Pain-specific Reactions or Indicators of a General Stress Response?: Investigating the Discriminant Validity of 5 Well-established Neonatal Pain Assessment Tools

Development of the neonatal pain response variable set: a mixed methods consensus process

While over 40 neonatal pain assessment scales have been published, owing to a lack of consensus and standardized metrics, there are more than 100 assessment indicators with varying descriptors and quality differences. This study aims to reach a consensus on optimal and comprehensive variables for neonatal pain assessment, leading to the development of a multidimensional neonatal pain response variable set. This study consisted of three phases: (1) A literature review was conducted to identify influencing factors and assessment indicators of neonatal pain response. (2) Panel meetings involving neonatal healthcare professionals evaluated and screened factors and indicators to develop an initial draft of the variable set. (3) Through two rounds of Delphi study achieved consensus, and determined the neonatal pain response variable set. Through a literature review and a panel meeting, the identified factors and indicators were categorized into contextual, physiological, and behavioral variables, forming an initial draft of the variable set. Sixteen professionals participated in two rounds of the Delphi study, with response rates exceeding 70%, and authority coefficients surpassing 0.7 in both rounds. The final iteration of the variable set includes 9 contextual variables, 2 physiological variables, and 5 behavioral variables.   Conclusion: Neonatal pain response variable set developed in this study is scientific, comprehensive, and multidimensional, aligning with the characteristics of neonatal pain response and clinically applicable. The inclusion of contextual variables enhances the ability to confront the complexity of clinical environments and individual differences. It can provide a practical and theoretical basis for clinical research on neonatal pain assessment. What is Known: • Neonatal pain assessment relies on scales used by healthcare professionals currently. But there is no "gold standard" for neonatal pain assessment. • While over 40 neonatal pain assessment scales have been published, owing to a lack of consensus and standardized metrics, there are more than 100 assessment indicators with varying descriptors and quality differences. Most of scales overlook the clinical environment complexity individual differences in pain responses, diminishing the accuracy and applicability. What is New: • In addition to the commonly used physiological and behavioral variables in the scales, we have incorporated contextual variables to better address the complexity of clinical environments and individual differences in pain responses. • Through an evidence-based approach, developed a neonatal pain response variable set comprising 9 contextual variables, 2 physiological variables, and 5 behavioral variables.

Validity and Reliability of Pain and Behavioral Scales for Preterm Infants: A Systematic Review

OBJECTIVE

To systematically review the instruments used to assess behavior, stress, and/or pain in preterm newborns in the neonatal intensive care unit (NICU) and verify the validity and reliability of these instruments.

DATA SOURCES

Electronic searches were conducted in PubMed/MEDLINE, Cochrane Library, Web of Science, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature on Health Sciences (LILACS), and EBSCOhost Research Platform. 12,295 records were found.

REVIEW/ANALYSIS METHODS

37 studies met the inclusion and exclusion criteria.  The COnsensus-based Standards for selecting health Measurement INstruments (COSMIN) checklist was used to assess the quality assessment and measurement properties.

RESULTS

We identified 25 scales that assessed behavior, pain, and/or stress in preterm newborns. The Behavioral Indicators of Infant Pain (BIPP), Crying, Requires Oxygen, Increased Vital Signs, Expression, Sleeplessness (CRIES), Premature Infant Pain Profile (PIPP), and Premature Infant Pain Profile-Revised (PIPP-R) had scored "very good" in quality data. The PIPP and PIPP-R scales received the "very good" classification in validity assessment. The Evaluation Enfant Douleur (EVENDOL), Children's and Infants Postoperative Pain Scale (CHIPPS), PIPP-R, Neonatal Pain Agitation and Sedation Scale (N-PASS), Bernese Pain Scale for Neonates (BPSN), Faceless Acute Neonatal Pain Scale (FANS), BIIP, and Pain Assessment Scale for Preterm Infants (PASPI) obtained an assessment classified as excellent on reliability, both for inter-rater reliability and internal consistency, and the BPSN demonstrated a very strong value to intra-rater reliability.

CONCLUSIONS

Considering the assessments of inter-rater reliability, internal consistency, and quality of scales by COSMIN, the BIPP, and PIPP-R, were the scales considered appropriate.

The physiology, assessment, and treatment of neonatal pain

Studies have clearly shown that development of pain receptors starts as early as 20-weeks' gestation. Despite contrary belief, the human fetus develops a similar number of receptive pain fibers as seen in adults. These receptors' maturation is based on response to sensory stimuli received after birth which makes the NICU a critical place for developing central nervous system's pain perception. In practice, the assessment of pain relies mostly on bedside staff. In this review we will discuss the various developing features of pain pathways in the neonatal brain and the modification of pain perception secondary to various interactions immediately after birth. We also discuss the various tools utilized in the NICU for pain assessment that rely on physiological and behavioral patterns. Finally, we address the management of pain in the NICU by either pharmacological or non-pharmacological intervention while highlighting potential benefits, disadvantages, and situations where one may be preferred over another.

Sensorial saturation improves infants' procedure-related pain behaviour in the cardiac intensive care unit: A quasi-experimental study

BACKGROUND

Painful procedures are unavoidable when providing critical care to infants in intensive care units. These adverse experiences during infancy can lead to later hyperalgesia and poor neurodevelopmental outcomes. Thus, appropriate interventions are required to relieve infant pain during these procedures.

OBJECTIVES

This study evaluated the effectiveness of sensorial saturation in reducing pain for infants during jugular central venous catheter removal procedures in intensive care units.

METHODS

This study involved a quasi-experimental, repeated-measures design. Data were collected from participants sequentially recruited from April to June 2019 (control period) and July to September 2019 (experimental period). Participants included 78 infants younger than 1 year with congenital heart disease. The control group (n = 38) received a general nursing intervention using swaddling, a common child-care practice that consists of wrapping infants to restrict movements, whereas the experimental group (n = 40) received sensorial saturation using oral sugar, body massage, and verbal interaction. Infants' physiological reactions to procedural pain were measured by changes in heart rate, oxygen saturation, and respiratory rate. Infants' procedural pain and behavioural indicators were measured using the Modified Behavioural Pain Scale. Data were analysed using descriptive statistics, independent t-tests, χ² tests, and repeated-measures analysis of variance.

RESULTS

Compared with the control group, the experimental group had lower heart rates (F = 53.15, p < .001), respiratory rates (F = 15.19, p < .001), and behavioural pain scores (F = 45.21, p < .001), both during and after the procedure.

CONCLUSIONS

Sensorial saturation can be used as a nursing intervention in infants. Given the many invasive procedures that are part of infant clinical care, sensorial saturation may be a safe analgesic alternative. The findings of this study could lead to the development of evidence-based clinical practice guidelines for the nonpharmacological management of acute pain in infants.

Neonatal pain assessment: Do we have the right tools?

BACKGROUND

The assessment and management of neonatal pain is crucial for the development and wellbeing of vulnerable infants. Specifically, neonatal pain is associated with adverse health outcomes but is often under-identified and therefore under-treated. Neonatal stress may be misinterpreted as pain and may therefore be treated inappropriately. The assessment of neonatal pain is complicated by the non-verbal status of patients, age-dependent variation in pain responses, limited education on identifying pain in premature infants, and the clinical utility of existing tools.

OBJECTIVE

We review research surrounding neonatal pain assessment scales currently in use to assess neonatal pain in the neonatal intensive care unit.

METHODS

We performed a systematic review of original research using PRISMA guidelines for literature published between 2016 and 2021 using the key words "neonatal pain assessment" in the databases Web of Science, PubMed, and CINAHL. Fifteen articles remained after review, duplicate, irrelevant, or low-quality articles were eliminated.

RESULTS

We found research evaluating 13 neonatal pain scales. Important measurement categories include behavioral parameters, physiological parameters, continuous pain, acute pain, chronic pain, and the ability to distinguish between pain and stress. Provider education, inter-rater reliability and ease of use are important factors that contribute to an assessment tool's success. Each scale studied had strengths and limitations that aided or hindered its use for measuring neonatal pain in the neonatal intensive care unit, but no scale excelled in all areas identified as important for reliably identifying and measuring pain in this vulnerable population.

CONCLUSION

A more comprehensive neonatal pain assessment tool and more provider education on differences in pain signals in premature neonates may be needed to increase the clinical utility of pain scales that address the different aspects of neonatal pain.

[Item Reduction to Improve Practicability of Neonatal Pain Assessment Tools - Comparison of NFCSshort and PIPP in Daily Clinical Practice]

HINTERGRUND

Trotz über 50 psychometrisch validierter Beobachtungsverfahren gibt es bisher keinen Konsens über das praktikabelste Schmerzassessment bei Neugeborenen. Die Items von NFCSshort und PIPP wurden mit der Schmerzeinschätzung der prozedurbeteiligten Behandler verglichen und es wurde evaluiert, ob eine Itemreduktion zu Gunsten der Alltagsanwendung möglich wäre.

MATERIAL UND METHODEN

52 Neugeborene wurden in unserer Beobachtungsstudie einer klinisch indizierten peripheren Venenpunktion unterzogen. Patient und Monitordaten wurden standardisiert auf Video aufgezeichnet. Die Schmerzintensität wurden durch sieben unabhängige Untersucher mittels NFCSshort und PIPP bewertet und hinsichtlich der Variabilität zwischen den Untersuchern verglichen.

ERGEBNISSE

Nur vier Items des PIPP (Herzfrequenz, Augenbrauenvorwölbung, zusammengekniffene Augen, betonte Nasolabialfalte) wiesen einen signifikanten Zusammenhang mit der geschätzten Schmerzhaftigkeit der Prozedur auf. Die Items 1 (Gestationsalter), 2 (Wachheitsgrad) und 4 (Sauerstoffsättigung) hatten bei keinem Untersucher Einfluss auf das Schmerzmessergebnis. Die Auswertung des NFCSshort zeigte bei zwei Untersuchern für das Item 1 (Vorwölbung der Augenbrauen) und bei einem Untersucher für das Item 2 (zusammengekniffene Augen) keine Einflüsse auf das Messergebnis.

DISKUSSION

Die Ergebnisse der Studie legen eine Kürzung des PIPP um drei Items nahe, da diese keinen Einfluss auf das Schmerzmessergebnis zeigten. Eine Reduktion des PIPP um das Item Gestationsalter erscheint fraglich, da es in weiteren Studien als bedeutsames Item bewertet wurde. Ein Verzicht auf das Item Sauerstoffsättigung geht mit einem geringeren Messaufwand einher. Eine weitere Kürzung der bereits gekürzten Version (NFCSshort) auf weniger als fünf Items ist auf Basis unserer Ergebnisse nicht zu empfehlen.

BACKGROUND

Despite more than 50 laboratory-evaluated measurement systems, there is no consensus on the most practicable pain assessment in newborns in daily practice. For this purpose, the items of NFCSshort and PIPP were compared to the pain assesment of the involved medical practitioner. The aim of the study was to evaluate whether an item reduction of the assesments in favor of everyday use is feasible.

METHODS

In 52 neonates of a paediatric ward venous blood collection was performed in this observational study. Cameras recorded patients and monitor in a standardized way. The pain intensity was assessed with NFCSshort and PIPP by seven independent observers. The ratings were compared for variability between observers.

RESULTS

Of the seven PIPP items, only four were significantly associated with procedural pain assessment for all seven observers (heart rate, brow bulge, eye squeeze, nasolabial furrow). For the NFCSshort, no significant association with procedural pain assessment was found for two observers for the item "brow bulge" and for one observer for the item "eye squeeze".

CONCLUSION

The results of the study suggest a possible reduction of the PIPP by three items. Disregarding item 1 (gestational age) appears questionable, since its impact as context variable has been proven repeatedly. The waiver of item 4 (oxygen saturation) is associated with less measuring effort. A further reduction of the already shortened version of the NFCS with ten items (NFCSshort, five items) is not recommended by our results.

Sedoanalgesia in neonatal units

Pain recognition and management continues to be a challenge for health professionals in Neonatal Intensive Care Units. Many of the patients are routinely exposed to repeated painful experiences with demonstrated short- and long-term consequences. Preterm babies are a vulnerable high-risk population. Despite international recommendations, pain remains poorly assessed and managed in many Neonatal Intensive Care Units. Due to there being no general protocol, there is significant variability as regards the guidelines for the approach and treatment of pain between the different Neonatal Intensive Care Units. The objective of this article is to review and assess the general principles of pain in the initial stages of development, its recognition through the use of standardised scales. It also includes its prevention and management with the combination of pharmacological and non-pharmacological measures, as well as to establish recommendations that help alleviate pain in daily clinical practice by optimising pain and stress control in the Neonatal Intensive Care Units.

Assessment of four pain scales for evaluating procedural pain in premature infants undergoing heel blood collection

BACKGROUND

Procedural pain is underestimated in hospitalized preterm infants. The aim of this study was to assess the reliability, validity, and clinical utility of the Neonatal Facial Coding System (NFCS), Douleur Aiguë du Nouveau-né (DAN) scale, Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP) in premature infants undergoing heel blood collection. We assume that the four scales were similar in reliablility and validity (but different in clinical utility).

METHODS

The pain assessments were performed on 111 premature infants using the four scales. Internal consistency was determined by Cronbach's α, and the reliability was determined by the intraclass correlation coefficients. Concurrent validity was evaluated by Spearman's rank correlations. Bland-Altman plots were used to investigate the convergent validity.

RESULTS

The internal consistency and their reliability of the scales were high (p < 0.001). Scores were significantly higher at the time of blood collection (p < 0.001). Mean scores of clinical utility of PIPP were significantly higher than NFCS and DAN (p < 0.05) but not higher than the NIPS (p > 0.05).

CONCLUSIONS

The four scales were reliable and valid. This study suggests that the PIPP and NIPS has good clinical utility and are better choice for evaluating procedural pain in premature infants.

IMPACT

The aim of this study was to assess the reliability, validity, and clinical utility of NFCS, DAN, NIPS, and PIPP in premature infants undergoing heel blood collection. The results showed that the four scales have high reliability and internal consistency; the PIPP and NIPS have good clinical utility and are better choice for evaluating procedural pain in premature infants. Our study results provided a reference for clinical workers in choosing pain assessment scales and conduction intervention.

Practical approaches to sedation and analgesia in the newborn

The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.

Neonatal Pain, Agitation, and Sedation Scale's use, reliability, and validity: a systematic review

The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) is recommended by the American Academy of Pediatrics to measure neonatal pain and sedation. However, little is known regarding its reliability and validity for diverse neonatal subpopulations. Twenty-nine studies were included in our review, demonstrating broad application of N-PASS and good or excellent reliability and validity for various neonatal subpopulations. Our systematic review found N-PASS to be valid and reliable for many but not all neonatal subpopulations. There is a lack of support for N-PASS reliability and validity for measuring prolonged pain and sedation in nonmechanically ventilated infants and for acute pain in postoperative infants in any gestational age category. Overall, N-PASS is a psychometrically sound and pragmatic instrument evaluating pain and sedation for most neonatal populations. Future research using N-PASS is encouraged to evaluate and report its validity and reliability, especially for neonatal subpopulations not included in this review.

Quantification of neonatal procedural pain severity: a platform for estimating total pain burden in individual infants

There is increasing evidence that long-term outcomes for infants born prematurely are adversely affected by repeated exposure to noxious procedures. These interventions vary widely, for example, in the extent of damage caused and duration. Neonatal intensive care unit (NICU) procedures are therefore likely to each contribute differently to the overall pain burden of individual neonates, ultimately having a different impact on their development. For researchers to quantify the procedural pain burden experienced by infants on NICU, we aimed to estimate the pain severity of common NICU procedures using published pain scores. We extracted pain scores over the first minute (pain reactivity) from the literature, using 59 randomized controlled trials for 15 different procedures. Hierarchical cluster analysis of average pain scores resulted in 5 discrete severity groups; mild (n = 1), mild to moderate (n = 3), moderate (n = 7), severe (n = 3), and very severe (n = 1). The estimate of the severity of individual procedures provided new insight into infant pain reactivity which is not always directly related to the invasiveness and duration of a procedure; thus, both heel lance and skin tape removal are moderately painful procedures. This estimate of procedural pain severity, based on pain reactivity scores, provides a novel platform for retrospective quantification of an individual neonate's pain burden due to NICU procedures. The addition of measures that reflect the recovery from each procedure, such as brain activity and behavioural regulation, would further improve estimates of the pain burden of neonatal intensive care.

The influence of pain, agitation, and their management on the immature brain

Preterm infants are exposed to frequent painful procedures and agitating stimuli over the many weeks of their hospitalization in the neonatal intensive care unit (NICU). The adverse neurobiological impact of pain and stress in the preterm infant has been well documented, including neuroimaging and neurobehavioral outcomes. Although many tools have been validated to assess acute pain, few methods are available to assess chronic pain or agitation (a clinical manifestation of neonatal stress). Both nonpharmacologic and pharmacologic approaches are used to reduce the negative impact of pain and agitation in the preterm infant, with concerns emerging over the adverse effects of analgesia and sedatives. Considering benefits and risks of available treatments, units must develop a stepwise algorithm to prevent, assess, and treat pain. Nonpharmacologic interventions should be consistently utilized prior to mild to moderately painful procedures. Sucrose may be utilized judiciously as an adjunctive therapy for minor painful procedures. Rapidly acting opioids (fentanyl or remifentanil) form the backbone of analgesia for moderately painful procedures. Chronic sedation during invasive mechanical ventilation represents an ongoing challenge; appropriate containment and an optimal environment should be standard; when indicated, low-dose morphine infusion may be utilized cautiously and dexmedetomidine infusion may be considered as an emerging adjunct.

Assessment of pain in newborn infants

Hospitalized newborn infants experience pain that can have negative short- and long-term consequences and thus should be prevented and treated. National and international guidelines state that adequate pain management requires valid pain assessment. Nociceptive signals cause a cascade of physical and behavioral reactions that alone or in combination can be observed and used to assess the presence and intensity of pain. Units that are caring for newborn infants must adopt sufficient pain assessment tools to cover the gestational ages and pain types that occurs in their setting. Pain assessment should be performed on a regular basis and any detection of pain should be acted on. Future research should focus on developing and validating pain assessment tools for specific situations.