The relationship between nociceptive brain activity, spinal reflex withdrawal and behaviour in newborn infants

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Abstract

Measuring infant pain is complicated by their inability to describe the experience. While nociceptive brain activity, reflex withdrawal and facial grimacing have been characterised, the relationship between these activity patterns has not been examined. As cortical and spinally mediated activity is developmentally regulated, it cannot be assumed that they are predictive of one another in the immature nervous system. Here, using a new experimental paradigm, we characterise the nociceptive-specific brain activity, spinal reflex withdrawal and behavioural activity following graded intensity noxious stimulation and clinical heel lancing in 30 term infants. We show that nociceptive-specific brain activity and nociceptive reflex withdrawal are graded with stimulus intensity (p < 0.001), significantly correlated (r = 0.53, p = 0.001) and elicited at an intensity that does not evoke changes in clinical pain scores (p = 0.55). The strong correlation between reflex withdrawal and nociceptive brain activity suggests that movement of the limb away from a noxious stimulus is a sensitive indication of nociceptive brain activity in term infants. This could underpin the development of new clinical pain assessment measures.

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Most cited references 35

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Consensus statement for the prevention and management of pain in the newborn.

K J Anand (2001)

To develop evidence-based guidelines for preventing or treating neonatal pain and its adverse consequences. Compared with older children and adults, neonates are more sensitive to pain and vulnerable to its long-term effects. Despite the clinical importance of neonatal pain, current medical practices continue to expose infants to repetitive, acute, or prolonged pain. Experts representing several different countries, professional disciplines, and practice settings used systematic reviews, data synthesis, and open discussion to develop a consensus on clinical practices that were supported by published evidence or were commonly used, the latter based on extrapolation of evidence from older age groups. A practical format was used to describe the analgesic management for specific invasive procedures and for ongoing pain in neonates. Recognition of the sources of pain and routine assessments of neonatal pain should dictate the avoidance of recurrent painful stimuli and the use of specific environmental, behavioral, and pharmacological interventions. Individualized care plans and analgesic protocols for specific clinical situations, patients, and health care settings can be developed from these guidelines. By clearly outlining areas where evidence is not available, these guidelines may also stimulate further research. To use the recommended therapeutic approaches, clinicians must be familiar with their adverse effects and the potential for drug interactions. Management of pain must be considered an important component of the health care provided to all neonates, regardless of their gestational age or severity of illness.

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Assessing distress in pediatric intensive care environments: the COMFORT scale.

Bruce Ambuel, Kim Hamlett, Celeste Marx … (1992)

Managing psychological distress is a central treatment goal in Pediatric Intensive Care Units (PICUs), with medical and psychological implications. However, there is no objective measure for assessing efficacy of pharmacologic and psychological interventions used to reduce distress. Development of the COMFORT scale is described, a nonintrusive measure for assessing distress in PICU patients. Eight dimensions were selected based upon a literature review and survey of PICU nurses. Interrater agreement and internal consistency were high. Criterion validity, assessed by comparison with concurrent global ratings of PICU nurses, was also high. Principal components analysis revealed 2 correlated factors, behavioral and physiologic, accounting for 84% of variance. An ecological-developmental model is presented for further study of children's distress and coping in the PICU.

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Pain expression in neonates: facial action and cry.

R Grunau, Adrian Craig (1987)

Pain expression in neonates instigated by heel-lance for blood sampling purposes was systematically described using measures of facial expression and cry and compared across sleep/waking states and sex. From gate-control theory it was hypothesized that pain behavior would vary with the ongoing functional state of the infant, rather than solely reflecting tissue insult. Awake-alert but inactive infants responded with the most facial activity, consistent with current views that infants in this state are most receptive to environmental stimulation. Infants in quiet sleep showed the least facial reaction and the longest latency to cry. Fundamental frequency of cry was not related to sleep/waking state. This suggested that findings from the cry literature on qualities of pain cry as a reflection of nervous system 'stress', in unwell newborns, do not generalize directly to healthy infants as a function of state. Sex differences were apparent in speed of response, with boys showing shorter time to cry and to display facial action following heel-lance. The findings of facial action variation across sleep/waking state were interpreted as indicating that the biological and behavioral context of pain events affects behavioral expression, even at the earliest time developmentally, before the opportunity for learned response patterns occurs. Issues raised by the study include the importance of using measurement techniques which are independent of preconceived categories of affective response.

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Journal

Journal ID (nlm-ta): Sci Rep

Journal ID (iso-abbrev): Sci Rep

Title: Scientific Reports

Publisher: Nature Publishing Group

ISSN (Electronic): 2045-2322

Publication date (Electronic): 31 July 2015

Publication date Collection: 2015

Volume: 5

Electronic Location Identifier: 12519

Affiliations

[1 ]Department of Paediatrics, University of Oxford , OX3 9DU, UK

[2 ]Nuffield Department of Clinical Neurosciences, University of Oxford , OX3 9DU, UK

[3 ]Nuffield Department of Anaesthesia, John Radcliffe Hospital , OX3 9DU, UK.

Author notes

[a ] caroline.hartley@ 123456paediatrics.ox.ac.uk

Article

Publisher Item ID: srep12519

DOI: 10.1038/srep12519

PMC ID: 4521152

PubMed ID: 26228435

SO-VID: 272b6b83-19a7-49d8-b658-e5eb415b67ba

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The relationship between nociceptive brain activity, spinal reflex withdrawal and behaviour in newborn infants

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Most cited references 35

Consensus statement for the prevention and management of pain in the newborn.

Assessing distress in pediatric intensive care environments: the COMFORT scale.

Pain expression in neonates: facial action and cry.

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