Conceptualising pain in critically ill neonates or infants

Emre Ilhan and Simon van Rysewyk


The belief that neonates or infants can feel pain is relatively recent development. Historically, major cardiac surgery was performed in some neonates or infants without anaesthesia, based on the belief that infants had immature nervous systems; therefore, they were incapable of pain, and were fatally vulnerable to the side-effects of anaesthesia. What was standard medical practice in the past is now considered medically unsound and morally unjust. Given that neonates or infants cannot linguistically describe their pain, researchers and clinicians have considered behavioural, physiological, and neurophysiological cues to determine pain in neonates or infants. Pain assessment based on behavioural cues is not an ‘indirect’ means of inferring pain in the neonate and infant because pain experience is not totally separable from its behavioural manifestations. Since pre-linguistic neonates or infants do not possess the concept of pain, in social settings involving pain, the neonate and infant expresses pain only by virtue of a courtesy extended to signs of pain by linguistically competent adults who have already mastered the practice of using ‘pain’. Thus, the aim of this paper is to describe how clinicians and researchers have conceptualised neonatal or infant pain, and what implications these may have in the study of neonatal or infant pain. Craig’s social communications model emphasises how intra- and interpersonal factors surrounding assessment of infant pain influences the caregiver’s ability to decode the behavioural, physiological, and neurophysiological expression of the neonate’s and infant’s pain. Although the neonate’s or infant’s ability to express pain through behavioural signs is an essential aspect of pain assessment, the role of pain detection falls heavily on the caregiver. In some circumstances, such as severe disease acuity, neonates or infants may not have the capacity to respond behaviourally or physiologically to pain. Therefore, it is argued, examining the caregiver’s conceptualisation of the pain is even more important in these circumstances, as it has obvious implications for pain management.

Keywords: neonate, infant, pain, neonatal intensive care unit, pre-linguistic, meaning, concept 

Read the article here.

What the face reveals: the experience of pain

Presented at: De/Constructing the Body: Ancient and Modern Dynamics, Workshop 3:Trans-Formation, April 9, 2021.

Abstract here.

Slide transcript

Slide 2
Human beings are describable in two distinct, but complementary ways: in terms of the way the world is, through scientific descriptions of the causal mechanisms and laws that explain physical things, or, in terms of the way the world seems, through descriptions of personal experiences and meanings.

As a person, I can recognise within myself a perspective or point of view on the world and identify it as belonging to me. Every person has such a unique perspective; this is partly what it means to be a person rather than a physical thing. In contrast, a scientific description of the world does not presuppose any personal point of view. Physical or biological science does not use words like “I”, “here”, or “now”.

Slide 3
The features of personal experience—thought, feeling, speech and action—are amenable to standard scientific explanation as specific changes in the body.

A philosophical assumption held by some neurophysiologists is that a person is identical with his or her body. Person and body are one and the same thing. This assumption is behind the slogan in pain science, “pain is in the brain”.

In terms of personal experience, however, the identity between person and body escapes understanding. For example, when I feel a pain, there is no information or evidence, or nothing that I could discover about my body subsequent to the experience of pain, that could demonstrate it to be false. When I feel a pain, I simply I am in pain.

Slide 4
In person-to-person interactions, we commonly respond to each other as though we are not identical with the human body, but in a compelling sense operating “through” the body, which seems to be a vehicle of thought, emotion, pain or suffering.

We feel that each person we encounter in the world is a unique perspective that is not the body, but the “self”, which is lodged in the face.

Slide 5
Pain is not an action, but a personal experience. Yet, pain reveals itself in those gestures, or expressions, which cannot fail to reveal the person in pain.

People in pain communicate their experience through a range of actions, ranging from self-report, to nonverbal actions, which include paralinguistic vocalisations, bodily activity and facial expressions.

Verbal self-report is mostly voluntary, and relies on reflection and deliberation, whereas nonverbal expression is involuntary and reflexive.

Slide 6
But the involuntary transformations revealed in the face are more meaningful than in other body-parts. This is because body-parts do not have the individuating meaning of the face: the meaning of revealing me, here, now. When I observe another’s pain facial expression, I am not perceiving a physical part of him, as I am when I notice his injured arm or leg. I am meeting him, a real person, who reveals himself in the face.

A person may be perceived by his arm, but not in his arm.

Involuntary facial changes show the person with pain “as he really is”, because he does not fully control them.

We express preference for non-verbal behaviour over verbal behaviour when judging or interpreting the credibility of pain displays.

Slide 7
Pain expressed through the face acquires, for us, an individuality, a personality, that readies us for the human encounter.

Not understanding a face means not seeing where it fits into our gallery of portraits, and therefore not knowing how to properly relate to the person whom it prefigures. One study showed that physicians tended to attribute lower levels of pain to physically attractive patients than physically unattractive patients. Another study found that physically attractive and male patients were perceived as experiencing less pain and disability than physically unattractive and female patients. Finally, in another study, observers judging patient facial pain expressions on video perceived older and less physically attractive patients to be of lower overall functioning.

I can decide to enter into another’s pain expression; or I can decide to remain outside it, as it were, and to see it as a thing apart; perhaps more darkly, as something foreign, or subordinate to my will. How we judge a face may affect the outcomes the patient can achieve.

Slide 8
Pain imposes a significant vulnerability on persons: the vulnerability of a free person who is overwhelmed in his or her body by the presence of pain. This can make the person with pain feel answerable for what he or she experiences. Men who adopt a stoical attitude to their pain are less likely to express pain in the presence of others.

The expression on a face is an offering in the world of mutual responsibilities: it projects into our interpersonal relations a particular person’s “being there”. As soon as I notice pain in another person’s face, my responsibilities are engaged. Facial expressions of pain call on you to respond to me.

The face has this meaning for us because it is the boundary at which the other appears, offering “this person” as one in need of help.

Slide 9
However, expressing pain does not always lead to compassionate reactions, and people are careful about when and with whom they express pain.

Voluntary control of pain through facial actions is normally judged to be an insincere expression of pain, and open to doubt. The controlled pain face is perceived as a mask, which conceals the person lying “behind” it. The expressions on the human face are not always transparent effects of the personal experiences that elicit them, as perhaps they are in non-human mammals. Human beings can deceive through their faces, and children and adults can use the face to fake, and amplify, or suppress, pain.

The capacity to modulate pain expressed through the face has led to difficulty in interpreting the meaning of facially expressed pain. The fidelity with which facial signs mean “pain” is limited to a narrow range of involuntary facial expressions of pain. It is often uncertain whether the presence or absence of information means “pain” or, if they are exaggerated or suppressed consistent with perceived situational demands.

Slide 10
If there is a configuration of facial actions that signals pain, then assessing its presence is amenable to pattern recognition technologies. Substantial progress has been made toward the development of IT-based analysis of pain facial expression.

These systems raise ethical questions about control of patient information.
As these IT systems are used in health care settings, informed consent will need to be obtained for collecting and storing patients’ images, but also for the specific purposes for which those images might be analyzed by these systems.

IT systems can store data as a complete facial image or as a facial template. Facial templates are considered biometric data and thus personally identifiable information. The notion that a photo can reveal private health information is relatively new, and privacy regulations and practices are still catching up. Clinicians should advise patients that there may be limited protections for storing and sharing data when using an facial recognition tool.

Pain in the brain is like a melody in music

A flash of lightning produces a single sound. Pain in the brain is not like that. Neurons in the brain can excite or inhibit many other neurons, to which they are connected. Pain is not controlled by a single neuron.

A flash of lightning has no intended direction. But pain in the brain is not like that. The synaptic connections between neurons enable coordinated patterns of activation between millions of interconnected neurons. A type of pain is just a type of activation pattern.

Pain in the brain is not conducted like a symphony orchestra by a single individual. It is more like a free-jazz ensemble whose music is produced by loose and coordinated effort among the ensemble members.

‘Do you try to find the real artichoke by stripping it of its leaves?’ Wittgenstein once said. The same can be said of pain in the brain.

The brain is a causal mechanism to convey pain as a sensation. Pain also conveys to us itself. Pain in the brain is like a melody in music. When we feel a pain, the pain doesn’t convey something else that compounds with the activation patterns in the brain. We get the feeling of a pain because pain just is an activation pattern.

In the absence of a general theory of pain or brain function, metaphor and philosophy serve useful placeholder roles.

It is not obvious that experiences of pain are identical to brain activation patterns. In reply, it is not obvious that an ensemble of human beings could produce exciting jazz music, either.

Computers will soon act like human beings – then what?

One day, artificial thought will be achieved.

An artificially intelligent computer will say, “that makes me happy.”

Will it feel happy? Assume it will not.

Still: it will act as if it did.  It will act like an intelligent human being. And then what?

My hunch is that adult human beings will view intelligent computers as simplified versions of  themselves (child-like). Human children will view them as peers; ‘friendships’ will form between children and intelligent computers.

Why? I am reminded of Wittgenstein’s remark: ‘The human body is the best picture of the human soul’.

Look at this video of ASIMO.

How would you interact with ASIMO? What would your reactions be?

It is also remarkable that ASIMO does not possess any physiology.