Facial expressions of acute pain in 23‐week fetus

Bernardes, Lisandra Stein; Rosa, A.S.; Carvalho, Mariana Azevedo; Ottolia, J; Rubloski, J M; Velloso, A; Silva, V A da; Andrade, Daniel Ciampi de

doi:10.1002/uog.23709

Cited by 6 publications

(10 citation statements)

References 6 publications

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“…Facial expressions (horizontal mouth stretch, open lips, vertical mouth stretch, and brow lowering) were elevated in those fetuses receiving injections compared to controls. As noted above, Bernardes et al demonstrated pain-related facial expressions, comparable to those observed in neonates, during anesthetic puncture of the fetal thigh at 23 weeks gestation ( 2021a ).…”

Section: Behavioral Evidencementioning

confidence: 69%

“…As noted by researchers in 2019, “It is now recognised that the developing motor and sensory systems are able to function long before they have completed their neural maturation” ( Borsani et al 2019 , 225). This has raised growing concern that the necessity of the cortex for pain perception may have been overstated, and that fetal pain perception is possible even with an immature cortex ( Bellieni 2020 ; Bernardes et al 2021a ; Derbyshire and Bockmann 2020 ; Merker 2007 ).…”

Section: Neuroanatomical Evidencementioning

confidence: 99%

“…These indices reflect the earlier development of the upper facial muscles compared to the lower facial muscles. Fetal pain assessments have also been conducted using the NFCS during painful intramuscular injections prior to fetal surgery ( Bernardes et al 2021a , 2021b , 2018 ). Facial expressions (horizontal mouth stretch, open lips, vertical mouth stretch, and brow lowering) were elevated in those fetuses receiving injections compared to controls.…”

Section: Behavioral Evidencementioning

confidence: 99%

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Fetal Pain in the First Trimester

Thill

2021

Linacre Q

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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.

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Section: Behavioral Evidencementioning

confidence: 69%

Section: Neuroanatomical Evidencementioning

confidence: 99%

Section: Behavioral Evidencementioning

confidence: 99%

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Fetal Pain in the First Trimester

Thill

2021

Linacre Q

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“…In the 2010s, researchers determined that the physiologic capacity to perceive pain developed during the second trimester (14–28 weeks), ranging from before ( 23 , 45 ) and after thalamocortical connectivity at 24 weeks ( 34 ). In the 2020s, researchers suggest that the necessity of the cortex in pain perception may have been overestimated ( 4 , 16 , 35 , 46 ). Recent evidence indicates that thalamic projections to the subplate at 12 weeks gestation may be functionally equivalent to thalamocortical connections that develop at 24 weeks gestation ( 4 ), signifying that fetal pain mediated by the subplate and subcortical structures may be possible as early as the first trimester (<14 weeks) ( Figure 4 ) ( 4 , 35 , 36 , 47 ).…”

Section: An Evolving Understanding Of Painmentioning

confidence: 99%

“…Both the fetus and preterm infant <24 weeks gestation have an immature cerebral cortex ( 12 ) and an active, functional cortical sublate ( 13 , 14 ). Both mount hormonal and hemodynamic stress responses ( 6 , 15 ) and demonstrate pain-related facial expressions ( 6 , 16 ) and body movements ( 6 , 15 ) following noxious stimuli. The standard of care for preterm infants, according to the American Academy of Pediatrics, is pain management utilizing validated pain assessment tools.…”

Section: Introductionmentioning

confidence: 99%

The fetal pain paradox

Thill

2023

Front. Pain Res.

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Controversy exists as to when conscious pain perception in the fetus may begin. According to the hypothesis of cortical necessity, thalamocortical connections, which do not form until after 24–28 weeks gestation, are necessary for conscious pain perception. However, anesthesiologists and neonatologists treat age-matched neonates as both conscious and pain-capable due to observable and measurable behavioral, hormonal, and physiologic indicators of pain. In preterm infants, these multimodal indicators of pain are uncontroversial, and their presence, despite occurring prior to functional thalamocortical connections, has guided the use of analgesics in neonatology and fetal surgery for decades. However, some medical groups state that below 24 weeks gestation, there is no pain capacity. Thus, a paradox exists in the disparate acknowledgment of pain capability in overlapping patient populations. Brain networks vary by age. During the first and second trimesters, the cortical subplate, a unique structure that is present only during fetal and early neonatal development, forms the first cortical network. In the third trimester, the cortical plate assumes this function. According to the subplate modulation hypothesis, a network of connections to the subplate and subcortical structures is sufficient to facilitate conscious pain perception in the fetus and the preterm neonate prior to 24 weeks gestation. Therefore, similar to other fetal and neonatal systems that have a transitional phase (i.e., circulatory system), there is now strong evidence for transitional developmental phases of fetal and neonatal pain circuitry.

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