Making Sense: The healing power of touch
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Listen to our latest episode, Anna, wherever you get your podcasts. All knowledge must come through the senses. All that we perceive and all of the awareness of our daily existence. Light. Double rainbow. Oh my God. Sound. Listen to me. Listen to me. Touch. Squeezes. Odors. Ew. And tastes. Mmm. Mmm.

What are your thoughts concerning the human senses? As meat and wine are nourishment to the body, the senses provide nutriment to the soul. All that we perceive, see, all the awareness, hearing, all knowledge must come through the senses. I have an incredible sense of touch. We perceive, tasting, all the awareness, smelling, all knowledge must come through the senses. Doesn't make sense. Scenery lawful.

It's unexplainable. I'm Noam Hassenfeld. And this is episode two of Making Sense, our series on some of the most perplexing questions about our senses. Last week, we talked about the way our brain actually creates a lot of what we think we're hearing. This week, science editor Brian Resnick examines the elusive sense of touch and its evil twin, pain.

And just a heads up before we start, this episode discusses painful experiences that happen to infants. Okay, here's Brian.

I've been talking to Naomi Rendina. She's a researcher. She has a PhD in medical history. But I wanted to ask her about her own medical history. I wanted her to tell me a story from 13 years ago when she was pregnant. Warning on this one, I make no promise I don't burst into tears at some point in this. It was her first pregnancy. She was really excited. I spent my whole life

imagining what it was going to be like to be pregnant and what it was going to be like to be a mom. At 30 weeks, as scheduled, she went in for a checkup with her doctor. And her doctor noticed that her blood pressure was really high. So they ran some tests and

They really quickly discovered a lot of things were going wrong all at once. Things with her heart, with her liver. It went very quickly from a very healthy, very normal pregnancy to a very dangerous, very scary pregnancy. Her life was at risk, and so she went to a nearby hospital. And I called my mom, and I said, Mommy. And my mom knows that that's... I only call her and say, Mommy, when something's wrong.

Doctors needed to save Naomi's life, and the only solution was to deliver the baby more than two months early. So Naomi was taken in for an emergency C-section. So she came out, butt to the world, and I did get to hear her first cry. And it sounded like the tiniest little kitten. It was so tiny, but it was there. She had it. She took that breath. She made that effort, and she cried.

Naomi's daughter was alive, but she was also really small and really weak. So the doctor sent Naomi's daughter to the NICU.

That's the neonatal intensive care unit. And she stayed there for 92 days. And, you know, while she didn't need any large invasive surgeries, it wasn't necessarily an easy experience. Every day there were these pricks and prods, blood drawn from the baby's heel, lots of IVs placed into her veins. And they do this really terrifying exam of like,

pull down the eyelid and like push on the eyeball. It's really strange and it looks like it's really like painful and it's barbaric. But I remember, you know, the ophthalmologist being like, it doesn't cause any pain. Doctors kept telling her this. What her baby was feeling wasn't pain, maybe something like sensory overload. But Naomi could sense whatever this experience was, it was potentially going to have a long-term effect on her baby.

Someone somewhere knows enough that there are psychological consequences of the NICU on these infants and toddlers and school-aged kids that we'll never know because they're not able to articulate, "I'm scared because I remember whatever." The reality here is that pain is really hard to recognize and hard to treat in anyone, even adults. For babies in the NICU, the challenges are even greater.

This is a story about those challenges. It's about how you figure out if an infant is even in pain and whether or not it's possible to treat it. Let's start with some basic definitions here because pain is super tricky to describe. First of all, it is part of our sense of touch. This all starts in our skin, in our muscles, like everywhere throughout our bodies. There are these receptors, one's for touch, one's for pain.

These are the doorways through which forces from the outside world enter our nervous systems. There's no one doorway. There's all sorts of them. There's one for light touch, like the graze of a finger against your arm. Then there are even different doorways for heat and cold.

But ultimately, pain is something that is an experience. Like it happens in the brain. And the brain can do so much to pain. It can lower the volume on it. It can amp it up. You know, if we're anxious or scared, painful things can actually feel more painful. If we're distracted and happy, like sometimes they don't hurt as much.

So when it comes to adults, everything already about the system is hard and complicated. But for preterm infants like Naomi's daughter, it's even harder. So the central dilemma is how to recognize pain in these babies because they can't talk and tell us.

what they're experiencing. This is Terri Ender. She's the chair of pediatric newborn medicine at Brigham and Women's Hospital in Boston. And she says in the last century that there has been a lot of incredible progress in neonatal science and care. It used to be that a lot of children born more than a month early would die, and now most all of them survive. But really, amid all that progress, pain was overlooked.

Doctors knew that these preterm infants had the nerves to sense pain, but they didn't think the brain had been developed enough to experience it. They see it almost like a blob of clay that isn't got the same degree of integrity and experience and capacity to feel and experience and know and have ideas about

And so this was very much the case for the premature baby who was believed right through even into the 80s to not experience pain because they weren't fully developed. So just to pause on something here, this conversation about how developed or not developed a preterm baby's brain is can quickly get near conversations about fetuses or what this means for the abortion debate.

The healthcare professionals I spoke to saw the experiences of these preterm babies as separate. They're outside of the womb. They're developing brains or experiencing things that are just very different from what happens inside of the womb.

And up until the 80s, these babies in the NICU just dealt with a lot. Surgical procedures such as open heart surgery were done without any anesthesia or pain relief during this period because it was believed the baby didn't experience any pain. Other researchers told me that maybe doctors, this was just a story they told themselves to put themselves at ease. They just didn't want to feel like they were hurting preterm babies, but

Whatever the reason was, it became clear that it was just incorrect. The turning point really came from the observations of a pediatric anesthesiologist who noted that during these open chest cardiac procedures that were done on these babies without any anesthesia or pain relief, the heart rate went up dramatically. And it wasn't just the heart rate.

He began also measuring other markers of stress hormones and showed that indeed there were these dramatic rises in stress hormones indicating the baby indeed was experiencing distress. This was in the late 70s, early 80s. And I hate to say that that evolution of knowledge and understanding is still in progress.

But one thing they have learned is that in some ways, the pain these preterm infants feel might even be worse than what adults feel.

They can't localize the pain in the same way that we can as mature adults. So a heel prick on the back of the heel can feel as though it's coming somewhere from the whole foot or even the leg. A sharp pinch isn't a sharp pinch, but a widespread ache. It's a much more diffuse and impactful kind of pain.

This type of pain just really isn't easy to treat with powerful drugs like opioids, which also can be dangerous, especially for young, fragile infants. Even options like Tylenol or Advil can be harmful too. They can be dangerous for the kidneys and liver. So the preterm babies are just left experiencing a lot of repeated painful things. The average premature baby will go through...

at least 10 to 12 unpleasant or painful experiences every 24 hours for the first four weeks of life.

They include placing IV lines and even tubes into the stomach and through the nose and mouth. Blood tests, which are often done several times a day, either by a heel stick or by a venipuncture. They can also include things that maybe don't seem painful but are still distressing. Like the baby could just be like really uncomfortable in the position it's laying in.

Or like they could be prodded or pricked by a nurse in an uncomfortable way that leaves an indenture on their skin. And so these things are all pretty invasive to the babies and we know do cause experiences of distress.

It's not about any one single instance of pain. The problem here is that babies are experiencing just a large volume of pain repeated over time. And that might be bad for brain development. Those last weeks a baby would be in the womb are just hugely important for brain growth. Your brain goes from being completely smooth to being complexly folded, just like the adult brain. And so this period is very sensitive.

to any environmental influences. Studies here have found that no matter if a preterm baby in the NICU is really sick or really healthy, that there's a correlation here. The more painful things they experience in those last 12 weeks, the more changes scientists start to see in their brain development. And what we see is smaller hippocampi, the memory area,

smaller amygdala with different types of connections, which is the area for emotional processing. We see alterations in the cerebellum, which is a critical area for language and motor development.

These are all very important regions for later childhood and adult brain functioning. Other studies have shown that the psychological consequences of those changes, those can appear when the preterm infants grow up.

So they're more likely to have lower general IQ, lower language functioning, and particularly they have more what we call dysregulation. So poorer attention, poor ability to kind of regulate emotionally, and they're much more likely to be anxious. Just really all summed up here, this evidence suggests that these repeated painful experiences become some type of lasting psychological injury.

just like Naomi feared. But there is some hope here. Terry says that even though drugs aren't a great option for treating preterm infants, there are all these non-drug tools that could make the NICU just less painful and also help protect these developing brains. We have the privilege to hopefully make a lifetime of difference. After the break, how a parent's loving touch might be just what the doctor ordered.

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And so you reach the delivery room, ready to deliver your... Unexplainable. We're back. I'm Brian Resnick. Before the break, we were talking about the pain that preterm infants likely feel when they're in the NICU. But to talk about how to treat that pain, I reached out to Mats Eriksson. I'm a specialist nurse in intensive care nursing.

So I used to work in the NICU for 30 years now. Today, Mats leads this research group in Sweden, and they're trying to learn how to better treat pain in NICU babies to prevent some of the consequences down the line. At least, that's the hope. Yeah, you need to have hope. Otherwise, I would not do this. Mats' story starts in the 1980s. He was a young NICU nurse then, and there was just a part of the job he hated.

The worst thing in my job was to take the metabolic test that we did on every child. The test involves drawing blood from the preterm baby's foot, and you have to squeeze their heel to collect enough. It was just hard to do and hard to watch. Yeah, the children were crying. The mothers almost fainted. I was sweaty all over. So it was a really tough job for everyone, and we had nothing to offer. Because in those days, we did not believe that

They could feel pain. We could see it, of course, but science said no. But instead of just getting frustrated, Matz was inspired. They started to

try new methods to alleviate pain. Powerful drugs like opioids just weren't great options. So Matt's approach was just to first try simple solutions. I started my research with testing sweet solution, glucose, as a pain relief. A spoonful of sugar does help the medicine go down. It works very well, actually. And I told you about those children I was stabbing in the heel when I started as a nurse.

And when you give them sugar, they don't react anymore. The hard work has been to try to explain why this works. And nobody actually has. But regardless of how it works, this sugar thing, it's not the perfect solution. Emma Olson, she's a nurse and researcher who works alongside Matt's.

she says there's also risks for using it. Some studies have showed a tendency that very small infants that have received very, very, very many doses of glucose during their time at the NICU seem to have a bit negative effects on the cognitive development. So while there is a place for glucose in treating pain, Emma prefers an even simpler and more potentially powerful idea.

Managing pain with parents, and specifically, using parents' touch. So, skin-to-skin contact. Putting preterm babies directly on their parent before doing something painful. I'm always sounding religious here, but when you draw blood from an infant who is laying on their mother or father...

And you don't see any reaction on the infant. That doesn't happen all the time. But when it happens, it feels very good. Sometimes this approach is called kangaroo care. And these aren't super rare practices. They're not some Swedish secrets.

But the course of treatment the Swedish researchers advocate for is just much, much more involved than what happens in the U.S. Touch from a non-family member just doesn't seem to work as well. The parents need to be around 24-7 in the NICU to help with pain management. The ideal NICU is where you have the incubator to the left and the parent bed to the right.

When I started working in pediatric care, then you thought small children, small rooms, no problem. But I mean, probably you need small children, even bigger rooms, because if you have a bed for the mother, maybe room for siblings, etc. And all the equipment.

In my 20 years at NICU, I've gone from being the one taking care of the infant to guiding the parents and teaching them how to take care of their own infant. And that's like it should be.

Just listening to Mats and Emma describe this Swedish approach, it's just so hard to imagine it working in the U.S. NICU stays can last months, and parents just can't always stay there the whole time. They might not be able to get the medical or parental leave from work, or they could have other children to take care of. And this is especially true for women of color and low-income women.

And they have some of the highest rates of preterm birth in America and also the least access to insurance and generous leave, which just makes this problem worse. But in Sweden, the government actually steps in and helps the parents out. So both parents get paid, right?

to be with the infant in the NICU. And that goes for the whole NICU stay. They don't have to take their original parental leave. That kicks in when the infant is at home. Where I understand in the US, for example, the parents can't be with their infant 24-7 because they don't have the parental benefits that we have, which I think is so sad. This method seems to really work.

And this is not just from anecdotal evidence. There are a lot of research that shows that it works. I've done one study where I compared drawing blood on the infant when they were in the incubator compared to when they were skin-to-skin.

It's really hard to measure pain objectively in infants. And this is a big hurdle in all this research, because if you can't measure pain, how do you know if the treatment is working? But there are some new tools here that look at the brain directly, and Emma used those here. They suggested that when the babies were on their parents, they were in less distress.

So the hope here is that relieving pain in the moment will also help minimize some of those long-term brain development effects later on. If we treat the pain here and now, I would hope that that means that we will treat some of the negative consequences of the pain later in life. But I don't have any scientific proof.

So even though scientists know that skin-to-skin contact works, they're really not totally sure how it works. They're not sure which of those complicated touch pathways it intervenes on. For now, they're just going with a pretty simple explanation. I think we all feel better with human touch. Skin-to-skin makes you feel very close to someone, either if it's holding hands or just being near someone.

I think it's just how we are programmed. There are just so many nerve endings on the skin. So many doorways to introduce a pleasant feeling into your body, to distract from or even override the pain. Think of yourself if you have a toothache or if you have a problem. If someone holds your hand or someone pats your back or gives you a hug, that relieves actually.

Gentle human touch can be very good. And for the premature infant, this touch is really as close as they can get to being back in the womb. You're feeling your mother or father breathing. You're snugged up because you put something over them. Is it too corny to say this is the healing power of touch? Or do you not see it like that? That's a phrase that we use sometimes. Yeah, so I would say that's what it is.

Throughout my reporting, I found there is a lot of frustration here with the state of pain management in the NICU. But there's also just so many things to feel good about. When I asked Terri Ender what she hoped people would take away from this story, she said she hoped that people just don't feel despondent that babies are suffering. She wants them to know how resilient they can be. Naomi's baby is one of these resilient babies. She turned 13 last week.

She is a delightful young woman. She is smart. She's adventurous. She's beautiful. She's kind. She's perfect. I'm only a little biased. Her daughter still does have some scars from NICU needles. But to Naomi, these scars aren't about pain. They're about resilience. I showed her last week the ones on her hand and reminded her that anytime that she, um,

has any sort of doubt about herself or doubts of her capability to look at her hand. And those little scars are there to remind her that she's capable more than she'll ever even understand. Because those are her scars of her time in the NICU and her reminders that she's my hero. This is episode two of our Making Sense series. Next week, episode three, Smell.

Dogs can smell all kinds of diseases like cancer, Parkinson's, even COVID. But can scientists build a robot nose that can do even better? I have just over $100 million worth of equipment. And it kind of pisses me off that a lowly dog can do better than $100 million worth of equipment. Something's off with that picture. I shouldn't be able to do this.

After smell, we've got some more sense mysteries, like how many tastes there might be, why some people can't visualize images, and even a sixth sense.

This episode was reported by Brian Resnick and produced by me, Brid Pinkerton. It was edited by Catherine Wells, Meredith Hodnot, and Noam Hassenfeld, who also wrote the music. Christian Ayala handled the mixing and sound design with an ear from Afim Shapiro. Richard Sima checked the facts. Tori Dominguez is our audio fellow. And Manding Nguyen's pigeon now has a name, Sunny. Thanks to Rebecca Slater as well for her time and her help.

To read more about The Senses or to read our show transcripts, go to vox.com slash unexplainable. And if you have thoughts about the show, you can always email us. We're at unexplainable at vox.com. Or you could also leave us a review or rating, which we would love to. Unexplainable is part of the Vox Media Podcast Network. And someone who knows told me we'll be back with episode three of our Sense series next week.