Tackling pain in premature babies

Eva Cignacco in an intensive care station at Basel University hospital swissinfo.ch

Premature babies suffer unnecessary pain in some hospitals. Swiss nursing expert Eva Cignacco is researching how best to tackle the issue.

An international pain management congress she has organised takes place in Bern on Thursday, with the aim of raising awareness among the medical profession of this long unrecognised problem.

“Until the mid-1980s, science thought that premature babies could not feel pain,” Cignacco told swissinfo.

“It was assumed that because the nerves were still not fully developed, they would not be able to transport pain signals to the brain.”

But the case of Jeffrey Lawson in the United States in the 1980s proved this theory wrong. “The premature baby, weighing only 500 grams, had a very serious heart defect and needed an operation,” explained Cignacco.

The child died a few weeks after the operation. His mother later found out that her son had received no pain relief at all during the long open-heart surgery, only sedatives. She went public and the case caused an outcry.

Soon afterwards neurophysiologist K. J. S. Anand started to work on the issue in the US, finding out that even foetuses react to pain.

It is now accepted that premature babies feel pain more strongly than infants born to term.

Measuring pain

Cignacco, a midwife with a nursing doctorate, says there are several ways to measure pain.

“Crying is a good pain indicator,” she said. “But a child also cries when it is hungry or doesn’t feel good. Therefore you have to learn how to distinguish pain from other possible causes.”

In Bern, nurses have developed the now internationally recognised Bernese Pain Scale for Neonates (BPSN), which defines nine parameters: crying, facial expression, body posture, sleeping, settling time, skin colour, respiratory rate, as well as heart rate and oxygen saturation, which can be read on a monitor.

Premature babies have to undergo many tests in their first two weeks of life. “On average there are about 23 per day, of which 17 could be painful,” said Cignacco.

These include putting a breathing tube into the baby’s nose or taking blood samples.

The frequency of such interventions could affect a child’s long- and short-term relation to pain.

Listlessness is a short-term consequence. “These very small children simply do not have enough energy left to react to painful impulses. And they need all their strength to grow,” explained the nursing expert.

Too much pain at an early age could mean that children become more sensitive to it or that their cognitive development is affected.

Lessening pain

In emergencies medication can be used to lessen pain, but Cignacco advises caution, pointing to possible side effects.

Studies show that sucrose can help to combat pain that arises from routine treatments. Body contact with the baby’s parents can give the child a feeling of security.

The effects of Cignacco’s research have reached nursing training. “Until about five years ago pain recognition and pain education were not on the agenda. Now they are being taught by several nursing institutes. And there are nurse specialists for neonatal pain at Bern University hospital.”

But there is more that can be done. “Children are neglected by the pharmaceutical industry. Too little has been done in recent years in developing pain medicines for this patient group,” she said.

Cignacco is hoping European guidelines will be developed to ensure that medicines are also tested on children and newborns.

The Bern conference is the first of its kind in a German-speaking country. Anand, who was inspired by the Lawson case, will be among the participants.

“We hope that we can raise awareness of the topic in the profession and that participants will be able to improve the pain management of premature babies in their practices,” commented Cignacco.

swissinfo, Etienne Strebel in Basel

Midwife with a doctorate

Eva Cignacco, born in 1961, trained as a social worker and then as a midwife.

She completed further academic studies in nursing, culminating in a Master of Science in Nursing in 2001. Her dissertation dealt with pain in premature babies on the intensive care ward.

She has carried out testing of the Bernese Pain Scale for Neonates (BPSN).

Cignacco received her doctorate from Maastricht University in December 2007, making her the first midwife in Switzerland to receive the title. She now works as a researcher at Basel University’s Institute of Nursing.