Pain assessment in human fetus and infants

The Chicken Embryo: An Alternative Animal Model in Development, Disease and Pharmacological Treatment

To examine various medications and substances, in vivo models such as rats and mice are routinely used. However, it is utterly desirable to reduce extensive amounts of animals for these experimental models, which are costly and time-consuming. Animals are frequently put through a variety of procedures that could cause them pain, distress, or even harm; therefore, it is important to think about the ethical ramifications of using them in research. Thus, by following the three R's of animal research: reduction, replacement, and refinement, living animals used in studies should be minimized. The embryo of Gallus gallus, the domestic chicken, is a great model to research many different diseases and conditions. Its efficient blood supply from the chorioallantoic membrane gives us a unique possibility to administer chemicals or cells to the embryo in a noninvasive manner. In this review, we evaluate some advantages and disadvantages of using the developing chicken as an alternative in vivo model for development, disease, and pharmacological treatment. We focus on the top two leading causes of death: neurological disorders and cancer. We present a number of studies that describe the use of the chicken embryo in neuroscience and neurodevelopment research, in cancer research, and pharmacodynamic and pharmacokinetic studies. These studies show that the chicken embryo is an inexpensive, readily available, self-sufficient model with a short incubation period, high accessibility, and ideal for drug screening, making it an appealing model that can provide insightful biological and pharmacological information.

Deep Learning for Face Detection and Pain Assessment in Japanese macaques (Macaca fuscata)

Facial expressions have increasingly been used to assess emotional states in mammals. The recognition of pain in research animals is essential for their well-being and leads to more reliable research outcomes. Automating this process could contribute to early pain diagnosis and treatment. Artificial neural networks have become a popular option for image classification tasks in recent years due to the development of deep learning. In this study, we investigated the ability of a deep learning model to detect pain in Japanese macaques based on their facial expression. Thirty to 60 min of video footage from Japanese macaques undergoing laparotomy was used in the study. Macaques were recorded undisturbed in their cages before surgery (No Pain) and one day after the surgery before scheduled analgesia (Pain). Videos were processed for facial detection and image extraction with the algorithms RetinaFace (adding a bounding box around the face for image extraction) or Mask R-CNN (contouring the face for extraction). ResNet50 used 75% of the images to train systems; the other 25% were used for testing. Test accuracy varied from 48 to 54% after box extraction. The low accuracy of classification after box extraction was likely due to the incorporation of features that were not relevant for pain (for example, background, illumination, skin color, or objects in the enclosure). However, using contour extraction, preprocessing the images, and fine-tuning, the network resulted in 64% appropriate generalization. These results suggest that Mask R-CNN can be used for facial feature extractions and that the performance of the classifying model is relatively accurate for nonannotated single-frame images.

An Evidence-Based Discussion of Fetal Pain and Stress

BACKGROUND

The concept of fetal pain results from procedures conducted without anesthesia in preterm newborns and fetuses, which indicate that it is possible to examine fetal pain based on stress hormone, metabolic, and behavioral changes. Anatomical and physiological data suggest that fetuses become capable of processing nociceptive stimuli around midgestation, although the associated changes in fetal brain development remain unclear. What constitutes fetal pain remains controversial in the light of the definition of pain adopted by the International Association for the Study of Pain (IASP), which posits pain as an "unpleasant sensory and emotional experience."

SUMMARY

Here, we examine the notion that human fetuses cannot "experience" pain and potential implications of this claim. We highlight the key scientific evidence related to fetal pain, including clinical studies on pain in fetuses and preterm newborns. We argue that consistent patterns of stress hormones, metabolic changes, body movements, hemodynamic changes, and pain-related facial expressions in fetuses exposed to invasive procedures overcome the need for subjective proof of pain as articulated in the IASP definition. No study to date has conclusively proven the absence of fetal pain beyond the age of viability.

KEY MESSAGES

Based on the current evidence, we propose that all fetuses receive anesthesia regardless of the invasive procedures being performed to guarantee the least possible pain and physiological, behavioral, or hormonal responses without exposing the mother or her baby to unnecessary complications.

Nociception in Chicken Embryos, Part I: Analysis of Cardiovascular Responses to a Mechanical Noxious Stimulus

Although it is assumed that chicken embryos acquire the capacity for nociception while developing in the egg, an exact time point has not yet been specified. The present research was an exploratory study aiming to determine when the capacity of nociception emerges during embryonic development in chickens. Changes in blood pressure and heart rate (HR) in response to a noxious mechanical stimulus at the base of the beak versus a light touch on the beak were examined in chicken embryos between embryonic days (EDs) 7 and 18. Mean arterial pressure (MAP) was the most sensitive parameter for assessing cardiovascular responses. Significant changes in MAP in response to a noxious stimulus were detected in embryos at ED16 to ED18, whereas significant changes in HR were observed at ED17 and ED18. Infiltration anesthesia with the local anesthetic lidocaine significantly reduced the response of MAP on ED18, so the measured cardiovascular changes may be interpreted as nociceptive responses.

Quantification of stress exposure in very preterm infants: Development of the NeO-stress score

BACKGROUND

Stress during treatment at the Neonatal Intensive Care Unit (NICU) has long-term negative consequences on preterm infants' development.

AIMS

We developed an instrument suited to validly determine the cumulative stress exposure for preterm infants in a NICU.

STUDY DESIGN

This survey study made use of two consecutive questionnaires.

SUBJECTS

NICU nurses and physicians from the nine NICUs in the Netherlands.

OUTCOME MEASURES

First, respondents rated the relevance of 77 items encompassing potentially stressful procedures, commented on their comprehensibility and the comprehensiveness of the list. We calculated the content validity per item (CVI-I) and included only the relevant items in a second questionnaire in which the participants rated the stressfulness from 0 (not stressful) to 10 (extremely stressful). A stressfulness index - representing the median score - was calculated for each included item.

RESULTS

Based on the CVI-I of the 77 items, step 1 resulted in 38 items considered relevant to quantify stress in preterm infants during the first 28 days of life. This list of 38 items exists of 34 items with a CVI-I if 0.78 or higher, one of these items was split into two items, and three items were added to improve comprehensiveness. The stressfulness index ranged from five to nine.

CONCLUSIONS

The NeO-stress score consists of stressful items including their severity index and was developed to determine cumulative stress exposure of preterm infants. Evaluating the cross-cultural validity, correlating it to behavioural and biological stress responses, and evaluating its ability to predict preterm infants at risk for the negative effects following stress might expand the possibilities for this instrument.

Fetal Pain in the First Trimester

Fetal pain perception has important implications for fetal surgery, as well as for abortion. Current neuroscientific evidence indicates the possibility of fetal pain perception during the first trimester (<14 weeks gestation). Evidence for this conclusion is based on the following findings: (1) the neural pathways for pain perception via the cortical subplate are present as early as 12 weeks gestation, and via the thalamus as early as 7–8 weeks gestation; (2) the cortex is not necessary for pain to be experienced; (3) consciousness is mediated by subcortical structures, such as the thalamus and brainstem, which begin to develop during the first trimester; (4) the neurochemicals in utero do not cause fetal unconsciousness; and (5) the use of fetal analgesia suppresses the hormonal, physiologic, and behavioral responses to pain, avoiding the potential for both short- and long-term sequelae. As the medical evidence has shifted in acknowledging fetal pain perception prior to viability, there has been a gradual change in the fetal pain debate, from disputing the existence of fetal pain to debating the significance of fetal pain. The presence of fetal pain creates tension in the practice of medicine with respect to beneficence and nonmaleficence.

Future roles of artificial intelligence in early pain management of newborns

The advent of increasingly sophisticated medical technology, surgical interventions, and supportive healthcare measures is raising survival probabilities for babies born premature and/or with life-threatening health conditions. In the United States, this trend is associated with greater numbers of neonatal surgeries and higher admission rates into neonatal intensive care units (NICU) for newborns at all birth weights. Following surgery, current pain management in NICU relies primarily on narcotics (opioids) such as morphine and fentanyl (about 100 times more potent than morphine) that lead to a number of complications, including prolonged stays in NICU for opioid withdrawal. In this paper, we review current practices and challenges for pain assessment and treatment in NICU and outline ongoing efforts using Artificial Intelligence (AI) to support pain- and opioid-sparing approaches for newborns in the future. A major focus for these next-generation approaches to NICU-based pain management is proactive pain mitigation (avoidance) aimed at preventing harm to neonates from both postsurgical pain and opioid withdrawal. AI-based frameworks can use single or multiple combinations of continuous objective variables, that is, facial and body movements, crying frequencies, and physiological data (vital signs), to make high-confidence predictions about time-to-pain onset following postsurgical sedation. Such predictions would create a therapeutic window prior to pain onset for mitigation with non-narcotic pharmaceutical and nonpharmaceutical interventions. These emerging AI-based strategies have the potential to minimize or avoid damage to the neonate's body and psyche from postsurgical pain and opioid withdrawal.

Assessment of 2-Year Neurodevelopmental Outcomes in Extremely Preterm Infants Receiving Opioids and Benzodiazepines

IMPORTANCE

Extremely preterm (EP) infants frequently receive opioids and/or benzodiazepines, but these drugs' association with neurodevelopmental outcomes is poorly understood.

OBJECTIVES

To describe the use of opioids and benzodiazepines in EP infants during neonatal intensive care unit (NICU) hospitalization and to explore these drugs' association with neurodevelopmental outcomes at 2 years' corrected age.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was a secondary analysis of data from the Preterm Erythropoietin Neuroprotection (PENUT) Trial, which was conducted among infants born between gestational ages of 24 weeks, 0 days, and 27 weeks, 6 days. Infants received care at 19 sites in the United States, and data were collected from December 2013 to September 2016. Data analysis for this study was conducted from March to December 2020.

EXPOSURES

Short (ie, ≤7 days) and prolonged (ie, >7 days) exposure to opioids and/or benzodiazepines during NICU stay.

MAIN OUTCOMES AND MEASURES

Cognitive, language, and motor development scores were assessed using the Bayley Scales of Infant Development-Third Edition (BSID-III).

RESULTS

There were 936 EP infants (448 [48%] female infants; 611 [65%] White infants; mean [SD] gestational age, 181 [8] days) included in the study, and 692 (74%) had neurodevelopmental outcome data available. Overall, 158 infants (17%) were not exposed to any drugs of interest, 297 (32%) received either opioids or benzodiazepines, and 481 (51%) received both. Infants exposed to both had adjusted odds ratios of 9.7 (95% CI, 2.9 to 32.2) for necrotizing enterocolitis and 1.7 (95% CI, 1.1 to 2.7) for severe bronchopulmonary dysplasia; they also had a longer estimated adjusted mean difference in length of stay of 34.2 (95% CI, 26.2 to 42.2) days compared with those who received neither drug. After adjusting for site and propensity scores derived for each exposure category, infants exposed to opioids and benzodiazepines had lower BSID-III cognitive, motor, and language scores compared with infants with no exposure (eg, estimated difference in mean scores on cognitive scale: -5.72; 95% CI, -8.88 to -2.57). Prolonged exposure to morphine, fentanyl, midazolam, or lorazepam was associated with lower BSID-III scores compared with infants without exposure (median [interquartile range] motor score, 85 [73-97] vs 97 [91-107]). In contrast, BSID-III scores for infants with short exposure to both opioids and benzodiazepines were not different than those of infants without exposure.

CONCLUSIONS AND RELEVANCE

In this study, prolonged combined use of opioids and benzodiazepines was associated with a risk of poorer neurodevelopmental outcomes as measured by BSID-III at 2 years' corrected age.

Brain Gene Expression Pattern Correlated with the Differential Brain Activation by Pain and Touch in Humans

Genes involved in pain and touch sensations have been studied extensively, but very few studies have tried to link them with neural activities in the brain. Here, we aimed to identify genes preferentially correlated to painful activation patterns by linking the spatial patterns of gene expression of Allen Human Brain Atlas with the pain-elicited neural responses in the human brain, with a parallel, control analysis for identification of genes preferentially correlated to tactile activation patterns. We identified 1828 genes whose expression patterns preferentially correlated to painful activation patterns and 411 genes whose expression patterns preferentially correlated to tactile activation pattern at the cortical level. In contrast to the enrichment for astrocyte and inhibitory synaptic transmission of genes preferentially correlated to tactile activation, the genes preferentially correlated to painful activation were mainly enriched for neuron and opioid- and addiction-related pathways and showed significant overlap with pain-related genes identified in previous studies. These findings not only provide important evidence for the differential genetic architectures of specific brain activation patterns elicited by painful and tactile stimuli but also validate a new approach to studying pain- and touch-related genes more directly from the perspective of neural responses in the human brain.

Analgesia for fetal pain during prenatal surgery: 10 years of progress

Some doubts on the necessity and safety of providing analgesia to the fetus during prenatal surgery were raised 10 years ago. They were related to four matters: fetal sleep due to neuroinhibitors in fetal blood, the immaturity of the cerebral cortex, safety, and the need for fetal direct analgesia. These objections now seem obsolete. This review shows that neuroinhibitors give fetuses at most some transient sedation, but not a complete analgesia, that the cerebral cortex is not indispensable to feel pain, when subcortical structures for pain perception are present, and that maternal anesthesia seems not sufficient to anesthetize the fetus. Current drugs used for maternal analgesia pass through the placenta only partially so that they cannot guarantee a sufficient analgesia to the fetus. Extraction indices, that is, how much each analgesic drug crosses the placenta, are provided here. We here report safety guidelines for fetal direct analgesia. In conclusion, the human fetus can feel pain when it undergoes surgical interventions and direct analgesia must be provided to it. IMPACT: Fetal pain is evident in the second half of pregnancy. Progress in the physiology of fetal pain, which is reviewed in this report, supports the notion that the fetus reacts to painful interventions during fetal surgery. Evidence here reported shows that it is an error to believe that the fetus is in a continuous and unchanging state of sedation and analgesia. Data are given that disclose that drugs used for maternal analgesia cross the placenta only partially, so that they cannot guarantee a sufficient analgesia to the fetus. Safety guidelines are given for fetal direct analgesia.

Multimodal neonatal procedural and postoperative pain assessment dataset

This paper presents the first multimodal neonatal pain dataset that contains visual, vocal, and physiological responses following clinically required procedural and postoperative painful procedures. It was collected from 58 neonates (27-41 gestational age) during their hospitalization in the neonatal intensive care unit. The visual and vocal data were recorded using an inexpensive RGB camera while the physiological responses (vital signs and cortical activity) were recorded using portable bedside monitors. The recorded behavioral and physiological responses were scored by expert nurses using two validated pain scales to obtain the ground truth labels. In addition to behavioral and physiological responses, our dataset contains clinical information such as the neonate's age, gender, weight, pharmacological and non-pharmacological interventions, and previous painful procedures. The presented multimodal dataset can be used to develop artificial intelligence systems that monitor, assess, and predict neonatal pain based on the analysis of behavioral and physiological responses. It can also be used to advance the understanding of neonatal pain, which can lead to the development of effective pain prevention and treatment.

Pain Scales in Neonates Receiving Mechanical Ventilation in Neonatal Intensive Care Units - Systematic Review

INTRODUCTION

Recently, interest in the problem of proper prevention and monitoring of pain, especially acute, has been increasing in relation to various age groups. Greater awareness of the problem prompts discussion about the purpose of analgesia in newborns treated with mechanical ventilation.

AIM

The purpose of the systematic review was to analyze current research on the use of pain scales in newborns treated with mechanical ventilation in the Neonatal Intensive Care Unit.

METHODS

Medline databases: PubMed, OVID, EBSCO, Web of Science and Cochrane Library were traced using the appropriate keywords. The search was limited to studies in English. The review took into account the years 2006-2019. Considering the criteria, 12 articles were included in further analysis, to which full access was obtained.

RESULTS

The analyzed scientific research showed differences in beliefs about the validity and credibility of the scales used. Researchers indicated that staff with practical experience in using scales in their daily practice was very skeptical of the results obtained on their basis.

CONCLUSION

Based on this review, no explicit evidence can be obtained to support the use of one proper scale in pain assessment. It can be inferred that the COMFORT and N-PASS scales are effective for pain assessment and for determining the need for analgesics in mechanically ventilated neonates. These scales may be equally effective in assessing chronic pain, especially in mechanically ventilated children. On the other hand, the PIPP and CRIES scales are most commonly recommended for assessing acute and postoperative pain.

Defining and distinguishing infant behavioral states using acoustic cry analysis: is colic painful?

BACKGROUND

To characterize acoustic features of an infant's cry and use machine learning to provide an objective measurement of behavioral state in a cry-translator. To apply the cry-translation algorithm to colic hypothesizing that these cries sound painful.

METHODS

Assessment of 1000 cries in a mobile app (ChatterBaby^TM). Training a cry-translation algorithm by evaluating >6000 acoustic features to predict whether infant cry was due to a pain (vaccinations, ear-piercings), fussy, or hunger states. Using the algorithm to predict the behavioral state of infants with reported colic.

RESULTS

The cry-translation algorithm was 90.7% accurate for identifying pain cries, and achieved 71.5% accuracy in discriminating cries from fussiness, hunger, or pain. The ChatterBaby cry-translation algorithm overwhelmingly predicted that colic cries were most likely from pain, compared to fussy and hungry states. Colic cries had average pain ratings of 73%, significantly greater than the pain measurements found in fussiness and hunger (p < 0.001, 2-sample t test). Colic cries outranked pain cries by measures of acoustic intensity, including energy, length of voiced periods, and fundamental frequency/pitch, while fussy and hungry cries showed reduced intensity measures compared to pain and colic.

CONCLUSIONS

Acoustic features of cries are consistent across a diverse infant population and can be utilized as objective markers of pain, hunger, and fussiness. The ChatterBaby algorithm detected significant acoustic similarities between colic and painful cries, suggesting that they may share a neuronal pathway.

New insights into fetal pain

Fetal pain is difficult to assess, because the main feature needed to spot pain, is the subject's capability of declaring it. Nonetheless, much can be affirmed about this issue. In this review we first report the epochs of the development of human nociceptive pathways; then we review since when they are functioning. We also review the latest data about the new topic of analgesia and prenatal surgery and about the scarce effect on fetal pain sentience of the natural sedatives fetuses produce. It appears that pain is a neuroadaptive phenomenon that emerges in the middle of pregnancy, at about 20-22 weeks of gestation, and becomes more and more evident for bystanders and significant for the fetus, throughout the rest of the pregnancy.

Phenomenology of pregnancy and the ethics of abortion

In this article I investigate the ways in which phenomenology could guide our views on the rights and/or wrongs of abortion. To my knowledge very few phenomenologists have directed their attention toward this issue, although quite a few have strived to better understand and articulate the strongly related themes of pregnancy and birth, most often in the context of feminist philosophy. After introducing the ethical and political contemporary debate concerning abortion, I introduce phenomenology in the context of medicine and the way phenomenologists have understood the human body to be lived and experienced by its owner. I then turn to the issue of pregnancy and discuss how the embryo or foetus could appear for us, particularly from the perspective of the pregnant woman, and what such showing up may mean from an ethical perspective. The way medical technology has changed the experience of pregnancy-for the pregnant woman as well as for the father and/or other close ones-is discussed, particularly the implementation of early obstetric ultra-sound screening and blood tests (NIPT) for Down's syndrome and other medical defects. I conclude the article by suggesting that phenomenology can help us to negotiate an upper time limit for legal abortion and, also, provide ways to determine what embryo-foetus defects to look for and in which cases these should be looked upon as good reasons for performing an abortion.

A Review of Automated Pain Assessment in Infants: Features, Classification Tasks, and Databases

Bedside caregivers assess infants' pain at constant intervals by observing specific behavioral and physiological signs of pain. This standard has two main limitations. The first limitation is the intermittent assessment of pain, which might lead to missing pain when the infants are left unattended. Second, it is inconsistent since it depends on the observer's subjective judgment and differs between observers. Intermittent and inconsistent assessment can induce poor treatment and, therefore, cause serious long-term consequences. To mitigate these limitations, the current standard can be augmented by an automated system that monitors infants continuously and provides quantitative and consistent assessment of pain. Several automated methods have been introduced to assess infants' pain automatically based on analysis of behavioral or physiological pain indicators. This paper comprehensively reviews the automated approaches (i.e., approaches to feature extraction) for analyzing infants' pain and the current efforts in automatic pain recognition. In addition, it reviews the databases available to the research community and discusses the current limitations of the automated pain assessment.

Defining pain in newborns: need for a uniform taxonomy?

A framework for defining pain terms such as acute, persistent, prolonged or chronic pain to newborns was derived from the scientific literature on neonatal pain assessments, previous attempts to define chronic pain and the clinical and neurophysiological features of neonatal pain. This novel framework incorporates the temporal features, localising characteristics, and secondary effects of the pain experienced, as well as the behavioural and physiological response patterns of newborns.

CONCLUSION

Although not evidence-based, this framework provides an initial starting point for defining commonly used neonatal pain terms. It will require future revision/refinement based on the accumulating evidence for non-acute pain.

Current status of fetal neurodevelopmental assessment: Four-dimensional ultrasound study

With the latest advent of four-dimensional (4-D) ultrasound, fetal neurobehavioral or neurodevelopmental assessment can be easily and readily performed. Using this technique, typical fetal movements and behavioral patterns have become apparent in all three trimesters of pregnancy. In twin pregnancy, 4-D ultrasound facilitates the precise evaluation of inter-twin contact and intra-pair stimulation. New fetal neurobehavioral assessment tests, such as Kurjak's Antenatal Neurodevelopmental Test and the Fetal Observable Movement System, may reflect the normal and abnormal neurological development of the fetus, and will facilitate more precise assessments of fetal neurobehavior or neurodevelopment, and fetal brain and central nervous system functions. In this review article, I also discuss interesting topics regarding maternal and fetal stress, fetal pain, and fetal consciousness. Four-dimensional ultrasound has opened the door to new scientific fields, such as 'fetal neurology' and 'fetal psychology,' and fetal neurobehavioral science is at the dawn of a new era. Knowledge on fetal neurobehavior and neurodevelopment will be advanced through fetal behavioral research using this technique.

Effect of change in sequence of administration of DTwP and Hepatitis B vaccines on perception of pain in infants: A randomized control trial

OBJECTIVE

This study was designed with objective to study pain response of infants to change in sequence of administration of Hepatitis B and DTwP vaccines.

METHODS

This was a randomized parallel control trial. The study was carried out in the immunization clinic of the Department of Pediatrics, LLRM Medical College, Meerut. One hundred and thirty healthy term infants up to 4 months of age were injected either DTwP vaccine first or Hepatitis B vaccine first, followed one minute later by the other vaccine.

RESULT

Baseline characteristics did not differ between the groups. The mean (SD) of AUC of MFCS and NIPS was significantly more in DF group as compared to HF group (for MFCS 25.5 ± 5.4 versus 22.5 ± 5.5, p<0.01; for NIPS 31.77 ± 5.5 versus 27.64 ± 6.9, p < 0.01). Similarly mean (SD) of AUC of Heart rate and saturation of oxygen showed significant variation in DF group as compared to HF group (for heart rate 591.6 ± 55 versus 559.6 ± 49, p< 0.01; for SpO2 326.4 ± 12 versus 335 ± 8, p < 0.01).

CONCLUSION

These results showed that infant experienced lesser pain when Hepatitis B was administered first than when DTwP vaccine was given first.

The long-term impact of early life pain on adult responses to anxiety and stress: Historical perspectives and empirical evidence

Approximately 1 in 6 infants are born prematurely each year. Typically, these infants spend 25 days in the Neonatal Intensive Care Unit (NICU) where they experience 10-18 painful and inflammatory procedures each day. Remarkably, pre-emptive analgesics and/or anesthesia are administered less than 25% of the time. Unalleviated pain during the perinatal period is associated with permanent decreases in pain sensitivity, blunted cortisol responses and high rates of neuropsychiatric disorders. To date, the mechanism(s) by which these long-term changes in stress and pain behavior occur, and whether such alterations can be prevented by appropriate analgesia at the time of insult, remains unclear. Work in our lab using a rodent model of early life pain suggests that inflammatory pain experienced on the day of birth blunts adult responses to stress- and pain-provoking stimuli, and dysregulates the hypothalamic pituitary adrenal (HPA) axis in part through a permanent upregulation in central endogenous opioid tone. This review focuses on the long-term impact of neonatal inflammatory pain on adult anxiety- and stress-related responses, and underlying neuroanatomical changes in the context of endogenous pain control and the HPA axis. These two systems are in a state of exaggerated developmental plasticity early in postnatal life, and work in concert to respond to noxious or aversive stimuli. We present empirical evidence from animal and clinical studies, and discuss historical perspectives underlying the lack of analgesia/anesthetic use for early life pain in the modern NICU.

Fetal Consciousness: Four-dimensional Ultrasound Study

How to cite this article

Hata T, Kanenishi K, AboEllail MAM, Marumo G, Kurjak A. Fetal Consciousness: Four-dimensional Ultrasound Study. Donald School J Ultrasound Obstet Gynecol 2015;9(4):471-474.

HDlive and 4D Ultrasound in the Assessment of Fetal Facial Expressions

Four-dimensional (4D) sonographic assessment of fetal facial expressions is considered to reflect normal and abnormal fetal neurological developments, and may be an important clue to predict the fetal brain function and well-being before and after birth. HDlive is a new surface-rendering mode, which uses an adjustable light source that facilitates the ability to create lighting and shadowing effects, thereby increasing depth perception. This technique facilitates extraordinarily realistic imaging of the fetal face, making it almost impossible to differentiate between actual photographs and HDlive images. In this article, we discuss recent topics regarding fetal facial expressions assessed by 4D ultrasound and HDlive, focusing on mouthing, sucking, yawning, blinking, tongue expulsion, scowling (pain/distress), and smiling. Moreover, we consider possibility of the existence of fetal emotion or awareness.

How to cite this article

Hata T, Kanenishi K, Hanaoka U, Marumo G. HDlive and 4D Ultrasound in the Assessment of Fetal Facial Expressions. Donald School J Ultrasound Obstet Gynecol 2015;9(1):44-50.

COMFORT behaviour scale and skin conductance activity: what are they really measuring?

AIM

To assess how efficiently the COMFORT behaviour scale measures acute pain in neonates, in comparison with skin conductance activity, a validated measure of pain and stress.

METHODS

Images of 36 newborns were analysed before, during and after painful heel pricks to measure glucose levels and compared with skin conductance activity variables.

RESULTS

Scale indicators and skin conductance variables were sensitive to changes in the periods 'during-before' and 'during-after' (Wilcoxon's test, p < 0.01). Significant values were found between all scale indicators and number of waves for Kendall's coefficient (p < 0.05), although responses differed when it came to how long they took to increase and correlations varied from fair to moderate (r < 0.6). Facial tension was more closely related to 15 sec after the painful event, while crying and calmness were more closely related to the later intervals (30 and 180 sec).

CONCLUSION

All scale indicators were related to skin conductance activity in all periods, indicating pain perception. Facial tension was the most efficient indicator, while others varied in performance after painful events and possibly indicated stress after trauma. These results are discussed from a phenomenological approach and in an anxiety paradigm.

The challenges of assessing osteoarthritis and postoperative pain in dogs

The challenge of measuring pain in veterinary medicine is compounded by the lack of fully validated, reliable methods to measure and assess pain in nonverbal patients. In human medicine, there are numerous, validated pain assessment tools (PATs) for assessing various, specific types of pain. The advances in human medicine pain management and numerous validated pain scales should serve as incentives and templates to facilitate similar advances in the development of validated PATs for use in dogs (and other species). The limited number of canine PATs constrains our ability to adequately and reliably assess pain. Improving the ability to quantify osteoarthritis and postoperative pain in dogs would enhance the development of analgesics for animals, advance the management of animal pain, facilitate the use of animal pain models in preclinical trials for human analgesics, and provide insight into the quantification of pain responses in humans who lack the ability to adequately communicate. This review describes the need for practical, valid, and reliable PATs for use in veterinary patients and discusses some currently available PATs commonly used to evaluate acute and chronic pain in dogs.