At one time, many doctors and nurses believed that newborn babies couldn’t feel pain. Now we know that even the tiniest babies experience pain. Furthermore, high levels of pain early in life can have lasting effects on the brain development and stress responses of babies born very preterm. This dramatic shift is due in part to the research of BC Children’s Hospital investigator Dr. Ruth Grunau who has dedicated her career to understanding and managing the effects of pain on young babies.

In recognition of her extraordinary contributions to child health, Dr. Grunau received the 2018 Jeffrey Lawson Award for Advocacy in Children’s Pain Relief from the American Pain Society. Dr. Grunau’s research and leadership has led to changes in health policy and clinical practice worldwide to improve the way clinicians recognize and manage pain in the smallest patients.


Dr. Grunau’s accomplishments in her field began during her PhD studies at the University of British Columbia (UBC) when she produced the Neonatal Facial Coding system, a tool to help health care providers recognize infant pain based on facial expression. This work contributed to the growing consensus that newborns do feel pain and has helped health care workers recognize and respond to infants experiencing pain.

Dr. Ruth Grunau

Dr. Grunau went on to conduct pioneering research on the long-term effects of pain on infants born very preterm. When babies are born two to four months early, the rapid brain development that typically happens in the womb takes place in a hospital where they’re experiencing an average of 10 life-saving medical procedures a day. Dr. Grunau’s research has shown that exposure to repetitive pain during such a critical period of brain development and programming of stress systems can have lasting effects on learning and behavior. 

“The medical procedures that very preterm babies undergo are necessary and beneficial,” says Dr. Grunau.

“In my research program, we’re working to understand how pain effects the development of these babies, so we can find ways to reduce any unintended long-term consequences from the life-saving medical care they receive at the beginning of life.”

Roughly eight per cent of babies in Canada are born prematurely, before 37 weeks of pregnancy. Thanks to medical advances over the last several decades, more and more of the tiniest babies born two to four months early survive, however, many experience lifelong health problems including challenges with learning, memory, communication and behavior that can negatively impact their schooling and social relationships.

Dr. Grunau has led multidisciplinary research projects to evaluate the cognitive, social and behavioral development of babies who were born early. After controlling for a number of factors related to prematurity, she and her colleagues found babies exposed to a greater number of painful procedures show changes to brain structure and the regulation of stress hormone levels that can contribute to lower IQ, attention, memory and learning problems, as well as mental health issues. 

Thanks in part to Dr. Grunau’s body of research, health care workers around the world now recognize that managing pain in preterm babies is an important part of their care.

“It’s been my honour to have contributed a major change in the way we understand and respond to pain in preterm babies,” says Dr. Grunau.

“Health care workers in neonatal intensive care units now make an effort to assess and treat pain and ensure babies receive comforting measures like hands-on facilitated tucking and skin-to-skin contact when possible.”

Dr. Grunau continues to study the long-term effects of pain on preterm infants in her research program at BC Children’s. Dr. Grunau and colleagues are currently conducting two studies using MRIs to look at the brains of children who were born very preterm. One study follows babies and the other follows school-age children. Researchers are using these scans, which allow them to quantify and measure how the brain is maturing, to examine how factors related to prematurity and painful procedures effect brain structure and health."

Dr. Grunau is also evaluating different methods of managing infant pain to help doctors provide babies with the most effective, safest relief.

“Medications that calm babies, make them sleepy and relieve their pain can make babies more comfortable,” said Dr. Grunau. “But these drugs might also negatively impact brain development.”

She and her colleagues have found that high doses of morphine and the sedative midazolam are sometimes associated with changes in brain structure that can contribute to developmental delays, while low-dose morphine is safe. Currently studies are underway here at BC Children’s and at SickKids and Mount Sinai Hospital in Toronto aimed at determining which drugs can relieve pain in preterm babies without harming the developing brain.

“We’ve made great advances in our understanding of infant pain, but there’s still much for us to learn about the effects of pain and the best ways to manage it,” says Dr. Grunau. “I’m looking forward to continuing this work so we can find better ways to minimize pain in preterm babies and give them the best chance to grow up healthy.”