Babies' pain relief may also affect outcome of surgery

January 03, 1992|By Jonathan Bor

When doctors sliced into the belly of his 3-day-old son last week, Marc Kemmer of Finksburg felt secure his baby was being cured of a digestive disorder that was making him regurgitate breast milk. But his relief went further: Daniel was feeling no pain.

It may seem a modest enough sentiment to want a baby to receive painkilling medication during and after surgery -- the sort of thing an adult would demand before ever allowing a surgeon to take a knife to his own tissues.

But in a practice that might not have occurred a decade ago, doctors at Johns Hopkins Hospital gave the infant enough narcotic anesthesia during surgery to erase any pain, and enough morphine in the day after surgery to ensure a painless recovery.

"Sure, we felt comfortable about that," said the baby's father, a 25-year-old Baltimore County firefighter whose wife, Barbara, gave birth on Dec. 27. "Our relief was unbelievable."

The baby, born with a blockage between his stomach and intestine, is recovering beautifully from surgery that should allow normal digestion.

Until research began to change the picture in the mid-1980s, it was common for babies to undergo surgery with either light anesthesia or no painkilling drugs at all. Doctors worried that "deep anesthesia" might kill newborns, and they consoled themselves with the belief that infants didn't perceive pain or wouldn't remember it if they did.

Anesthesia has become widely available for newborns in recent years, and a Boston study published in this week's New England Journal of Medicine should bolster its use even further, doctors say. Physicians at Boston Children's Hospital reported that the practice of withholding complete pain relief from newborns undergoing cardiac surgery actually endangers the babies' lives.

In the study, doctors gave 30 newborns complete pain relief with a narcotic during surgery and regular infusions for the first 24 hours after surgery. In contrast, 15 newborns received a light dose of an anesthetic gas during their operations and only intermittent doses of morphine during their recovery.

The second group not only produced high levels of stress hormones, an indication they were in pain, but four of the 15 babies died. This led doctors to conclude that the pain response itself is dangerous because it uses up resources needed to heal wounds and fight infection.

All the babies receiving deep anesthesia lived, and they showed low stress levels.

Yesterday at the Johns Hopkins Children's Center, anesthesiologist Myron Yaster was elated about the new findings.

"Pain relief is a right," said Dr. Yaster, director of the pediatric pain service. "It's an issue of ethics. But now I can say it's not only a right and ethical, but it makes a difference in outcome."

Dr. Yaster said he cannot assure parents that the powerful narcotic painkillers known as sufentanil and fentanil actually put babies to sleep: The babies only appear to be sleeping because drugs given to release their natural muscle tone also cause their eyes to close.

"What we tell parents -- very specifically -- is that their babies won't feel pain during surgery," he said. He's sure of that, saying: "You can measure the stress response."

He did just that in the mid-1980s, when he showed that babies receiving high doses of narcotic anesthesia showed much lower stress responses than babies receiving low doses of the same painkiller.

Around the same time, Dr. Sunny Anand at Boston Children's Hospital, who also led the recent study, compared newborns receiving narcotic painkillers with babies getting no pain relief at all. Some of the babies who endured surgery without anesthesia suffered brain bleeding, while the numbed babies did just fine.

In the last several years, most if not all U.S. hospitals have started giving infants opiate painkillers in surgery. But not all give pain relief during the recovery phase -- a period when the pain response can be most dangerous, according to Dr. Yaster.

Even at Hopkins, he said, the practice of giving painkillers to recovering newborns is a common but not universal part of care. Dr. Yaster said he would not only like to see deep anesthesia for all newborns recovering from surgery -- but local anesthesia for less dramatic procedures such as circumcisions.

"That's the frontier," he said.

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