Neonatal Suffering: How We Came to Care Through Data
Evidence-based medicine gives a voice to the voiceless.
Millions of newborns or “neonates” worldwide undergo invasive surgeries in their first 28 days of life. These infants are quickly put on operating tables and cut open, tubes inserted into their bodies, scalpels and forceps probing and manipulating their organs after just entering the world. And for decades these newborns were conscious of their pain. For the sake of successful surgeries neonates were often given muscle relaxers to paralyze their resistance, but they still felt the sensations of scalpel incisions, open heart surgery and chest tube insertions.
Prior to the 1980s, it was a common misconception that newborns or “neonates” did not experience severe pain. Medical experts relied on outdated theories suggesting that newborns couldn’t experience pain due to memory limitations and because their cerebral cortex had not yet undergone myelination: the process through which nerve fibers develop the capacity to rapidly transmit pain signals. General anesthesia to fully numb the neonate from pain was considered too risky for infants at the time, making experimentation unjustifiable for most researchers.
Countering this myth, in 1987 Dr. K.J.S. Anand and Dr. P.R. Hickey found that infants who undergo operations without anesthesia reported severe stress responses with steep spikes in cortisol and adrenaline levels. In their study, neonates expressed complex behavioral responses which proved that the infants’ attempts to resist or avoid pain when not sedated were not mere reflexes. Dr. Anand later ran a randomized trial on neonates given fentanyl and found that neonates who were given no fentanyl anesthetic not only endured severe pain but suffered from “circulatory and metabolic complications postoperatively.”
Later in 2010, scientists discovered that the nerve endings they previously thought could not communicate pain to the brain prior to myelination, were signaling pain in neonates, but at a slower rate. More progress in this field is expected to continue as studies in local and regional anesthetic show that such anesthetics lower neonatal overdose risks and reduce opioid use.
In 1987 the American Academy of Pediatrics deemed neonatal operations without local anesthetic unethical, and US medical practices shifted to implement neonatal anesthetic. It may seem easy to assume that the medical community must not have considered them sentient beings worthy of painless procedures. However, experimenting with infants and fentanyl is not without its risks. Thus, doctors had reason to perpetuate tradition and old expert practices of anesthetic free procedures even if at the cost of infant suffering.
The true impetus for change in neonatal treatment was not mere compassion, but a transformative paradigm shift in medical practice. While clinical research was not new to medicine, previously, doctors often favored expert opinion by the doctors with respected practice and reputation. However, doctors like Dr. Gordon Guyatt of McMaster University made a formal push in the 1990s for “Evidence Based Medicine” (EBM), which “de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research.” Put another way, the opinions of individual doctors would not take precedence over evidence-backed medical research.
The previous reliance on expert opinion created biased data and less standardization for what procedural techniques and diagnoses were most successful. Thus, a doctor in California could perform hernia repair surgery in a technique radically different from a doctor in New York. But as the EBM movement advocated, it is unlikely that two differing procedures have identical success rates. After realizing the benefits of prioritizing systematic reviews/meta-analyses, cross-sectional studies, and randomized control trials, over the experiences of seasoned doctors, the medical community was capable of greater safe experimentation and findings. Additionally, with the onset of digitized medical records tracking medical data overtime is much faster and cheaper. Thanks to the efforts of clinical researchers and evidence favoring doctors, we live in a world filled with data and research capable of tailoring high-risk anesthetics to the infants who just entered our world.
Over the past four decades, the use of anesthesia for newborns has become more standardized in all developed countries. Furthermore, with the globalization of medical knowledge, more low and middle-income countries have access to advanced anesthetic treatments capable of safely sedating infants and preventing severe pain in operations. Digitization of medical records, remote training, and the standardization of best practices have together increased global access to neonatal anesthesia.
Furthermore, according to the Institute For Health Metrics and Evaluation, newborn deaths preventable by neonatal surgery (e.g. congenital defects and birth trauma injuries) have also been on a steep decline since the international standardization of medicine and onset of global health initiatives. On the whole neonatal disorder deaths are declining at a steep rate. That’s partly a consequence of surgery now with safe neonatal anesthetic. With more advanced medical practices and anesthetic procedures now shared with and adopted by developing countries, global inequality in infant welfare overall is decreasing.
This transformation in neonatal concern not only represents our increased sensitivity to human suffering but also demonstrates how valuing empirical research enables us to identify and prevent such harm.
Author: Camille Miner, a rising senior at UC Berkeley studying Philosophy and Social Welfare and a Research Intern at Human Progress.
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