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Klin Padiatr 2012; 224(05): 291-295
DOI: 10.1055/s-0031-1301328
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

The Flexion Withdrawal Reflex Reveals an Increasing Threshold during the First Year of Life and is Influenced by the Infant’s State of Consciousness

Der Wegziehreflex zeigt einen Anstieg der Reizschwelle innerhalb des ersten Lebensjahres und wird vom Bewusstseinszustand des Kindes beeinflusst
B. Kühne
1   Childrens’ Hospital, Department of Neonatology and Paediatric Intensive Care, University of Cologne, Germany
,
H. Stützer
2   Institute for Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
,
B. Roth
1   Childrens’ Hospital, Department of Neonatology and Paediatric Intensive Care, University of Cologne, Germany
,
L. Welzing
1   Childrens’ Hospital, Department of Neonatology and Paediatric Intensive Care, University of Cologne, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
17 April 2012 (online)

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Abstract

Background:

The idea that preterm and term infants are capable of experiencing pain is now widely accepted. However, there is still insufficient knowledge how pain perception develops throughout infancy. A promising approach to quantify the level of spinal excitability in infants is to measure cutaneous sensitivity by the flexion withdrawal reflex (WR). In our study we wanted to test how the threshold of the WR develops in healthy infants during the first year of life. Furthermore, we aimed to analyse the impact of the state of consciousness on the reflex threshold.

Patients and Method:

In 44 healthy infants we tested the threshold of the WR with calibrated von-Frey-Filaments at the age of 3 days as well as with 4, 12, 26 and 52 weeks. To analyse the influence of the state of consciousness on the reflex threshold, we documented at 12, 26 and 52 weeks whether the infants were quietly awake or lightly asleep during testing.

Results:

The median threshold of the WR increased during the first year of life from 1.2 g up to 4.6 g at the age of 1 year. At 12, 26 and 52 weeks we found significantly lower thresholds in sleeping infants compared to infants being awake (p=0.004, p<0.001 and p=0.086, respectively).

Conclusion:

The threshold of the flexion withdrawal reflex increases during infancy, probably reflecting neuronal maturation processes in the first year of life. Besides postnatal age, the threshold of the WR also depends on the state of consciousness. Therefore, future studies about the WR should consider postnatal age as well as the state of consciousness.

Zusammenfassung

Hintergrund:

Es ist mittlerweile unbestritten, dass sowohl reife Neugeborene als auch Frühgeborene Schmerzen empfinden können. Insgesamt ist die Entwicklung der Nozizeption im Verlauf des Säuglingsalters jedoch noch unzureichend geklärt. Ein vielversprechender Ansatz zur Quantifizierung der spinalen Erregbarkeit von Säuglingen ist dabei die Messung des kutanen Wegziehreflexes (WR). In der vorliegenden Studie wollten wir longitudinal untersuchen, wie sich der Schwellenwert zur Auslösung des WR bei gesunden Säuglingen im Verlauf des ersten Lebensjahres verändert. Weiterhin war es unser Ziel, den Einfluss vom Bewusstseinszustand auf die Reizschwelle des WR zu analysieren.

Patienten und Methodik:

Wir untersuchten an 44 gesunden Säuglingen mittels kalibrierter von-Frey-Filamenten die Reizschwelle zur Auslösung des WR im Alter von 3 Tagen, 4, 12, 26 und 52 Wochen. Um den Einfluss des Bewusstseinszustandes auf die Reizschwelle zu analysieren, dokumentierten wir im Alter von 12, 26 und 52 Wochen, ob die Kinder während der Untersuchung schliefen oder im ruhigen Wachzustand waren.

Ergebnisse:

Die mediane Reizschwelle des WR stieg im Verlauf des ersten Lebensjahres von 1,2 g bis auf 4,6 g im Alter von 12 Monaten. Im Alter von 12, 26 und 52 Wochen fanden sich signifikant niedrigere Reizschwellen bei schlafenden Kindern im Vergleich zu wachen Kindern (p=0,004, p<0,001 bzw. p=0,086).

Schlussfolgerung:

Die Reizschwelle des WR nimmt im Säuglingsalter zu, was ein Hinweis für neuronale Reifungsprozesse der Schmerzwahrnehmung im Verlauf des ersten Lebensjahres darstellt. Neben dem postnatalen Alter wird die Reizschwelle des WR auch vom Bewusstseinszustand beeinflusst. Zusammenfassend müssen zukünftige Studien bei der Verwendung des WR daher sowohl das postnatale Alter als auch den Bewusstseinszustand der Kinder berücksichtigen.

Key words

infants - pain measurement - flexion withdrawal reflex - von-Frey-Filaments - state of consciousness

Schlüsselwörter

Säuglinge - Schmerzmessung - Wegziehreflex - von-Frey-Filamente - Bewusstseinszustand

Supplementary Material

 

  • References

  • 1 Abdulkader HM, Freer Y, Fleetwood-Walker SM et al. Bodily progression of motor responses to increasing mechanical force stimulation in the newborn infant and the effect of heel prick. Neonatology 2008; 94: 38-44
    CrossrefPubMedGoogle Scholar
  • 2 Abdulkader HM, Freer Y, Garry EM et al. Prematurity and neonatal noxious events exert lasting effects on infant pain behaviour. Early Hum Dev 2008; 84: 351-355
    CrossrefPubMedGoogle Scholar
  • 3 Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior?. Biol Neonate 2000; 77: 69-82
    CrossrefPubMedGoogle Scholar
  • 4 Andrews K, Fitzgerald M. The Cutaneous Withdrawal Reflex in Human Neonates – Sensitization, Receptive-Fields, and the Effects of Contralateral Stimulation. Pain 1994; 56: 95-101
    CrossrefPubMedGoogle Scholar
  • 5 Andrews KA, Desai D, Dhillon HK et al. Abdominal sensitivity in the first year of life: comparison of infants with and without prenatally diagnosed unilateral hydronephrosis. Pain 2002; 100: 35-46
    CrossrefPubMedGoogle Scholar
  • 6 Andrews K, Fitzgerald M. Cutaneous flexion reflex in human neonates: a quantitative study of threshold and stimulus-response characteristics after single and repeated stimuli. Dev Med Child Neurol 1999; 41: 696-703
    CrossrefPubMedGoogle Scholar
  • 7 Babinski J. Sur le réflexe cutané plantaire dans certaines affections organiques du système nerveux central. C R Soc Biol 1896; 48: 207-208
    PubMedGoogle Scholar
  • 8 Chiou YB, Blume-Peytavi U. Stratum corneum maturation. A review of neonatal skin function. Skin Pharmacol Physiol 2004; 17: 57-66
    CrossrefPubMedGoogle Scholar
  • 9 Fitzgerald M, Millard C, MacIntosh N. Hyperalgesia in premature infants. Lancet 1988; 1: 292
    Google Scholar
  • 10 Fitzgerald M, Shaw A, MacIntosh N. Postnatal development of the cutaneous flexor reflex: comparative study of preterm infants and newborn rat pups. Dev Med Child Neurol 1988; 30: 520-526
    PubMedGoogle Scholar
  • 11 Fitzgerald M, Millard C, McIntosh N. Cutaneous hypersensitivity following peripheral tissue damage in newborn infants and its reversal with topical anaesthesia. Pain 1989; 39: 31-36
    CrossrefPubMedGoogle Scholar
  • 12 Fitzgerald M, Butcher T, Shortland P. Developmental changes in the laminar termination of A fibre cutaneous sensory afferents in the rat spinal cord dorsal horn. J.Comp Neurol 1994; 348: 225-233
    CrossrefPubMedGoogle Scholar
  • 13 Fitzgerald M. The development of nociceptive circuits. Nat Rev Neurosci 2005; 6: 507-520
    CrossrefPubMedGoogle Scholar
  • 14 Fujiki A, Shimizu A, Yamada Y et al. The Babinski reflex during sleep and wakefulness. Electroencephalogr Clin Neurophysiol 1971; 31: 610-613
    PubMedGoogle Scholar
  • 15 Grimby L, Kugelberg E, Lofstrom B. The plantar response in narcosis. Neurology 1966; 16: 139-144
    CrossrefPubMedGoogle Scholar
  • 16 Hathway GJ, Koch S, Low L et al. The changing balance of brainstem-spinal cord modulation of pain processing over the first weeks of rat postnatal life. J Physiol 2009; 587: 2927-2935
    CrossrefPubMedGoogle Scholar
  • 17 Holmberg H, Schouenborg J. Postnatal development of the nociceptive withdrawal reflexes in the rat: a behavioural and electromyographic study. J Physiol 1996; 493: 239-252
    PubMedGoogle Scholar
  • 18 Huppertz-Kessler CJ, Verveur D, Pöschl J. To what Degree Does the NICU Environment Influence Neurodevelopment of Preterm Infants?. Klin Padiatr 2010; 222: 236-242
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Hünseler C, Roth B. Pharmacologic and Non-Pharmacologic Pain-Therapy in Neonatology: Synopsis of the Current Data. Klin Padiatr 2008; 220: 224-237
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Lenard HG, von Bernuth H, Prechtl HF. Reflexes and their relationship to behavioural state in the newborn. Acta Paediatr Scand 1968; 57: 177-185
    CrossrefPubMedGoogle Scholar
  • 21 Lidow MS. Long-term effects of neonatal pain on nociceptive systems. Pain 2002; 99: 377-383
    CrossrefPubMedGoogle Scholar
  • 22 Mellor DJ, Diesch TJ, Gunn AJ et al. The importance of ‘awareness’ for understanding fetal pain. Brain Res Brain Res Rev 2005; 49: 455-471
    CrossrefPubMedGoogle Scholar
  • 23 Pöschl J, Kölker S, Bast T et al. Gamma-Hydroxybutyric Acid Sedation in Neonates and Children Undergoing MR Imaging. Klin Padiatr 2007; 219: 217-219
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Schmidt B, Adelmann C, Stützer H et al. Comparison of sufentanil versus fentanyl in ventilated term neonates. Klin Padiatr 2010; 222: 62-66
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Stevens B, McGrath P, Gibbins S et al. Procedural pain in newborns at risk for neurologic impairment. Pain 2003; 105: 27-35
    CrossrefPubMedGoogle Scholar
  • 26 Vlach V. Evolution of skin reflexes in the first years of life. Dev Med Child Neurol 1989; 31: 196-205
    PubMedGoogle Scholar