There was a time when medical doctors believed that infants and especially preterm infants did not feel pain. Painful procedures including surgery were performed with no recognition of their suffering. Over the past quarter century we have become very attuned now to detecting pain in our infants.
The simplest expression of this is in the acute changes in vital signs such as tachycardia and a higher blood pressure but also in tension or grimacing of the facial muscles. While we have done a great job with our ability to determine neonatal pain, more subtler symptoms and signs are not as easy to detect or manage. In fact often as healthcare professional we write about or report the symptoms of our patients. This infant had symptoms of pulmonary edema, infection, or gastroesophageal reflux. The truth is, we often mislead ourselves in describing these observations as symptoms. Do we really know when an infant is complaining? Infants cannot speak, they have no fluid way to express their emotions. It seems to me at least that happy emotions are really difficult to tell. Preterm infants rarely smile or laugh. They show their level of comfort or pleasure by sleeping well. On the darker side, negative effects are expressed in visceral reactions such as grimacing, crying, agitation, inability to sleep, and of course my favorite, vomiting. When infants are really ticked off, they puke.
How many of you have had an upset stomach? As a pediatric gastroenterologist (or as my kids used to call me when they were younger, a gas-astronaut) as well as a neonatologist, it is only fitting that I have had my share of my own GI afflictions. The first was as a young child with motion sickness and a great propensity to vomit. I remember emesis being a really unpleasant thing, but it was the nauseous anticipation of emesis with the hypersalivation of salt water in the mouth as the sentinel warning sign that was much worse. Of course then it goes further without saying that my second child also was a happy puker and my wife and I spent the first year hosing down car seats, carrying lots of extra clothing, and keeping him upright whenever we could. Fortunately he recovered from all this, but still I would say he has a more sensitive gut than our daughter. Finally it would be that our beloved eleven year old schnoodle (half schnauzer-half poodle mix) not only would have a sensitive stomach and be quick to vomit with the wrong foods but be pretty much impossible to take for a long walk due to his irritable bowel syndrome from the excessive excitement and anticipation of the walk. We are talking 6-8 baggers before I get to the end of the street!
There is a condition called rumination. I have only seen one classic case of this in a 4 year-old boy who was having a terrible time going to school. The boy did have a history of reflux, which had been treated and gotten better with medications. At the point I saw him he could not walk more than a block to school before he would have to vomit on the ground. His mother was at her wits end and could not see the end to this daily trauma. This problem was not getting better now though. All other activities were however perfectly fine. The whole case sounded awfully familiar to the condition of rumination. Now, while cows ruminate by bringing up their food by storing it for later in a secondary stomach, humans typically are not biologically trained to vomit on demand. Somehow certain children are capable of this. One of the trick questions is to ask the child if he could vomit right there in the office. I asked this pivotal question and the remarkable answer came back as yes. I quickly stopped him from proceeding and then talked at length at how his voluntary vomiting or rumination was making him mother very unhappy. I asked him that since he could control this I wanted him to stop so that his mother would feel better and that all this vomiting might hurt his body too. He sheepishly agreed and amazingly this problem disappeared after that visit. I bring this story up because even in an older child, discerning what the real symptoms are can be challenging. Deciphering what is going on in a preterm infant is likening to reading minds.
So, we are not so lucky to know when our babies in the NICU are having trouble. How do we know when a baby has a stomachache, feels a headache coming on, or just has general malaise? Much of what we infer comes from specific signs that we observe and not symptoms that we can elicit. We are left with the visceral signs of discontent-fussiness, agitation, lack of sleep, posturing, etc. But more hidden signs also exist that provide important clues to how a baby is faring. This is where experience as a neonatal care provider comes in. With years of experience we often become very good at becoming “baby whisperers”, tuning into extremely subtle combinations of signs that indicate whether a baby is having a good day or a bad day. It could be a slight change in tone, increase in irritability, slight off-color skin tone. It is hard to extract the nature of this assessment skill, even more challenging to teach it, but nonetheless this valuable skill to pick up on these small clues are incredibly valuable in clinical medicine. I cannot count the number of times these kind of signs either reported to me or observed by me were the first warning signs of serious disease or infection coming along.
Much of pediatric medicine is based on astute observation skills. In neonatology this becomes even more important as we try very hard not to disrupt the sleep-wake cycles, day-night lighting conditions of these infants and minimize handling to reduce overall stress. Catching the subtleties of these clinical signs is crucial then to becoming good neonatal care providers. The trick for all of us is to figure out what is the best management before we are presented with the overt signs of distress or discomfort, before we have emesis all over the bed. So, keep up the good work baby whisperers out there, and keep “listening”!
Looking for additional professional perspective from Dr. Kim?
View his previous blog entry, Breaking Bad Eating Habits in the NICU.