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Consider the following scenario: Robert Smith R Barr is head nurse at a neonatal intensive care unit at a major teaching hospital; Joanne Johnston is the clinical director of the neonatology service. Both have been following closely the changing attitudes and published data on pain and stress in infants.1 They believe that the formerly widely held assumptions that infants do not experience pain and do not benefit from analgesia are wrong. They now believe that premature infants not only have the neurological capability to experience pain, but that they may be hypersensitive to nociceptive stimuli,2 3 and may remember pain experiences.4 They are aware of the classic study by Anand and colleagues5 and others since6 7supporting the idea that infants undergoing major painful operations will have better outcomes if given analgesics during surgery. Indeed, they have been active in a campaign to educate their colleagues that infants experience pain the way adults do. Many of their colleagues do not subscribe to this belief, which may partly explain why infants and children receive less analgesia for the same procedures than do adults.8-13 Finally, they have instituted measures for “individualised, developmentally focused intensive care,” where nursery routines and practices are organised to be as consistent as possible with the developmental strengths and vulnerabilities of premature infants.14
In pursuit of these aims, however, they have been trying to address the following question. What should be taken as evidence that the infant is in pain or stressed? This applies to premature infants undergoing repeated minor procedures some of which are painful and many of which are stressful, who are often recovering from major surgical procedures, and who may have chronic indwelling catheters, intravenous lines, etc. They recognise this poses a dilemma for several reasons. First, infants …