Ruth Guinsburg is a neonatologist in Sao Paulo who has been super-productive, especially in the area of pain control in the newborn. Her latest is an interesting comparison of how caregivers and parents rate pain in infants on ventilators.

Elias L, dos Santos A, Guinsburg R: Perception of pain and distress in intubated and mechanically ventilated newborn infants by parents and health professionals. BMC Pediatrics 2014, 14(1):44. (Open Access).

The group asked the participants to observe different babies who were 24 to 96 hours old, in an incubator on a conventional ventilator, who had a gastric tube and and IV, During the one minute of observation they were not handled and had no procedures.

The participants were in 3 groups, pediatricians, nurse technicians (who seem to be nursing auxiliary types who work under the supervision of RNs) and parents. There were enormous discrepancies between the observers regarding whether they thought the babies were in pain, or distressed. Which makes it really difficult to treat or prevent such pain and distress. I think that many preterm babies who are intubated and ventilated seem very calm in between interventions, and have little evidence of pain or distress, which is probably why there is little evident benefit of routine analgesic (or sedative) infusions during assisted ventilation. Some babies, especially I think, the more mature infants do seem somewhat distressed and may benefit from maneuvers to decreases this.

It is of interest then that the very long term follow up of one of the trials of continuous morphine infusion during assisted ventilation has now been published. (de Graaf J, van Lingen RA, Valkenburg AJ, Weisglas-Kuperus N, Groot Jebbink L, Wijnberg-Williams B, Anand KJS, Tibboel D, van Dijk M: Does neonatal morphine use affect neuropsychological outcomes at 8 to 9 years of age? Pain 2013, 154(3):449-458).  There were 132 survivors of the original trial, of whom 89 were seen at 8 to 9 years. Reassuringly there were no adverse effects of the morphine detected, and there was even a tendency for executive functions to be better in the morphine group. With all the concerns about such agents potential effects on brain development and increase in apoptosis, it is comforting that very little was found.