Researchers spend hours studying newborns' pain at being circumcised

'Descriptive understanding' is painstaking work

Tuesday, December 30, 2003

For hours on end, the small group of British Columbia researchers sat in a darkened room, repeatedly watching videotapes of the circumcisions of 10 baby boys.

As they observed the three video screens before them, the researchers systematically noted and itemized the behaviour they witnessed, assigning each head twitch, each leg kick, each eye squeezing, one of more than 230 designated codes on a scale meant to scientifically classify the infants' distress-related behaviour.

For lead researcher Fay Warnock, a professor at the University of British Columbia's School of Nursing, this kind of detailed data collection meant exhaustive and successive viewing of each of these 90-minute tapes on a second-by-second basis.

Dr. Warnock says her work "is very basic in that it is focused on detailing normally occurring newborn pain-related distress behaviours.... Its usefulness is conceptual and, hopefully, will result in a deeper and more comprehensive descriptive understanding of newborn pain expression."

She says the study focused on circumcision because it is "an intense form of newborn acute pain," but stressed that further research in this area requires ongoing descriptions of other kinds of acute pain.

While impassioned debates about the pros and cons of circumcision continue unabated in living rooms and medical offices across the country, Dr. Warnock and her researchers stared at the loop of images for days on end, intently scrutinizing the most minute responses.

For the purposes of the study, each of the baby's anatomical regions (head, upper torso, upper extremities, etc.) was viewed in successive order and the videotape was run at fast-forward speed to identify further changes and any natural clustering in behaviours. Speeding up the tape and playing up to three videotapes concurrently also made it easier to identify when, and under what circumstances, certain behaviours occurred together and in all babies.

The equipment allowed the researchers to monitor the screens at a pace of 30 frames per second, but the observation process actually meant it took a skilled rater about 2 1/2 hours to code a single minute of videotaped data.

In the end, all of these minute observations were compiled to create an exhaustive behavioural scientific listing, or ethogram, of neonatal distress behaviour in response to acute pain.

The completed ethogram, outlined this year in a paper in the journal Infant Behaviour & Development, is an eight-page roster of various motor movements, positionings, respirations and vocalizations. In this format, the quality of each baby's body movement fits one of seven categories, ranging from nil to frantic to tremulous, jerky and unco-ordinated; respiration is further classified in one of 15 ways, including grunt, gasp, gag, hiccup, catching and rapid inspiration.

Dr. Warnock says this preliminary ethogram showed a wide range of distress behaviours that can be easily and reliably identified, including some responses previously unidentified by researchers, such as: gasping and breath-holding; exaggerated shift-like movements of the upper torso; strained downward movements of the shoulders; and flailing, frantic movements of the upper and lower extremities.

She is quick to say this research, though fascinating, has no immediate or direct practical benefit because it represents descriptive, conceptual information about a single instance of pain - circumcision.

[One direct practical benefit would be if people recognised that the simplest method of avoiding this pain is not to circumcise.]

"Because my work is basic, it cannot be interpreted at this stage to be clinically applicable.... The aim was to add to pain behaviour knowledge simply by describing behaviours about which we know little."

An ethogram of neonatal distress behavior in response to acute pain
(newborn male circumcision)

Fay Warnock,
Center for Community Child Health Research, BC Research Institute for Children's and Women's Health, 4480 Oak Street, L408, Vancouver, BC, Canada V6H 3V4

Received 20 August 2002; revised 12 February 2003; accepted 25 February 2003. ; Available online 4 June 2003.

Abstract

The aim of this basic observational study was to initiate development of a reliable ethogram of neonatal distress-related pain behavior. The videotapes of 10 full-term male newborns were observed repeatedly and systematically to inductively generate an exhaustive and structured listing of behavior. All 10 neonates were 72 hours of age or less, and all underwent the same distress-inducing events associated with newborn male circumcision. The reliably established ethogram contained 235 molecular and molar items for describing variation in neonatal motor movement, body postures, responsiveness, self-comfort, respiration, and vocalization. Also included were items for describing three distress-provoking stimuli: ambient sound, procedure-related stimuli, and innate responses made by the neonates. Novel descriptions contained in the ethogram extend knowledge of how neonates respond behaviorally to pain and non-pain situations. In combination with existing knowledge, they provide the descriptive prerequisites needed to distinguish newborn pain and the basis for further investigating important but poorly understood topics, such as newborn ability to self-organize or recover from significant exposure to pain and stress.

Author Keywords: Pain; Distress; Neonate; Pain behavior; Ethological methods; Basic observation [Why not "circumcision"?]

Corresponding author. Tel.: +1-604-875-3570; fax: +1-604-875-3569.

Infant Behavior and Development Volume 26, Issue 3 , August 2003, Pages 398-420