First Posted 2/6/2014
A few weeks ago I wrote about the differing standards of care for women who deliver babies while treated with buprenorphine for opioid dependence. Some hospitals require newborns exposed to buprenorphine to stay in the neonatal ICU for arbitrary length of time. Intravenous infusions of opioid agonists are given to infants whose first yawns or cries are interpreted as neonatal abstinence syndrome. Other hospitals allow women on buprenorphine to take babies home at the regular schedule, allowing a natural taper from buprenorphine by breast-feeding.
Regardless of hospital policy, many women on buprenorphine enter into the delivery process with a sense of dread, knowing they are harshly judged by doctors and nurses. Doctors warn women that their babies will suffer from withdrawal if they don’t taper off their medication before delivery. And members of the media decry the selfishness of women treated for addiction who become pregnant, suggesting the more responsible expectant mothers would use ‘will power’ to avoid all substances.
Even while experts recommend that women treated for addiction stay on medication treatment regimens during pregnancy, society looks negatively on women who do the right thing. A new mom on SuboxForum recently wrote about how horrible she felt, for putting her baby through such a difficult time. But should women compliant with recommended treatment for opioid dependence feel so guilty?
Until 30 years ago or so, newborns having major surgery often received paralytic agents with little or no anesthesia or pain medication. Surgeons and anesthesiologists did not think babies with heart anomalies would survive anesthetics, and saw no reason to anesthetize a brain that lacked a ‘record’ function. Now, most babies having major surgery receive anesthesia. But in many situations, non-medicated babies are simply restrained during procedures that would be painful in adults, ranging from awake intubation to circumcision to multiple attempts at IV access (the latter is required when doctors insist on treating neonatal abstinence with morphine infusions).
I did not enjoy working on newborns in those settings back in my anesthesia days, especially after having three children. But there will always be times when anesthesia is too dangerous or impractical, leaving no choice but to tune out the baby’s cries and focus on safety. In these cases, do babies experience pain? We know that babies react to stimuli that adults would find painful, and generate stress responses to those stimuli. But the answer to the question about pain is far more complicated than a simple ‘yes’ or ‘no.’
People having conscious sedation for colonoscopy, gastroscopy, or some emergency procedures (like reduction of a displaced fracture, emergency D and C, or insertion of a chest tube) often appear awake while appropriately sedated. Patients who will later think that they were blissfully sleeping, in reality, carry on conversations and move about as directed on the OR table. Depending on the anesthetic used, patients may react strongly to pain. Patients who can’t be fully anesthetized because of the risk of aspiration or airway obstruction may yell out in response to the injection of local anesthetic, even when administered enough Versed and Ketamine to guarantee full amnesia. They moan in pain throughout the procedure, and then thank their anesthesiologist for keeping them completely ‘asleep’. Similar experiences are the norm in every GI suite across the country.
In this common scenario, do patients experience pain? When someone sedated beyond the point of recall complains of discomfort, did the discomfort really happen? Did the patient feel pain and then forget it? How do we know? Before my endoscopy, I knew that I would experience pain going forward in time. But afterward, when I thought back about the procedure, it was a piece of cake. Did I suffer? Not at all.
Similar experiences occur in newborns. Babies are not capable of remembering those first weeks or months. One could argue that repeated discomfort creates brain pathways that lead to a heightened stress response in later years… but if that is true, how does the brain differentiate ‘normal’ pain experiences of the newborn from ‘abnormal’ pain? The baby’s head is squeezed hard enough during delivery to change the shape of the skull. That has to hurt… not to mention the discomfort of being squeezed inside a uterus during the last 4 weeks before delivery. During delivery, the baby is transferred from a 37 degree uterus, where oxygen is delivered through the umbilical cord, to a bright, cold, environment where getting oxygen requires gasping for air, with every bit of strength. Sounds traumatic to me! During deliveries, babies sometimes experience dislocated shoulders and major nerve damage (shoulder dystocia). Forceps or suction cups may be used to pull the baby, by the head, from the birth canal.
Newborns have immature nerve supply to the gut, so early peristalsis– the coordinated contracting that propels digestible material downstream in the fully developed intestine– creates cramping and ‘pain’ in infants (sometimes called ‘colic’). Limb muscles are spastic, and the spasticity would likely be painful in an adult. Choking or coughing on breast milk is a normal part of the newborn experience.
How does ‘withdrawal’ compare? What is the worst part of withdrawal— diarrhea? Cramping? Body aches? Anxiety? Depression? Compared to the normal experience of a newborn, how do these symptoms rate? Babies do not feel embarrassed or ashamed of their condition. They don’t feel guilty or remorseful. And after raising children through, I don’t think a baby coming off buprenorphine could be more ‘depressed’ than other babies. Can a baby who turns purple crying his lungs out, feel any worse? Normal infants get pretty miserable at baseline!
Like most parents I have always been willing to put my life or discomfort before that of my kids, if that were possible. I don’t lack empathy for babies experiencing pain. But ‘to keep it real’, writing about those ‘poor babies going through withdrawal’ is an emotional response, not an accurate understanding of the newborn experience.
Most new moms torture themselves enough with fears about their mothering skills, without the medical profession piling on.
First Posted 2/6/2014