It was a big decision, says Dava White, when the pediatric urologist who was to operate on her 2-month-old son, David, asked if she would object to the use of deep anesthesia followed by postoperative narcotics.
"It was terrible and I was so worried and it went so well and now I'm so happy," the Eastern Shore mother of two said yesterday.
"I was afraid some harm might come to my baby," said the woman from Galena, which is near Chestertown. "What if they gave him too much anesthesia or not enough? The doctor was telling me that babies that young can feel pain and I didn't want David to have pain."
On New Year's Eve, the 11-pound, 12-ounce infant underwent abdominal surgery at Johns Hopkins Children's Center to remove a blockage in his left kidney, which had become enlarged. The condition had been diagnosed by sonogram, a sophisticated test, while he was still in his mother's womb.
David was closely monitored while he was on intravenous Demerol and Valium for about 12 hours following surgery.
Yesterday, he was back to his normal schedule, alternating between catnaps and being fully awake and smiling at a colorful mobile hanging above his hospital bed.
Deep anesthesia plus postoperative use of narcotics for newborns undergoing surgery is fairly uncommon in medical centers across the country, according to Dr. Myron Yaster, who directs the Hopkins Pediatric Pain Service.
But, at Hopkins -- despite some resistance by some medical doctors and surgeons -- this approach is increasingly being used, said Yaster, an associate professor of anesthesiology, critical care medicine and pediatrics.
"One of the stated goals of the hospital, adopted about a year and a half ago, is to make the Children's Center pain-free," he said.
Hopkins also is using continuous infusion of local anesthetics, such as epidurals often used by women in labor, for newborns undergoing surgery, which Yaster contends "is unheard of across the nation."
Local anesthetics produce as much pain relief as narcotics and protect against a side effect that can cause difficulty in breathing, he explained. At the first sign of a breathing problem, newborns are given an antidote or taken off narcotics.
In yesterday's New England Journal of Medicine, two Boston researchers said the use of deep anesthesia followed by postoperative high doses of a painkiller, sufentanil, appears to increase the survival of newborns, and the stress of surgical pain, even if the tiny patients are unconscious, seems to significantly increase the risks of surgery.
The study, conducted on newborns undergoing heart surgery, was performed by Dr. Sunny Anand of the Massachusetts General Hospital and Dr. Paul R. Hickey of Children's Hospital. It showed that all of the 30 babies who received deep anesthesia plus postoperative high doses of the painkiller survived while four of the 15 babies who were treated with standard light anesthesia died after surgery.
The doctors found that the babies getting light anesthesia produced high levels of stress hormones. In addition, they were more prone to infection, their blood made unnecessary clots, and acid built up in their muscles.
"The new thing about this study is that it shows that not only is it important to give deep anesthesia during the operation, but also to treat pain postoperatively," said Yaster, who like the Boston researchers has been interested in these issues since the mid-1980s.
Myths and misconceptions about the perception as well as use of narcotics and other painkillers were keeping children in unnecessary pain, he said.
Meanwhile, Hopkins has been doing studies, looking at what doses of opiates to use and how to treat new borns with these drugs.
Until the early 1980s, according to Yaster, many physicians did not believe that newborns perceived pain and they also thought the drugs that were used to treat pain were very dangerous. "The net effect was that many children underwent surgery and minor surgery without any anesthesia," he said.
Since the middle 1980s, across the country, the majority of newborns undergoing surgery receive standard anesthesia; however, newborns who have painful procedures done out of the operating room still are rarely given pain relief. "For example, circumcision, which is among the most common operations performed in the United States, is almost never done with any kind of pain relief," Yaster said.
But in 1992, experts know that newborns feel pain, that newborns respond to pain the same way that adults do, and that it's unconscionable to torture somebody, he said.
"This new study also now says that if you don't provide anesthesia and if you don't provide postoperative analgesia you're going to kill people . . . ," he said.