PAIN Assessment
Najmeh Ajoodanian, MS, NICU
2014
Pain Perception
• 28 week of gestation
• pain threshold that is 30% to 50% lower
than that of adults
• lower pain tolerance than older children
• Premature infants are even more
hypersensitive to nociceptive
stimuli than full-term infants
Pain . . .
• As the fifth vital sign,
• pain needs to be monitored routinely in
the clinical practice
• infants cannot speak and advocate
Pain . . .
• Pain assessment and measurement
are the cornerstones of pain
management
• The purpose of this review pain
measures in both preterm and full
term newborns by introducing a
conceptual framework
defines pain
The International Association for the
Study of Pain
(IASP)
“an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.”
“Pain is subjective”
FRAMEWORK FOR MEASUREMENT OF
NEONATAL PAIN
Neonatal Pain Responses
• Behavioral
• Physiologic
• Autonomic
• Biochemical
Behavioral Pain Responses
• Facial expression
 cleaning the heel or changing diapers
• Facial expression include:
• facial grimacing, brows bulged and
furrowed
• eye squeezed, nasolabial furrowing,
• lips opened and pursed, cupped tongue,
quivering chin
• agitation.
Crying is a common response to pain in
infants
preterm and acutely ill infants may
not audibly cry during heel sticks and
other painful procedures
silent cry
Observations of gross motor responses
including:
• body movements of arms, legs and trunks,
• Whole body, finger splay and fisting,
• attempts to withdraw from a painful
stimulus
Observation sleep wake alterations
Physiologic Responses
• increases in heart rate, respiratory rate, blood
pressure
• increases intracranial pressure, and palmar
sweating
• decreases in transcutaneous oxygen saturation,
vagal tone, and peripheral blood flow
Autonomic Responses
• changes in skin color, nausea, vomiting,
gagging
• hiccoughing, diaphoresis, palmar
sweating
• dilated pupils
Biochemical Responses
• increased secretion of catecholamines (ie,
norepinephrine and epinephrine), glucagon, and
corticosteroids or cortisol
• decreased prolactin, insulin, and immune
responses
Infant Contextual Parameters in
Pain Assessment
• Age
• Previous pain experiences
• Gender
• Health status
• especially in preterm infants
Health providers’ knowledge, ability, and
attitudes toward neonatal pain are
significant factors in observation, and using
appropriate pain tools to recognize a
neonate’s pain.
PAIN ASSESSMENT TOOLS
1. Unidimensional Tools
2. Multidimensional Tools
Unidimensional Infant Pain Measures
• Designed for measurement of acute/procedural
pain
• MAX: Maximally Discriminative Facial Coding
System
• NFCS: Neonatal Facial Coding System
• IBCS: Infant Body Coding System;
• DAN: Douleur Aiguë du
• BIIP: Behavioral Indicator of Infant Pain
Unidimensional Infant Pain Measures
• Designed for measurement of postoperative pain
•
•
•
•
CSS: Clinical Scoring System
LIDS: Livepool Infant Distress Scale
FLACC: Face, legs, activity, cry, consolability
UWCH: University of Wisconsin Children’s
Hospital Pain Scale
• CHIPPS: Children’s and Infant’s Postoperative
• Pain Scale
Unidimensional Infant Pain Measures
Designed for measurement of prolonged pain
• BPS: Behavioral Pain Score
• EDIN: Echelle Douleur Inconfort Nouveau-Ne
Neonatal Pain and Discomfort Scale
• COMFORTneo: modified from the COMFORT
Multidimensional Infant Pain Measures
Designed for measurement of acute/procedural
pain
•
•
•
•
•
NIPS: Neonatal Infant Pain Scale;
NPAT: Neonatal Pain Assessment Tool
PIPP: Premature Infant Pain Profile
DSVNI: Distress Scales for Ventilated Newborn
Infants
Multidimensional Infant Pain Measures
Designed for measurement of acute/procedural
pain
•
•
•
•
SUN: Scale for Use in Newborns
PAIN: Pain Assessment in Neonates
BPSN: Bernese Pain Scale for Neonates
FANS: Faceless Acute Neonatal Pain Scale
Multidimensional Infant Pain Measures
Designed for measurement of postoperative
pain
• COMFORT Scale (not primarily developed for
neonates
• PAT: Pain Assessment Tool
• CRIES
• MIPS: L Modified Infant Pain
• MAPS: Multidimensional Assessment Pain Scale;
Multidimensional Infant Pain Measures
Designed for measurement of prolonged/ongoing
pain
• N-PASS: Neonatal Pain, Agitation, and Sedation
Scale
Premature Infant Pain Profile
CRIES scale
• C-crying
• R-requires O2
• I-increased VS
• E-expression
• S-sleepless
Simple and easy to use-uses a scale of 1-10,
similar to APGAR scoring
score of 4 or greater requires intervention
objective and behavioral categories
FLACC Scale
• F-face (expression)
• L-legs (tone)
• A-activity
• C-cry
• C-consolability
score is tallied, similar to APGAR (0,1, or 2 for
each category)
greater than 4 is indicative of pain
behaviorally based
Measure
CRIES
Age Level
Crying, requires O2 for saturation,
increased vital signs (HR and BP),
expression, sleepless
Postoperative Pain
Preterm & Full- term neonates
Time to calm, skin color, eyebrow bulge
with eye squeeze, posture, breathing
pattern, heart rate, oxygen saturation
Procedural pain in
neonates with or
without ventilation
Preterm & Full- term neonates
Facial expression, cry, breathing pattern,
arms, legs, state of arousal
Procedural pain
Full- term neonates
Posture, tone, sleep pattern, expression,
color, cry, respiration, heart rate, oxygen
saturation, blood pressure, nurses
perception of infant pain
postoperative pain
Preterm & Full- term neonates
Gestational age, behavioral state, heart
rate, oxygen saturation, brow bulge, eye
squeeze, nasolabial furrow
Procedural and
postoperative pain
Preterm & Full- term infants
Central nervous system state, breathing,
movement, tone, face, heart rate, blood
pressure
Procedural pain
PAT
PIPP
SUN
Pain Stimulus
Preterm & Full- term Up to 60
Weeks gestation age
BPSN
NIPS
Indicator
New Techniques for Pain Measurement
• Heart Rate Variability
• Skin Conductance
• Brain-Oriented Approach
Thank you for your attention
If you have any question contact
to:
ajoodaniyan@yahoo.com
References
 Cong X. Cusson RM. Pain Assessment and
Measurement. Foundations in Newborn Care. 2013;379395
 Kenner C, Lott JW. Comprehensive Neonatal care an
interdisciplinary approach chapter 17: Pain in the
Newborn and Infant . 2010
 Verklan MT, Walden M. Care curriculum for Neonatal
intensive care unit 2010