Minimising the pain of infant surgery

“Twenty-five years ago, when Kanwaljeet Anand was a medical resident in a neonatal intensive care unit, his tiny patients, many of them preterm infants, were often wheeled out of the ward and into an operating room.  He soon learned what to expect on their return.  The babies came back in terrible shape: their skin was gray, their breathing shallow, their pulses weak.  Anand spent hours stabilizing their vital signs, increasing their oxygen supply and administering insulin to balance their blood sugar.”

The previous post here mentioned Drs K J S Anand and Paul R Hickey, who came to prominence in 1987 by exposing the fact that much infant surgery to that time was being done without sufficient or any pain relief because of the often-heard and widely-held mantra that “fetuses and babies don’t feel or remember pain”.

In a research report in the leading New England Journal of Medicine these men told of the scientific work and findings that had led them to expose this fallacy.  The distinguished New York Times promptly publicised Dr Anand’s work in 1987 and several more times in later years.  A quarter century later, articles in the magazine USA Today in 2005 and in 2008 The New York Times again helped give the Drs Anand and Hickey’s world-wide publicity.  The quotation above is from the latter article; here is another excerpt from journalist Anne Murphy Paul’s February 2008 NYT feature, The First Ache:

“When the surgeon lowered his scalpel to the 25-week-old fetus, [anesthesiologist] Paschall saw the tiny figure recoil in what looked to him like pain.  A few months later, he watched another fetus, this one 23 weeks old, flinch at the touch of the instrument.  That was enough for Paschall.  In consultation with the hospital’s pediatric pain specialist, ‘I tremendously upped the dose of anesthetic to make sure that wouldn’t happen again,’ he says.  In the more than 200 operations he has assisted in since then, not a single fetus has drawn back from the knife.”

The Just Facts website gives a factual summary of the current knowledge of when and how we humans begin to sense and remember pain – starting not in our first years but much, much earlier, in the first months after our conception.  Fetal or pre-natal surgery has become possible for a list of congenital conditions including spina bifida, tumours, and heart defects which can threaten a newborn’s hold on life or its quality.  The proof that foetuses feel pain has clear implications for pre-natal surgery and other medical practices.  And, we might argue, how much more so for newborn infants.

This quotation from the website makes one wonder why the medical world has denied the reality of pre-natal and infant pain for so long:

“Physicians know that foetuses feel pain … because [among other things]: ‘Nerves connecting the spinal cord to peripheral structures have developed between six to eight weeks.  Adverse reactions to stimuli are observed between eight and 10 weeks…. You can tell by the contours on their faces that aborted foetuses feel pain.’”

The ground-breaking study of Drs Anand and Hickey has had far-reaching consequences since 1987.

• The September 1987 issue of the USA-based Pediatrics journal posted its revision of the policies and protocol of US pediatricians. However, I have noticed that an American Society of Anesthiologists overview of the history of pediatric anesthesia in the USA published in 2011 made many references to major and significant changes in this field but no mention of the landmark work of Dr Anand and others, of the major revision of their policy and practice, nor of the opposition to these changes in some quarters!
• Change there has been nevertheless, supported by the growing recognition that pediatric surgery and anesthesia are indeed specialist disciplines, and by the development of safer drugs and management of their use. Crudely performed infant surgery and minimal pain control of medical procedures on infants are increasingly regarded as unacceptable and should become increasingly rare.  The incidence of long-term trauma effects will also be greatly reduced.
• Dr Anand’s work is part of a growing and worldwide recognition of the trauma that old-style infant surgery could cause. In the previous post I mentioned other specialists in the fields of medicine, psychiatry, clinical psychology and child development who have contributed greatly to this recognition and thus also to its management and treatment.  In coming posts I plan to review the contributions of such people.

Those who have needed infant surgery (and even those subjected to elective infant circumcision) and their distressed parents owe Drs Anand and Hickey and their like a huge debt of gratitude.  As someone who had rather basic pyloric stenosis surgery back in 1945, I have certainly learnt much and been hugely helped in my own self-understanding and healing from the long-term effects of my infant surgery.