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Neonatal Procedural Pain and Preterm Infant Cortisol Response to Novelty at 8 Months
* Centre for Community Child Health Research, British Columbia Research Institute for Children’s & Women’s Health, Vancouver, British Columbia, Canada
Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
Department of Anatomy and Cell Biology, University of British Columbia, Vancouver, British Columbia, Canada
Objectives. Stress systems may be altered in the long term in preterm infants for multiple reasons, including early exposure to procedural pain in neonatal intensive care. This question has received little attention beyond hospital discharge. Stress responses (cortisol) to visual novelty in preterm infants who were born at extremely low gestational age (ELGA; 
28 weeks), very low gestational age (VLGA; 29–32 weeks), and term were compared at 8 months of age corrected for prematurity (corrected chronological age [CCA]). In addition, among the preterm infants, we evaluated whether cortisol levels at 8 months were related to neonatal exposure to procedural pain and morphine in the neonatal intensive care unit.
Methods. Seventy-six infants, 54 preterm (32 weeks’ GA at birth) and 22 term-born infants who were seen at 8 months CCA composed the study sample, after excluding those with major sensory, motor, or cognitive impairment. Salivary cortisol was measured before (basal) and 20 minutes after introduction of novel toys (post 1) and after developmental assessment (post 2).
Results. Salivary cortisol was significantly higher in ELGA infants at 8 months, compared with the VLGA and term groups before and after introduction of visual novelty. Term-born and VLGA infants showed a slight decrease in cortisol when playing with novel toys, whereas the ELGA group showed higher basal and sustained levels of cortisol. After controlling for early illness severity and duration of supplemental oxygen, higher basal cortisol levels in preterm infants at 8 months’ CCA were associated with higher number of neonatal skin-breaking procedures. In contrast, cortisol responses to novelty were predicted equally well by neonatal pain or GA at birth. No relationship between morphine dosing and cortisol response was demonstrated in these infants.
Conclusions. ELGA preterm infants show a different pattern of cortisol levels before and after positive stimulation of visual novelty than more maturely born, VLGA preterm and term-born infants. Exposure to high numbers of skin-breaking procedures may contribute to "resetting" basal arousal systems in preterm infants.
Key Words: pain • stress • premature infants • novelty • cortisol • morphine
Abbreviations: HPA, hypothalamic-pituitary-adrenal • NICU, neonatal intensive care unit • ELGA, extremely low gestational age • VLGA, very low gestational age • SNAP-II, Score for Neonatal Acute Physiology II • CCA, corrected chronological age
Received for publication Aug 29, 2003; Accepted Feb 11, 2004.
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