’ most babies sleep peacefully for normal periods even after major surgery. Fitzgerald’ urged that instead of “Do infants feel pain?,” we should ask “Can we measure pain response in infants, and are these measures sensitive to analgesics?” Fitzgerald also warned that observations regarding pain in infants are based on adult behavioral response to pain and, therefore, can be very misleading. Stoddard” described a 6-month-old infant suffering from 30% third-degree burns on the lower half of her body, who was observed to follow people with her eyes, but withdrew and whimpered rather than cried when in pain. Stoddard concluded that among the reactions of infants to the pain of a burn are withdrawal, a sad facial expression, eating and sleeping disturbances, and failure to respond favorably to caregivers. Infant response to acute pain also differs from that to more prolonged pain such as postoperative pain, as
was noted by Lutz,6 who reported that in children, although pulse, respiratory rate, and blood pressure may be normal in cases of prolonged and persistent pain, they increase when the pain is sudden, brief, or intense. In a recent study,” we found that, even if they did not cry, newborns responded to heel lance with an increase in heart rate and a change in facial expression (“pain face”). A General Dread of Promoting Addiction
Formerly a general dread of promoting addiction resulted in ineffective pain relief in adults. This restrictive attitude has slowly given way to a tendency to use analgesics not only to treat pain but to forestall it, a trend that has found no acceptance where children are concerned, not to mention infants. Comparing 50 adults with 50 children (ranging in age from 1 day to 14 years) concerning the administration of analgesics during the first 3 days after open heart surgery, Beyer et all2 found significant differences between the groups with regard to frequency of administration, type of drugs used, and therapeutic range; the children received 237 doses, the adults 564. In the present sample of 32 infants, of nine in the 2.5to 5.5-kg weight group, seven received no postoperative analgesics whatsoever; four of these seven infants
Table 3. Parents’ Statements
on Pain Relief to infants
l
“It can’t be right that they have to cry to get pain relief. How does crying affect a big wound? What are the long-term effects of pain
l
“A grown up, who has to undergo an operation as major as that undergone by our infant, would never put up with acetaminophen
l
“I was told that he could get acetaminophen
experienced during infancy?” as an analgesic.” or “something stronger.” He was given acetaminophen, which did not help, and then
we had to wait for 4 hours until something else could be given. The nurse said it would have been wrong to give a potent drug if a less potent one might have helped.” 0 “I did not like him to be in pain so I asked for acetaminophen,
but 4 hours had to pass between doses.”
l
“The nurses ensured that he did not receive too much pain relief.”
l
“I think he has received enough of pain relief.
I don’t
think he has ever been in pain.
I myself
never take any pain killers, if I have a
headache once a year, I go to bed and the headache disappears.” l
“They have to be in pain before they are given any pain relief. It would be better to prevent the pain.”
POSTOPERATIVE
PAIN RELIEF TO INFANTS
131
Table 4. Number of Doses of Analgesics Given to Infants (n = 32)
Table 5. Dosages and Number of doses of Ketogan Given During the
During the First 72 Hours After Surgery 2.5-5.5 kg (n = 9) Narcotics
Nonnarcotics
5.6-6.5 kg (n = 12) Narcotics
First 72 Hours Postoperatively,
6.6-11.5 kg In = 11)
Nonnarcotics
Narcotics
in Relation to the Infants’
Weight and Age Weight (kg)
Nonnarcotics
Age (mo)
Ketogan (mg)
No. of Doses
2
2
1
0
4
2
2
4.9
4
0.25
0
3
4
4
0
4
6.5
7
1
5
0
0
0
7
3
8
7.6
11
1
3
0
0
2
0
7
1
7.7
10
0.5
3
5
0.5
7
6
0.25
3
0
0
5
3
0
1
8.6
0
0
3
2
2
2
8.7
0
0
6
3
6
3
0
0
2
2
0
4
0
0
0
4
0
9
0
4
0
1
3
9
6
2
2
2
were newborns and three were less than 1 month old. There would seem to be a pattern: the younger the infant, the less pain relief is provided. Mather and Mackie,13 comparing the incidence of pain in 170 children after surgery, found that, irrespective of whether analgesics were given, only 25% of the children were reported to be pain-free on the day of surgery and 53% on the first postoperative day. They also found that analgesia was not ordered for 16% of the children; and that to the 29% for whom the physician had left the choice of narcotic or nonnarcotic agents to the discretion of staff nurses, exclusively nonnarcotic analgesics were given. In the present study, as can be seen from Table 4, less than 50% of the infants were given narcotic analgesics, and the type of analgesics was unrelated to body weight. Both dosage and the number of doses given were arbitrary; and in one weight group, some of the infants were given only one dose, whereas others received 10 or more. The As-Required Principle
The prescription of analgesics as required has been found to be interpreted by nursing staff to mean “as
little as possible”; even where the physician has left the choice between narcotic and nonnarcotic analgesics open, nurses prefer to give nonnarcotics.13 In the present study, these trends were confirmed by findings at interviews; in addition, nurses were found to be reluctant to reduce the 4-hour interval between doses of analgesics, and thus as required is interpreted to mean “as the nursing staff consider necessary, but only after a minimum interval.” It was also evident from the interviews that if a baby’s behavior, eg, crying, did not abate after administration of an analgesic, the behavior was then usually considered to have been due to other causes than pain, rather than because the analgesic might have been inadequate in type or dosage. Interviews with parents showed their general view that the infants were given unsatisfactory pain relief; nurses varied in their willingness to give analgesics, and young and inexperienced nurses dared not provide adequate pain relief. In conclusion, we would stress that infants are indeed in pain after major surgery. In consistencies in the administration of analgesics and in interpretation of the as required principle are common features of postoperative pain relief. We would propose that infants as well as adults need preventive and continuous pain relief, which might, as has been demonstrated in adults,14 result in a general reduction in overall consumption.
REFERENCES 1. Rawlings DJ, Miller PA, Engel RR: The effect of circumcision on transcutaneous PO, in term infants. Am J Dis Child 134:676-678,198O 2. Wiliamson PS, Wiliamson by a local anaesthetic during 71:36-40, 1983
ML: Physiologic stress reduction newborn circumcision. Pediatrics
3. Owens ME, Todt EH: Pain in infancy: heel lance. Pain 20:77-86, 1984
Neonatal
4. Grunau RV, Craig JSD: Pain expression action and cry. Pain 28:395-410, 1987
reaction
in neonates:
5. Johnston C, Strada ME: Acute pain responses multidimensional description. Pain 24:373-382, 1986
JSJS, Sippell WG, Aynsley-Green
Facial
in infants:
6. Lutz WJ: Helping hospitalized children and their cope with painful procedures. J Pediatr Nurs 1:24-32,1986 7. Anad
to a
A: Randomised
A
parents trial
of fentanyl anaesthesia in preterm babies undergoing surgery: Effects on the stress response. Lancet 1:62-65, 1987 8. Hatch DJ: Analgesia in the neonate. Br Med J 294:920, 1987 9. Fitzgerald M: Pain and analgesia in neonates. Trends Neurosci 10:344-346, 1987 10. Stoddard FJ: Coping with pain: A developmental approach to treatment of burned children. Am J Psychiatry 139:736-740.1982 11. Elander G, Ericson K: A method for assessing pain in newborn infants. (in press) 12. Beyer JE, DeGood DE, Ashley LC, et al: Patterns of postoperative analgesic use with adults and children following cardiac surgery. Pain 17:71-81, 1983 13. Mather L, Mackie J: The incidence of postoperative pain in children. Pain 15:271-282, 1983 14. Killander E: Smlrt-och symtomlindring vid svPr sjukdom. Avd fiir klin. farm. Regionssjikhuset, LinkBping, 1988, pp lo-12
Study
By Gunnel Elander, Tor Lindberg, and Birgitta Quarnstriim Lund, Sweden and Ume$ @Twenty subjects (nurses or parents) were interviewed concerning postoperative pain and pain relief in infants. Details of postoperative analgesics given were obtained from hospital records of 32 infants, aged 0 to 12 months, who had undergone major surgery, and routines for postoperative pain relief in infants were investigated at four Swedish hospitals where major surgery is performed on infants. Although both nurses and parents were foundto be able to recognize postoperative pain reactions in infants, attitudes to pain relief were not uniform. In principle, postoperative pain relief is given “as required,” although both dosage and intervals between doses are arbitrary. Copyright 8 1991 by W.B. Saunders Company INDEX WORDS:
Pain, postoperative
relief, infants.
I
T HAS BEEN ASSUMED that newborn infants feel no pain, and that perception of pain increases with age. One reason for this belief was the neurological immaturity of infants, pain being thought to be dependent on the degree of myelination present in the nervous system-the less the myelination, the less the perception of pain. However, pain is now known to be transmitted both by the lightly myelinated A delta fibers and by the unmyelinated C fibers, and there is no doubt that infants do indeed feel pain, and react both spontaneously and vigorously to painful stimuli.lm5 Due to their rapid development and individual differences in their response to painful stimuli, the assessment of pain in infants is difficult. Somatic response to pain, for instance, from being diffuse in the first month of life evolves to become more specific to the pain source between 3 and 10 months of age. Anticipatory fear of pain begins to appear around 6 months of age.6 Little attention has been paid to postoperative pain in infants despite the fact that it constitutes a very real problem with regard to providing adequate care. When prescribed at all, postoperative pain relief is given “as necessary”; whereas this might be satisfactory in adults or where the patient is capable of
Sweden
communicating a need of relief, the infant is wholly dependent on the judgement of others. In turn, such judgement is dependent on a number of factors, eg, on someone actually being present to observe the infant in the first place, on that person’s capacity for recognizing the infant’s signals of distress, and on their attitudes toward pain and its relief. The aims of this study were to ascertain (1) how infants behave in response to pain following surgery; (2) what attitudes parents and nurses may have toward pain relief; and (3) the type and amount of analgesics routinely administered to infants following major operations. MATERIALS AND METHODS
Interviews Twenty subjects (either nurses or parents) connected with two surgical wards at one of the four Swedish hospitals where major surgery is performed on infants were selected to be interviewed regarding pain in infants and its relief. The nurses were recruited by posting lists in the two wards, on which nurses willing to be interviewed could put their names; this procedure was adopted with a view to recruiting people both interested and experienced in the topic. Parents to be interviewed were selected by the head nurse, who was asked to approach parents of infants who had undergone major surgery (eg, kidney, gastrointestinal, or heart operations), but who were otherwise healthy. Shortly before such an infant was due for discharge, its parents were given a written resume outlining the aims of the study and the form the interview would take. None of the parents thus approached declined to participate. The interviews, which took place in the autumn of 1987 and the spring of 1988 and were tape-recorded, consisted of more or less informal conversation or discussion. Transcriptions of the taperecordings were analyzed with a view to answering the question of how to recognize when an infant is in pain and requiring analgesics for relief.
Questionnaire To obtain data on routines practiced in Sweden in 1988, a questionnaire comprising items regarding standard practice visa-vis postoperative pain relief in infants was sent to the four national hospitals where major surgery is performed on infants.
Examination of Hospital Records From the Care Research Unit, University of Lund, Lund, Sweden and the Department of Pediatrics, University of Umei;, Umei, Sweden. Date accepted: February 7,1990. Address reprint requests to Gunnel Elander, DMSc, Care Research Unit, Box 5116,220 05 Lund, Sweden. Copyright o 1991 by W. B. Saunders Company 0022-3468/91/2602-0002$03.0oQI0
128
To obtain details of analgesics administered to infants at the hospital where the interviews were done, a scrutiny was made of the hospital records of all infants born after January 1, 1986 who had undergone major surgery during 1987 (n = 32) any cases of postoperative complications being exciuded. The details noted were age, weight, type of surgery, type of anesthetic used, type and amount of analgesics given, the time(s) at which they were given, and any comments by nurses before or afterward.
Journalofkdiatric
Surgery, Vol26, No 2 (February), 1991: pp 128-131
POSTOPERATIVE
129
PAIN RELIEF TO INFANTS
RESULTS
Interviews
Analysis of professional and parental opinions of the infants’ postoperative experience and behavior, obtained in interviews at the hospital, enabled two main issues to be identified-recognition that an infant is in pain, and attitudes to and treatment of pain in infants. Recognition of Pain
Cues or symptoms described by nurses or parents as pain reactions of the infants are given in Table 1. None of the cues listed in Table 1 were predominantly mentioned by nurses or by parents. Several of those interviewed emphasized that although they knew when an infant was in pain, it was not always easy to pinpoint how this pain was expressed-“It is just something you feel, because the baby seems to radiate anxiety and restlessness.” However, all those interviewed were able to describe some symptoms of pain, and there was no hesitation in distinguishing between the expression of pain and signs of hunger or other distress. Attitudes to Pain Relief
Statements concerning the recognition and treatment of pain in infants by nurses are summarized in Table 2, and those by parents in Table 3. Synthesis of Questionnaire Answers
Analgesics are prescribed for pain relief as necessary at all four hospitals, and continuously at none. At one hospital physicians alone decide the need of pain relief; at another physicians, nurses, and parents decide; and at the two remaining hospitals nurses and physicians make the decision. At all four hospitals, nonnarcotic analgesics are tried first. Table 1. Symptoms of Pain Described by Nurses and Parents Tense muscles Tense body Legs bent “upward” “Pain face” Unsteady gaze Gaze full of agony Face of anxiety Crying Special crying Sound asleep and suddenly start to crawl around Head turns from side to side Scratch the sheet Kick the legs Difficult to calm down Totally uninterested in the environment
Data Collected From Hospital Records
In Table 4 is summarized the administration of analgesics (narcotic v nonnarcotic) among all 32 infants during the first 72 hours after surgery. The infants varied in age from 1 day to 12 months. Narcotic analgesics (ketogan or pethidine) were given by injection, and nonnarcotic analgesics (acetaminophen) were given as suppositories. Of the nine infants in the 2.5 to 5.5-kg weight group, seven received no pain relief whatsoever (Table 4). Of these seven, one, a day-old neonate, was observed to be apathetic and gavage was necessary for 6 days; another day-old neonate, whose heart rate fluctuated between 50 and 250 beats/min, received no pain relief until the fourth day after surgery, and an entry-“pain affect?“-was made in the record by a nurse; and yet another newborn, who was given a tranquilizer (diazepam) on the first day after surgery but no analgesic for the first 4 days, also had an irregular heart rate and the same entry (“pain affect?“) was made in the record. Occasionally, comments on the effect of analgesics were entered in the record; in one case a 6-month-old infant was given 60 mg of acetaminophen the night after surgery, but although this was without effect and the infant noted as “inconsolable,” no additional analgesic was given until 4 hours had elapsed. As can be seen from Table 5, ketogan dosages varied widely, as did the intervals between doses. DISCUSSION
The findings of this study raise three main issues. First, infants are in pain after major surgery and both nurse and parent participants asserted that they could recognize when infants were in pain; they also declared themselves able to distinguish symptoms of pain from signs of hunger or other distress. Second, despite general agreement as to the recognition of pain in infants, opinion differed among the nurses and parents interviewed as to whether analgesics should be given to infants. Finally, both the answers to the questionnaire and the examination of hospital records showed the prescription or administration of analgesics to be inconsistent with regard to type (ie, narcotic v nonnarcotic), dosage, relation of dosage to body weight, number of doses given, and intervals between doses. There are several explanations for these findings, as we shall consider in the following sections. General Attitudes to Infant Sensitivity to Pain
Not long ago it was generally assumed that infants feel no pain, and certain types of surgery such as
130
ELANDER, LINDBERG, AND OUARNSTR6M
Table 2. Nurses’ Statement 0 “The baby was crying and was given acetaminophen.
on Pain Relief to Infants
Since it did not help, it was agreed on that pain was not the cause of the problem.”
l
“His behavior did not change, but since acetaminophen had been given we knew that he was no longer in pain.”
l
‘We are told to be generous with acetaminophen,
l
“The infants are given very potent drugs for various reasons, but to increase the dosage for pain relief is considered dangerous.”
l
“The parents are very brave and keep telling us that we can postpone pain relief to the infant.”
l
“If we give morphine they can develop addiction.”
l
“There are no general rules, we always start by giving the least potent medicine. If that does not help, something else is tried.”
l
“When the father came to visit he complained about all the medicine that the infant had received. He considered crying in infants to be
l
“We do not follow a schedule, if we did, we might give pain relief to an infant who did not need it.”
l
“Usually the parents are in favor of pain relief, but sometimes they disagree to the infant receiving medicine.”
l
“Pain relief is never regularly given to infants and if the parents are not aware of the infant’s pain, they do not ask for analgesics.
but if we were, we would exceed the general prescription.“
normal behavior.”
I do
not
understand that pain relief is not prescribed. To adults, pain relief is given as prevention, why not to infants? The prescription is to administer pain relief according to demands. Of course infants are in pain after major surgery, and if one or two babies are not, I don’t think they will be hurt by an extra dose of acetaminophen.”
circumcision are still performed without anestethics.’ An analysis of 40 published reports has shown that 77% of neonates undergoing surgical ligation of patent ductus arteriosis received either muscle relaxants alone or only intermittent nitrous oxide.7 Opinion continues to differ as to whether neonates and young infants can feel pain, and according to Hatch’ most babies sleep peacefully for normal periods even after major surgery. Fitzgerald’ urged that instead of “Do infants feel pain?,” we should ask “Can we measure pain response in infants, and are these measures sensitive to analgesics?” Fitzgerald also warned that observations regarding pain in infants are based on adult behavioral response to pain and, therefore, can be very misleading. Stoddard” described a 6-month-old infant suffering from 30% third-degree burns on the lower half of her body, who was observed to follow people with her eyes, but withdrew and whimpered rather than cried when in pain. Stoddard concluded that among the reactions of infants to the pain of a burn are withdrawal, a sad facial expression, eating and sleeping disturbances, and failure to respond favorably to caregivers. Infant response to acute pain also differs from that to more prolonged pain such as postoperative pain, as
was noted by Lutz,6 who reported that in children, although pulse, respiratory rate, and blood pressure may be normal in cases of prolonged and persistent pain, they increase when the pain is sudden, brief, or intense. In a recent study,” we found that, even if they did not cry, newborns responded to heel lance with an increase in heart rate and a change in facial expression (“pain face”). A General Dread of Promoting Addiction
Formerly a general dread of promoting addiction resulted in ineffective pain relief in adults. This restrictive attitude has slowly given way to a tendency to use analgesics not only to treat pain but to forestall it, a trend that has found no acceptance where children are concerned, not to mention infants. Comparing 50 adults with 50 children (ranging in age from 1 day to 14 years) concerning the administration of analgesics during the first 3 days after open heart surgery, Beyer et all2 found significant differences between the groups with regard to frequency of administration, type of drugs used, and therapeutic range; the children received 237 doses, the adults 564. In the present sample of 32 infants, of nine in the 2.5to 5.5-kg weight group, seven received no postoperative analgesics whatsoever; four of these seven infants
Table 3. Parents’ Statements
on Pain Relief to infants
l
“It can’t be right that they have to cry to get pain relief. How does crying affect a big wound? What are the long-term effects of pain
l
“A grown up, who has to undergo an operation as major as that undergone by our infant, would never put up with acetaminophen
l
“I was told that he could get acetaminophen
experienced during infancy?” as an analgesic.” or “something stronger.” He was given acetaminophen, which did not help, and then
we had to wait for 4 hours until something else could be given. The nurse said it would have been wrong to give a potent drug if a less potent one might have helped.” 0 “I did not like him to be in pain so I asked for acetaminophen,
but 4 hours had to pass between doses.”
l
“The nurses ensured that he did not receive too much pain relief.”
l
“I think he has received enough of pain relief.
I don’t
think he has ever been in pain.
I myself
never take any pain killers, if I have a
headache once a year, I go to bed and the headache disappears.” l
“They have to be in pain before they are given any pain relief. It would be better to prevent the pain.”
POSTOPERATIVE
PAIN RELIEF TO INFANTS
131
Table 4. Number of Doses of Analgesics Given to Infants (n = 32)
Table 5. Dosages and Number of doses of Ketogan Given During the
During the First 72 Hours After Surgery 2.5-5.5 kg (n = 9) Narcotics
Nonnarcotics
5.6-6.5 kg (n = 12) Narcotics
First 72 Hours Postoperatively,
6.6-11.5 kg In = 11)
Nonnarcotics
Narcotics
in Relation to the Infants’
Weight and Age Weight (kg)
Nonnarcotics
Age (mo)
Ketogan (mg)
No. of Doses
2
2
1
0
4
2
2
4.9
4
0.25
0
3
4
4
0
4
6.5
7
1
5
0
0
0
7
3
8
7.6
11
1
3
0
0
2
0
7
1
7.7
10
0.5
3
5
0.5
7
6
0.25
3
0
0
5
3
0
1
8.6
0
0
3
2
2
2
8.7
0
0
6
3
6
3
0
0
2
2
0
4
0
0
0
4
0
9
0
4
0
1
3
9
6
2
2
2
were newborns and three were less than 1 month old. There would seem to be a pattern: the younger the infant, the less pain relief is provided. Mather and Mackie,13 comparing the incidence of pain in 170 children after surgery, found that, irrespective of whether analgesics were given, only 25% of the children were reported to be pain-free on the day of surgery and 53% on the first postoperative day. They also found that analgesia was not ordered for 16% of the children; and that to the 29% for whom the physician had left the choice of narcotic or nonnarcotic agents to the discretion of staff nurses, exclusively nonnarcotic analgesics were given. In the present study, as can be seen from Table 4, less than 50% of the infants were given narcotic analgesics, and the type of analgesics was unrelated to body weight. Both dosage and the number of doses given were arbitrary; and in one weight group, some of the infants were given only one dose, whereas others received 10 or more. The As-Required Principle
The prescription of analgesics as required has been found to be interpreted by nursing staff to mean “as
little as possible”; even where the physician has left the choice between narcotic and nonnarcotic analgesics open, nurses prefer to give nonnarcotics.13 In the present study, these trends were confirmed by findings at interviews; in addition, nurses were found to be reluctant to reduce the 4-hour interval between doses of analgesics, and thus as required is interpreted to mean “as the nursing staff consider necessary, but only after a minimum interval.” It was also evident from the interviews that if a baby’s behavior, eg, crying, did not abate after administration of an analgesic, the behavior was then usually considered to have been due to other causes than pain, rather than because the analgesic might have been inadequate in type or dosage. Interviews with parents showed their general view that the infants were given unsatisfactory pain relief; nurses varied in their willingness to give analgesics, and young and inexperienced nurses dared not provide adequate pain relief. In conclusion, we would stress that infants are indeed in pain after major surgery. In consistencies in the administration of analgesics and in interpretation of the as required principle are common features of postoperative pain relief. We would propose that infants as well as adults need preventive and continuous pain relief, which might, as has been demonstrated in adults,14 result in a general reduction in overall consumption.
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