What could be more heartbreaking than witnessing some of the smallest, sickest babies undergoing painful medical procedures?
Yet that’s precisely the population subject to some of the most intrusive prodding and pricking, the “greatest number of painful stimuli” in the neonatal intensive care unit, or NICU.
Now the American Association of Pediatricians is calling for better, more comprehensive pain relief measures for newborns, including those born prematurely — both with medications and through alternative, non-drug measures — and for more research on effective treatments.
The AAP’s updated policy statement, published in the journal Pediatrics, asserts that “although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures.”
The AAP calls for new measures, specifically:
Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.
If you’ve ever been in a NICU, you may have seen these types of procedures take place: suctioning of various secretions from the nose and throat; blood draws from veins, arteries, feet or heels; IVs being placed; adhesive tape — used to keep all those tubes and IVs in place — removed.
A landmark 2008 study from France found that the vast majority of newborns in the NICU didn’t get pain relief; researchers found only about 21 percent of infants were given either pain medication or non-drug pain relief before undergoing a painful procedure.
Why is this important?
According to the new AAP statement:
The prevention and alleviation of pain in neonates, particularly preterm infants, is important not only because it is ethical but also because exposure to repeated painful stimuli early in life is known to have short- and long-term adverse sequelae [aftereffects]. These sequelae include physiologic instability, altered brain development, and abnormal neurodevelopment … which can persist into childhood.
Navil F. Sethna, M.D, one of the lead authors of the updated AAP guidelines, and a senior anesthesiologist at Boston Children’s Hospital, said in an interview that the most important takeaway is this:
“Even premature infants do feel pain and their pain needs to be treated…their pain can have long-term, negative consequences in the development of the nervous system. That’s the message: even though there are controversies [about what is the best medication and about adverse effects of the drugs, for instance] overall, we are obligated to treat the pain, because not treating the pain can have serious consequences for the developing brain.
Sethna said 20 to 30 years ago, there was a widespread misconception that premature babies didn’t feel pain because their nervous system wasn’t fully developed. Now, it’s clear that’s not the case. “We know now that infants do respond to pain,” he said, “and we have more objective data, observed data where we see them crying, wincing, and withdrawing as a result of painful stimulus, but we also know they have the capability of releasing stress hormones in response to tissue injury — that could be during surgery, or when they get stuck with a needle.”
Technology has also made an impact, he said. “We now have functional MRI, so in the last few years…studies coming out show how infants of different ages, when they’re exposed to pain what happens to their brains…A lot of studies have shown if infants are exposed to intense pain, like a burn, or daily and relatively minor procedures such as the heel stick to draw blood in the intensive care unit, their behavior and cognitive function (and sensitivity to pain] is abnormal compare to those not exposed to intense pain.”
He added: “We don’t have all the answers…but this new information, these new studies make us think about how important it is to treat the pain, and also do more research to find better medications to treat the pain with minimal adverse effects and also reduce any short-and long-term consequences from not treating the pain.”
Baruch Krauss, a senior associate physician at Children’s Hospital Boston who specializes in alleviating pain in pediatric patients, said the new AAP guidelines are “much needed.” He sent me his thoughts via email:
This is a much needed third iteration of guidelines from the AAP for prevention and management of procedural pain in neonates. The first guidelines were published in 2000 and the second in 2006 … In this case, there have been considerable advances in our understanding of: 1) the short and long-term impact of repeated painful procedures on the neonate and premature infant; 2) the effectiveness of nonpharmacologic treatment strategies; and 3) an increased concern for the potential adverse effects of anesthetic drugs on the developing brain since 2006 when the last guidelines were published. Further, there has also been mounting evidence that there is a gap between published recommendations/guidelines and clinical practice, with underutilization of pain assessment and treatment strategies.
So I think the present guidelines are both a comprehensive update of the latest research with very clear evidence-based recommendations as well as an important and necessary call for increased awareness in this area. The update also highlights the many aspects of this area that we do not understand and calls for focused research.
According to the AAP report, pain relief for these babies includes a range of options, from glucose and sucrose, to topical anesthetics to opioids and benzodiazepines — although these drugs obviously have possible downsides too.
As for the non-drug options, Krauss said there are quite a few, including “sucking on [a] pacifier, skin-to-skin care and contact, swaddling and positioning, massage and breastfeeding.”
About 12.7 million Americans enrolled in private health insurance through the federal and state marketplaces for 2016, the Obama administration said Thursday.
Sign-ups in the third enrollment period for the Affordable Care Act’s online marketplaces — and the last that will be completed while President Barack Obama is in office — easily topped last year’s amount and also beat the administration’s forecast.
The 2016 enrollment period began Nov. 15 and ended Jan. 31. Except for limited exceptions such as job losses, Americans will have to wait until mid-November to enroll again.
The annual Obamacare enrollment numbers routinely draw debate. Supporters boast that millions of people have gained coverage. Republican detractors stress millions remain uninsured because they can’t afford coverage and that not enough healthy young adults are enrolling. The latter issue threatens to make coverage uneconomical for insurers, causing them to lose money and raise prices or drop out of the exchanges.
Of the 12.7 million consumers enrolling in marketplace coverage, more than 9.6 million came through the federal healthcare.gov exchange that handles 37 states. The rest, 3.1 million, selected a plan through the 13 state-based marketplaces.
About 4 million enrollees on healthcare.gov this year enrolled in the coverage for the first time, according to the Department of Health and Human Services.Use Our Content This KHN story can be republished for free (details).
At the end of last year’s enrollment period, 11.7 million people had chosen plans, but that figure dropped to 9.3 million by September because not everyone paid premiums and some found coverage elsewhere, such as through employers.
In October, the White House estimated that 10.1 million Americans would have health care coverage through the exchange at the end of 2016, a figure that counts people who paid and were covered at end of the entire year.
Today, February 4, marks the 75th anniversary of the 1941 founding of the United Service Organizations (USO).
General George C. Marshall first suggested and President Franklin D. Roosevelt recommended that civilian, public service organizations form the United Service Organizations to provide recreation for on-leave members of the U.S. Armed Forces and their families in 1941. The USO was composed of the Salvation Army, Young Men’s Christian Association, Young Women’s Christian Association, the National Jewish Welfare Board, the National Catholic Community Service, and the Travelers Aid Association of America. The USO created centers to support the welfare of the troops, providing for their social, educational, entertainment, and spiritual needs through recreational clubs, live entertainment, and quiet places to talk and write letters.more than 1 million volunteers operated recreational clubs during the war. The USO was disbanded in 1947 but reorganized a few years later during the Korean War and expanded during subsequent wars. Today, the USO retains the identity that FDR recommended—a private, voluntary, civilian organization not part of the federal government but is federally chartered and incorporated.
In 2003 the USO Congressional Caucus was formed and today includes more than 200 congressional members. It is a bipartisan and bicameral caucus with members from both parties and both chambers offering support to service members and their families. Even the president of the United States plays a role in this organization, as the honorary chairman, as has every president since 1941.
The USO works in the U.S. and abroad. The USO offers programs for service members during their time in service, when transitioning out of the armed forces, and caring for injured or fallen service members and their families.
Today the USO has centers in more than 160 locations worldwide to provide a “home away from home” for service members and their families. Of course, the most visible tradition that began in 1941 is boosting morale among the military with concerts, tours, and other events. Bob Hope is well-known for his support and touring for more than fifty years. The Library of Congress has an excellent online exhibition of his life and time touring in the USO shows.
In 2014, USO centers were visited more than 7 million times and aided by more than 30,000 volunteers who continue to carry on the mission started 75 years ago to keep service members connected to the people, places, and things they love.