From the day they are born, babies can feel and express pain. An assessment of pain in babies relies mostly on observing behaviours. Pain reduction techniques include incorporating physical methods and medication for procedures that are known to cause pain.
What is pain?
Newborns, both premature and term, feel pain and stress in specific situations and in response to specific interventions. Most commonly, pain results when we are exposed to situations that are likely to lead to injury or tissue damage. The brain cannot detect pain directly. It relies on a system of nerves and receptors in the skin, muscles, joints and organs, and their connections to the spinal cord and brain. In this respect, pain helps us protect ourselves from possible further damage and aids the healing process. Reflexively flinching from a hot kettle is an example of this function.
At the same time, pain is different for everyone and is always experienced within an individual emotional, intellectual and situational context. Compared to older children and adults, a baby’s context for feeling pain is not as developed. However, they do feel pain and feel it within their own emotional and situational context.
While pain messages go back and forth between the body and the brain, so do many other types of messages. This is important in terms of pain relief because pain messages and other types of messages compete with one other. This is why if you hurt your knee, rubbing it may help relieve the pain. The soothing messages created by the rubbing compete with the pain messages created by the injured knee. In the case of babies, soothing sensations may help alleviate pain in the same way.
Signs and symptoms of pain
There are three types of pain responses that babies express: behavioural, physical and contextual.
Behavioural responses to pain
Babies in pain tend to display pain in their facial expressions, arm and leg movements, and cries. They may try to guard or protect a sore part of their body or even pull on it. Changes in feeding, moving and sleeping can also be indicators of pain.
Facial expressions are generally regarded as the best single behavioural indicator of pain in all age groups. A grimace, eyes squeezed shut and mouth stretched open with a tensed and curled tongue are common expressions of pain.
Babies also cry for reasons such as hunger, anger or fear, but the cries of pain are distinctive. The typical pain cry is high-pitched, tense, harsh, non-melodious, sharp, short and loud. However, the absence of crying does not mean a baby is not in pain. A baby in severe pain may not cry at all. They may simply not have the energy to cry.
Very young babies may not move and may become still in response to pain. This absence of movement has also been noted in older children recovering from surgery. They recognize that moving hurts and so remain still to minimize the amount of pain.
Assessing a baby’s pain by observing takes skill and requires an understanding of infant development. This is why no single measure is used on its own. Several measures are used to determine a baby’s level of pain.
Physical reactions to pain
Physical indicators, including heart rate, breathing rate, blood pressure, skin colour, vomiting, sweating and dilated pupils, are also used to determine if a baby is in pain. Because these changes can have other causes, including physical stress, fear or anxiety, they can be difficult to interpret. However, when used with behavioural and contextual indicators, these signs can be useful as part of an overall assessment for a baby in pain.
Contextual indicators
In addition to behavioural and physical reactions to pain, the context of the situation will also be considered when assessing pain. For example, when multiple procedures are going on, sometimes a baby will have an exaggerated response to non-painful stimuli or to a procedure that usually causes minimal pain. Other babies may become limp and stop responding to repeated painful procedures. Studies are underway to determine why babies tend to respond one way or the other.
Time and experience can also be contextual factors that influence pain. For example, if a baby has had to endure multiple painful procedures, over time, their response to the next painful procedure is often reduced.
In premature babies, gestational age can also influence pain. In general, extremely premature infants tend to have less response to pain compared to older premature babies. However, this does not necessarily mean they are feeling less pain. They may simply show fewer signs of pain.
What causes pain in babies?
Newborns can respond to painful events such as a heel prick within the first minutes of life.
Babies, especially those in hospital, may experience pain because they are sick or injured in some way or from painful procedures. Procedural pain might include needles for IVs, blood sampling, suctioning of the mouth and nose, injections or surgery. The pain that is anticipated from those procedures can usually be minimized with standardized approaches to pain management.
Diagnosis of pain
Pain assessment tools for babies
Although there are established and proven methods to assess pain in premature and term babies, pain assessment is not an exact science. To lessen the guesswork, pain assessment tools, which are generally checklists of possible pain indicators, take into account behavioural, physiological and contextual measures. They are used regularly to assess pain in hospitalized babies so that the health-care team can intervene and reduce pain.
Treatment of pain
Treating pain in babies involves a multi-pronged approach. It includes modifying the baby's environment, using physical pain management methods and giving medication.
Environment of the hospital
Because of their limited understanding and self-awareness, babies may need the intervention of others and a positive environment to become more relaxed and to decrease pain.
Health-care providers may use low lighting and restrict noise in the hospital to help keep a baby as comfortable as possible. If a baby requires treatments, these treatments may be done at the same time to minimize interruptions. Sometimes, treatments can be delayed until the baby is more stable.
Physical pain management methods
Massage and touch
Babies respond well to feeling warm and secure, so they may be bundled with blankets and positioned comfortably on their side with their hands near their mouth.
Gentle massage and touch are useful therapies for decreasing anxiety and increasing a sense of well-being. Both have been shown to improve the well-being and development of babies. Often, the simple act of touching a baby during a painful procedure can lessen both anxiety and pain.
Non-nutritive sucking
Other pain-relieving strategies, such as non-nutritive sucking or using a pacifier with sweet solutions such as sugar water, have been shown to relieve pain and reduce stress from procedures such as heel pricks.
Skin-to-skin contact
Skin-to-skin contact or kangaroo care between a parent and baby also has a pain-relieving effect. In general, the strategy is to produce a calm environment and encourage loving and comforting contact between parent and baby. This can reduce pain from some needle procedures such as heel pricks.
Breastfeeding
Although it is not always possible, breastfeeding has been shown to reduce pain and stress in babies, especially during procedures. If breastfeeding is possible during a procedure, parents are encouraged to breastfeed to reduce pain.
Pain medications
Depending on their condition and the amount of pain present, premature and term babies may be given acetaminophen (Tylenol) or stronger medications such as morphine or fentanyl. These medications act on the body as a whole and are used to reduce moderate to severe pain. If babies need these medications over a prolonged period, they may need to be slowly weaned once they no longer need the medications for pain control.
Babies may also be given topical or local anaesthetics, which are medications that act only where they are applied on the body. These are most often used for injections such as immunizations.
Premature and term babies may also be given sucrose as a pain reliever. Studies have shown that a baby’s pain can be relieved when they suck on a pacifier dipped in sucrose, although how and why this happens is not well understood.
Role of parents in pain management
It can be difficult to witness a baby suffering in pain, especially for babies who are hospitalized. It is helpful for parents to have an understanding of the types of pain their baby might experience and of the ways available to relieve the pain. Given this information, parents can concentrate on helping make sure that their baby gets what they need to prevent or treat pain most effectively.
Parents who learn specific strategies to help their baby can also participate in reducing pain and provide comfort measures even during procedures. Strategies such as skin to skin and breastfeeding are very effective in reducing pain from needles. During painful procedures, parents can talk and sing to their baby, stroke their baby and hold their baby’s soother to provide comfort and reduce pain in conjunction with other pain-relieving treatments such as sucrose or analgesics (pain-relieving medications).
Parents are encouraged to ask how they can help relieve their baby’s pain, especially ahead of a painful event. Parents are in an ideal position to act as advocates for their baby’s pain relief and provide many of the comfort strategies.