BABIES DON'T FEEL PAIN

Abstract
During the 20th Century, when medicine rose to dominate childbirth in developed countries, it brought with it a denial of infant pain based on ancient prejudices and 'scientific' dogmas that can no longer be supported. The painful collision of babies with doctors continues today in neonatology, infant surgery with anesthetic, aggressive obstetrics and genital modification of newborn males. This presentation includes an historical review of empirical findings on infant pain, some the reasons for physicians' indifference, and speculations about the negative consequences of violence to infants.
Introduction
Babies have had a difficult time getting us to accept them as real people with real feelings having real experiences. Deep prejudices have shadowed them for centuries: babies were sub-human, prehuman, or as Luis de Granada, a 16th- century authority put it, "a lower animal in human form."
In the Age of Science, babies have not necessarily fared better. It may shock you to consider how many ways they have fared worse. In the last hundred years, scientific authorities robbed babies of their cries by calling them "random sound;" robbed them of their smiles by calling them "muscle spasms" or "gas;" robbed them of their memories by calling them "fantasies" and robbed them of their pain by calling it a "reflex."
In this paper, I reflect on the painful impact of medicine on infants over the last century. This is not an easy story to tell. It has been a century of discovery and denial, of promise and disillusionment, and the story still has a very uncertain ending.
In the 20th Century, infants have had a head-on collision with physicians, typically male physicians. Before this time, they always found themselves in the hands of women: mothers, grandmothers, aunts, and midwives. In the collision, infant senses, emotions, and cognitions were generally ignored. Over the years, doctors paid increasing attention to the pain of mothers but not to the pain of infants. Actually birth become more painful for infants. We must try to understand why.
Experiments with Infant Pain
Against a back of general (scientific) ignorance of infant behavior, experiments were undertaken as early as 1917 at Johns Hopkins University to observe newborn tears, smiles, reactions to having blood drawn, infections lanced, and to a series of pin-pricks on the wrist during sleep.1 In these experiments (the first of many), infants reacted defensively. When blood was taken from the big toe, the opposite foot would go up at once with a pushing motion against the other ankle. Lancing produced exaggerated crying, and pin-pricks during sleep roused half the babies to move the hand and forearm. Rough cleaning of the back and head to remove vernix provoked vigorous battling movements of the hands, frantic efforts to crawl away, and angry crying. Psychologist Mary Blanton concluded:

The reflex and instinctive equipment of the child at birth is more complex and advanced than has hitherto been thought.2

This line of investigation continued in a series of experiments 3,4,5 at Northwestern University and Chicago's Lying-In Hospital in which newborns were stuck with needles on the cheeks, thighs, and calves. Virtually all infants reacted during the first hours and first day after birth, but the trend, the researchers noted, was toward more reaction to less stimulation from day one through day twelve. As a physiologic finding, this suggested that, at birth, newborns were not very sensitive, but became so gradually. However, they failed to tell us (and apparently overlooked the possible consequences) that all the mothers had received anesthetic drugs during labor and delivery! For the missing information, we are indebted to psychologist Daphne Maurer.6
The Shermans discovered infants would cry in reaction to hunger, to being dropped two to three feet (and caught), to having their heads restrained with firm pressure, or to someone pressing on their chins for 30 seconds.7,8 Babies tried to escape and made defensive movements of the arms and legs, including striking at the object to push it away. Today, we would see these behaviors as "self-management," an example of "kinesthetic intelligence," but in those days, experts were arguing about whether the head or tail end of a human baby was more sensitive9
Subsequent studies to learn how well infants could feel were directed at the big toe,10 calf,11 head, trunk, upper and lower extremities. Especially influential was an ambitious study at Myrtle McGraw12 at Columbia University and The Babies' Hospital, New York, using pin pricks to reveal the progressive maturation of nerves. Seventy-five infants were stimulated with a blunt sterile safety pin at intervals from birth to four years, and their responses duly recorded (half were recorded on motion picture film). Ten pricks in each area ensured that reactions were sufficiently "intense." (We are not told if the mothers had received anesthetics.)
McGraw reported that some infants a few hours or days old showed no response to pin prick. The usual response, she said, "consists of diffuse bodily movements accompanied by crying, and possibly a local reflex." In spite of the fact that these babies did react, did cry, and did try to withdraw their limbs, Dr. McGraw concluded there was only limited sensitivity to pain and labeled the first week to ten days a period of "hypesthesia" (abnormally weak sense of pain, heat, cold, or touch.) Her reference to "a local reflex" reflected the common medical view that reactions were mechanical and had not mental or emotional importance. In the discussion section of her paper, she reveals the belief behind the interpretations:

Even when there is sensitivity is it reasonable to assume that neural mediation does not extend above the level of the thalamus. 13
To physicians, McGraw's work seemed thoroughly scientific and justified the continuation of painful encounters between physicians and newborns. In retrospect, the conclusion that infants were somehow not yet sensitive to pain was a prejudiced interpretation, which fit comfortably into the traditional view expressed in medical journals reaching back into the 19th Century.14,15 In recent research, newborns and older babies pinched on the arm reacted instantly to the pain:16 No suggestion of "hypesthesia." There were more pin-prick experiments. In 1974, in ignorance of the experiments already performed Rich tested 124 full-term babies to determine the "normal response" to a succession of pin pricks around the knee. They concluded that: "The normal response is movement of the upper and lower limbs usually accompanied by grimace and/or cry."17
All infants demonstrated the "complete" response after six or fewer pin pricks.18
A different method for studying infant pain was to run water of different temperatures through cylinders attached to the baby's abdomen, leg, or forehead while filming their reactions as the water was made hotter or colder. This line of research began in Europe in 1873 and was taken up in America by Pratt, Nelson & Sun at Ohio State University19 and by Crudden at the University of Michigan Hospital in 1937.20 Babies reacted violently, especially to cold water. Crudden found that any deviation from normal body temperature produced immediate respiratory and circulation changes in all subjects: No sign of "hypesthesia" here either.
Do Babies Really Feel Pain?
Do babies feel pain? I certainly think they do, but, to find out, we should not have stuck them with pins. there are other objective indications of pain.
1. Crying. It seems perfectly obvious now, but for a long time, experts were informing the public that infants cries were only "random" sounds, not genuine communications. It took a quarter century of cry research to prove otherwise.21 Cries are not only meaningful signals, but often compelling ones. They increase in intensity with degrees of pain. Spectrographic studies that reduce sound to an elaborate visual portrait show just how varied and complex cry language is.22 Acoustic studies show that changes in pitch, temporal patterning, and harmonic structure also reflect the degree of pain and urgency. For example, in a thorough study of cries during circumcision, acoustic features precisely reflected the degree of invasiveness of the surgery.23
Parents present at circumcision (a rarity) have recalled how their babies cried. One father, present in the delivery room told me of his great surprise when the obstetrician proceeded to circumcise this boy at delivery. Having been quiet through the entire birth, the boy proceeded to protest loudly about the circumcision! A Jewish father, reflecting on this boy's circumcision on the eighth day, said it was the saddest occurrence of his babyhood: the boy cried more that afternoon, he said, than anytime in his whole first year.
2. Facial expressions. Second, the pain that babies feel is clearly expressed on their faces.24 Brows bulge, crease, and furrow. Eyes squeeze shut: bulging of the fatty pads about the eyes is pronounced. There is a nasolabial furrow that runs down and outwards from the corners of the lip. Lips purse, the mouth opens wide, the tongue is taut, and the chin quivers. This look on a human face of any age communicates pain. Why do we doubt that it means the same on the face of a baby?
3. Body movement. Body language in its larger motor dimensions is also a language that babies share with older humans. In response to pain, babies jerk, pull back, try to escape, swing their arms, use their hands to push away, and frantically scrape one leg against the other to dislodge an offending stimulus in that area. They strike out with their upper extremities and kick with the lower. Fitzgerald and Millard25 made close observations of babies receiving routine heel lancing, a deep wound made in the heel to obtain blood samples. Using calibrated hairs, they gently stroked the corresponding areas in the injured and non-injured heel. Even premature infants showed the same well-defined hypersensitivity to tissue injury that is found in adults.
4. Vital signs. Fourth, we can see how baby pain is revealed by changed in vital signs and blood chemistry. Pain causes increased respiration. Babies hold their breath and release it in piercing cries. Researchers have observed infant heart rates increase 50 beats per minute and peak above 180 beats per minute.26,27,28 In a study to compare behavioral states of the newborn to those of the fetus, Pillai and James29 discovered that the heart rate during newborn crying was unlike anything seen in prenatal life. This racing heartbeat was unstable, often reaching peaks in excess of 200 bpm, in spite of the fact that baseline heart rates after birth are generally 20-25 bpm lower than they are in utero. These extremely elevated heart rates signal a serious and urgent disturbance.
Serum cortisol is a measure of stress. In painful conditions, adrenals may release cortisol three to four times the baseline.30, 31,32,33 In one study, cortisol levels clearly differentiated between three different surgical techniques of circumcision.34
Under painful conditions, tissue and blood oxygen levels drop.35
5. Neurobehavioral assessments. Further consequences of infant pain can be seen in neurobehavioral assessments. Babies who have been subjected to pain may have difficulty quieting themselves. Following circumcision, the normal progression of sleep cycles is reversed with immediate and prolonged escape into Non-REM sleep.36 After circumcision, babies withdraw, change their social interactions with their mothers, and modify their motor behavior.37
Als, Lester, and Tonic38 developed an Assessment of Preterm Infants' Behavior, which includes a list of infant behaviors indicating stress and defense. Behaviors indicating pain include seizuring, tremoring, spitting up, trunk arching, finger splaying, fisting, squirming, inconsolability, and restlessness.
6. Memory. Finally, we know that newborns feel pain because they sometimes remember and speak of painful experiences as soon as they acquire sufficient language.39 At age two, my granddaughter, talking about her birth, asked her parents, "Why did they poke me with a thing?" Her mother asked, "What thing?" "Like a pencil," she said, "they hurted me." She was probably referring to heel lancing, done routinely in American hospitals at birth. Various studies have shown that lancing is always painful.40,41,41 Other such spontaneous memories of birth pain have surfaced, as I have shown by the collection of stories in chapter seven of my book, Babies Remember Birth.43
Adults also remember, although reports are rare. Three men have told me they have always remembered their circumcision in infancy. Another man, Keith, of Dallas, Texas, remembers that he was born with an open abdomen. He says he has always remembered that surgery and the emotions he felt at the time.
We may not like to think babies feel pain, but they do.