Bedside assessment of heel lance pain in the hospitalized infant

Neonatal pain: Knowledge and perception among pediatric doctors in Malaysia

BACKGROUND

Inadequate pain management is linked to potential neurodevelopmental and behavioral problems. Sufficient knowledge in neonatal pain is required to facilitate optimal pain management. The aim of this study was therefore to assess the knowledge and perception of pain experienced by neonates requiring intensive care among pediatric doctors working in a level III neonatal intensive care unit in Malaysian hospitals.

METHODS

This was a cross-sectional study conducted over a period of 18 months. A self-administered questionnaire assessing knowledge and perception regarding neonatal pain was used.

RESULTS

Twenty-four hospitals participated in the study, with 423 respondents. The response rate was 85%. One hundred and ninety-seven respondents (47%) were aware of tools for neonatal pain assessment, but only 6% used them in daily practice. Doctors with >4 years of experience in neonatal care had better awareness of available pain assessment tools (59.4% vs 40.9%, P = 0.001). Sixteen statements regarding knowledge were assessed. Mean score obtained was 10.5 ± 2.5. Consultants/specialists obtained a higher mean score than medical officers (11.9 vs 10.4, P < 0.001). More than 80% of respondents were able to discriminate painful from non-painful procedures.

CONCLUSION

Clinicians involved in neonatal care, especially those with longer experience were knowledgeable about neonatal pain. Gaps between knowledge and its application, however, remain. Implementation of clinical guidelines to improve the quality of assessment and adequate pain management in neonates is recommended.

Effects of breast milk on pain severity during muscular injection of hepatitis B vaccine in neonates in a teaching hospital in Iran

INTRODUCTION AND AIMS

Human breast milk is a natural pain reliever that contains endorphins. The aim of this study was to compare the effects of breast milk and powdered milk on pain severity after a muscular injection in 1-day-old neonates.

MATERIALS AND METHODS

One hundred neonates admitted to a teaching hospital in Ilam city, Iran, participated in a randomized clinical trial in 2016. One-day-old neonates were divided into four equal groups including: the control group (no feeding); the breastfed group; the bottle-fed mother's milk group and the powdered formula group. All infants received the hepatitis B vaccine by muscle injection in the same position of the thigh. The severity and duration of pain were compared among all groups during and after injection using the DAN scoring method (evaluation behavioral scale of acute pain in newborn infant).

RESULTS

One hundred neonates (57% boys) participated in this study. The mean±SD age and weight for participants were 39.15±0.05 weeks and 3016±28g, respectively. Crying duration either during or after the injection in breastfed infants was significantly shorter compared to the control and powdered formula groups (9.2±3.9 and 16±4.6s vs. 38.2±8.9 and 30.0±4.4s, respectively, during injection, P<0.003); (11.8±3.4 and 20.6±5.1s vs. 56.2±6.5 and 49.8±9.6s, respectively, after injection, P<0.006). There was also a significant relationship between behavioral variations and pain during injection (P<0.0001).

CONCLUSIONS

The results of this study showed that breastfeeding decreases pain severity during painful experiences in neonates, which is in accordance with other reports. Based on this finding, neonates are advised to be breastfed if a painful intervention such as vaccination is needed. The pain-relieving effect of breast milk could also be added to its other suitable effects.

Evaluation of pain in healthy newborns and in newborns with developmental problems (Down syndrome)

Newborns are often subjected to invasive and painful medical procedures. This happens even more frequently when they require hospitalization. The aim of this paper was to evaluate pain in healthy newborns and in newborns with Down syndrome (DS). We performed a prospective cohort study in the neonatal service of the San Cecilio University Hospital in Granada (Spain) from January 2008 to September 2013. The universe of our study comprised a study group of 20 newborns with DS and a control group of 20 newborns without DS. All of the infants were hospitalized, and thus had to undergo painful medical procedures. The variables studied were basal recovery time (as reflected in crying and the normalization of biological constants), number of punctures, oxygen saturation, heartbeat, blood pressure, response to skin-to-skin contact, and gestational age. The evaluation was performed during blood extraction, vein canalization, and heel puncture. The significant differences in the basal recovery time between the two groups of newborns indicated that those with DS were slower to express pain, and when they did, their response was not as clearly defined as that of babies without DS. The oxygen saturation in babies with DS after the puncture was found to be significantly lower than that of the control group (p < .001). The results of this study revealed that babies with DS were not as quick to perceive pain after a puncture. However, when pain was finally perceived, it persisted for a longer time. This situation should be taken into account in the design of pharmacologic and nonpharmacologic therapies.

The effects of skin-to-skin contact during acute pain in preterm newborns

BACKGROUND AND PURPOSE

Several promising non-pharmacological interventions have been developed to reduce acute pain in preterm infants including skin-to-skin contact between a mother and her infant. However, variability in physiological outcomes of existing studies on skin-to-skin makes it difficult to determine treatment effects of this naturalistic approach for the preterm infant. The aim of this study was to test the efficacy of mother and infant skin-to-skin contact during heel prick in premature infants.

METHOD

Fifty nine stable preterm infants (born at least 30 weeks gestational age) who were undergoing routine heel lance were randomly assigned to either 15 min of skin-to-skin contact before, during and following heel prick (n=31, treatment group), or to regular care (n=28, control group). Throughout the heel lance procedure, all infants were assessed for change in facial action (NFCS), behavioral state, crying, and heart rate.

RESULTS

Statistically significant differences were noted between the treatment and control groups during the puncture, heel squeeze and the post phases of heel prick. Infants who received skin-to-skin contact were more likely to show lower NFCS scores throughout the procedure. Both groups of infants cried and showed increased heart rate during puncture and heel squeeze although changes in these measures were less for the treated infants.

CONCLUSIONS

Skin-to-skin contact promoted reduction in behavioral measures and less physiological increase during procedure. It is recommended that skin-to-skin contact be used as a non-pharmacologic intervention to relieve acute pain in stable premature infants born 30 weeks gestational age or older.

Effect of concomitant opioid analgesics and oral sucrose during heel lancing

A sub-analysis was conducted of data from a study of prolonged use of sucrose for hospitalized infants (N=50 infants) during heel lancing. Results showed that pain responses differed when opioid analgesics were administered concomitantly with sucrose (n=79 pain assessments), than when sucrose was administered alone (n=364 pain assessments).

[Analgesic effect of breastfeeding when taking blood by heel-prick in newborns]

OBJECTIVE

To compare the analgesic effectiveness of breastfeeding when taking blood by the heel-lance procedure in healthy newborns, as opposed to other procedures.

PATIENTS AND METHODS

We studied 228 term infants from the Maternity Unit of our Hospital. The study was developed in two consecutive phases. In the first stage, 150 newborns were distributed into three randomised groups, the first group (50 newborns) did not receive any specific analgesic intervention; the second and third groups (50 newborns) received non-nutritive sucking-placebo or non-nutritive sucking-24% sucrose respectively. In the second phase, 78 newborns participated, and the blood was taken during breast-feeding. The results on a discomfort scale were compared with those obtained in the rest of examined analgesic procedures.

RESULTS

The group that received analgesia with breast-feeding showed a score on the discomfort scale of 0'62 and an average time of crying of 0'19s. The comparative analysis of the results obtained during breastfeeding, as opposed to the rest of procedures, showed that breast-feeding is the best analgesic option, with a reduction in the discomfort of 51% and of 98% in the time of crying (P<0,001).

CONCLUSIONS

Breast-feeding during the blood test by heel-prick procedure represents the most effective analgesic method. A containment procedure along with non-nutritive sucking is the analgesic method of choice in the newborn that does not receive maternal lactation.

[Analgesia when taking heel-lance blood in the newborn]

OBJECTIVE

To evaluate the pain in healthy newborns requiring blood test by a heel-prick procedure and compare different pain management methods.

PATIENTS AND METHOD

We studied 150 term infants, in three randomised groups, from the Maternity Unit of our Hospital for a period of three months. The first group of 50 newborns, received no specific analgesic intervention during blood tests, except our usual nursing intervention ("facilitated tucking"). The second and third group (50 newborns), received non-nutritive sucking-placebo and non-nutritive sucking-24% sucrose respectively.

RESULTS

In the control group, the average score on the scale of discomfort was 3.92, moderate pain, causing a crying time of 51.72 seconds; the group receiving a non-nutritive sucking-placeboscored 2.1, slight pain, 10.68 seconds crying, while the group receiving non-nutritive sucking-24 % sucrose, expressed a level of discomfort of 1.5 points, slight, with an average crying time of 10.70 seconds. The comparative results between the control group and groups of non-nutritive sucking on placebo and 24% sucrose, both showed significant differences in the scores of the scale of discomfort, as well as in the time crying (p < 0.001). The comparative analysis between groups of non-nutritive sucking sucrose and placebo showed no significant differences.

CONCLUSIONS

The blood test by heel lance represents a painful procedure of moderate intensity capable of analgesic treatment. A proper nursing method, along with a complement of non-nutritive sucking during extraction, significantly decreases the discomfort and crying, it being unnecessary to consider other analgesics.

The pain response of infants in Turkey to vaccination in different injection sites

This study was carried out with the aim of comparing pain responses of children who receive intramuscular (IM) vaccination in deltoid muscle versus the pain responses of those who receive IM vaccination in the vastus lateralis. A total of 185 infants were randomly assigned to one of the two study groups. The deltoid group and the vastus lateralis group were vaccinated respectively in the deltoid muscle and the vastus lateralis. Our results indicated that pain response of infants was similar in each group. However, crying duration of the children who received the vastus lateralis vaccination was shorter than that of the deltoid group after the procedure.

Cerebral hemodynamic changes during intensive care of preterm infants

OBJECTIVES

The objectives of this study were to examine the circulatory changes experienced by the immature systemic and cerebral circulations during routine events in the critical care of preterm infants and to identify clinical factors that are associated with greater hemodynamic-oxygenation changes during these events.

METHODS

We studied 82 infants who weighed <1500 g at birth and required intensive care management and continuous blood pressure monitoring from an umbilical arterial catheter. Continuous recording of cerebral and systemic hemodynamic and oxygenation changes was performed. We studied 6 distinct types of caregiving events during 10-minute epochs: (1) quiet baseline periods; (2) minor manipulation; (3) diaper changes; (4) endotracheal tube suctioning; (5) endotracheal tube repositioning; and (6) complex events. Each event was matched with a preceding baseline. We examined the effect of specific clinical factors and cranial ultrasound abnormalities on the systemic and cerebral hemodynamic oxygenation changes that were associated with the various event types.

RESULTS

There were highly significant differences in hemodynamics and oxygenation between events overall and baseline epochs. The magnitude of these circulatory changes was greatest during endotracheal tube repositioning and complex caregiving events. Lower gestational age, higher illness severity, chorioamnionitis, low Apgar scores, and need for pressor-inotropes all were associated with circulatory changes of significantly lower magnitude. Cerebral hemodynamic changes were associated with early parenchymal ultrasound abnormalities.

CONCLUSIONS

Routine caregiving procedures in critically ill preterm infants are associated with major circulatory fluctuations that are clinically underappreciated and underdetected by current bedside monitoring. Our data underscore the importance of continuous cerebral hemodynamic monitoring in critically ill preterm infants.

Prevention and management of pain in the neonate. An update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Measurement of pain-like response to various NICU stimulants for high-risk infants

BACKGROUND

Infants during neonatal intensive care are invariably exposed to various procedural and environmental stimuli in which the pain-like responses may vary depending on the nature of the stimuli and the infants' condition.

AIM

To examine firstly the pain-like responses to frequent stimulants in the neonatal intensive care unit (NICU) using CRIES, FLACC and PIPP, and secondly the clinical feasibility and validity of using these pain measurements for high-risk infants.

STUDY DESIGN AND SUBJECTS

In a correlational study of 110 premature infants receiving neonatal intensive care, the pain-like responses to 274 observations of 8 types of frequently applied stimulant, classified into three categories according to the degree of invasiveness, were observed using CRIES, FLACC and PIPP.

RESULTS

There was a significant difference in response scores among the three categories for CRIES and PIPP. In post-hoc Scheffé test, category A had the highest response scores. The response scores from CRIES and FLACC were lower for the premature infants than for the full-term infants in both categories A and B, whereas the PIPP scores were higher for the premature infants than for the term infants in category C.

CONCLUSIONS

Full-term infants tended to express more distinct pain-like responses to invasive procedures or direct contacts than premature infants did. However, PIPP may be more sensitive to evaluate the negative effects of environmental auditory stimulants, particularly for premature infants receiving neonatal intensive care. Further study to refine these instruments may increase the clinical feasibility of pain measurements in high-risk infants.

Prevention and management of pain in the neonate: an update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Self-reported pain scores in the emergency department: lack of association with vital signs

BACKGROUND

Some practitioners and investigators have presumed relationships between pain scores and heart rate, blood pressure, or respiratory rate. Previous literature has not adequately addressed the association of pain and vital signs.

OBJECTIVES

To identify any association between self-reported pain and heart rate, blood pressure, or respiratory rate.

METHODS

In this retrospective, observational study, emergency department patients older than 17 years of age presenting between May 2004 and April 2005 with verifiable painful diagnoses (including nephrolithiasis, myocardial infarction, small bowel obstruction, fracture, burn, crush injury, stab wound, amputation, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital's database, including patients' age, gender, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate.

RESULTS

Among 1,063 subjects, the most common diagnoses were nephrolithiasis (25%; n = 267) and fracture (23%; n = 249). The mean (+/- SD) triage pain score was 7 (+/- 3). The mean (+/- SD) heart rate was 85 (+/- 16) beats/min, mean (+/- SD) systolic blood pressure was 141 (+/- 23) mm Hg, and mean (+/- SD) respiratory rate was 19 (+/- 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores.

CONCLUSIONS

No clinically significant associations were identified between self-reported triage pain scores and heart rate, blood pressure, or respiratory rate.

Machine recognition and representation of neonatal facial displays of acute pain

OBJECTIVE

It has been reported in medical literature that health care professionals have difficulty distinguishing a newborn's facial expressions of pain from facial reactions to other stimuli. Although a number of pain instruments have been developed to assist health professionals, studies demonstrate that health professionals are not entirely impartial in their assessment of pain and fail to capitalize on all the information exhibited in a newborn's facial displays. This study tackles these problems by applying three different state-of-the-art face classification techniques to the task of distinguishing a newborn's facial expressions of pain.

METHODS

The facial expressions of 26 neonates between the ages of 18 h and 3 days old were photographed experiencing the pain of a heel lance and a variety of stressors, including transport from one crib to another (a disturbance that can provoke crying that is not in response to pain), an air stimulus on the nose, and friction on the external lateral surface of the heel. Three face classification techniques, principal component analysis (PCA), linear discriminant analysis (LDA), and support vector machine (SVM), were used to classify the faces.

RESULTS

In our experiments, the best recognition rates of pain versus nonpain (88.00%), pain versus rest (94.62%), pain versus cry (80.00%), pain versus air puff (83.33%), and pain versus friction (93.00%) were obtained from an SVM with a polynomial kernel of degree 3. The SVM outperformed two commonly used methods in face classification: PCA and LDA, each using the L1 distance metric.

CONCLUSION

The results of this study indicate that the application of face classification techniques in pain assessment and management is a promising area of investigation.

The verbal numeric pain scale: effects of patient education on self-reports of pain

BACKGROUND

Emergency department (ED) patients are frequently asked to provide a self-report of the level of pain experienced using a verbal numeric rating scale.

OBJECTIVES

To determine the effects of patient education regarding the verbal numeric rating scale on self-reports of pain among ED patients.

METHODS

In this prospective, interventional study, 310 eligible ED patients with pain, aged 18 years and older, were randomized to view either a novel educational video (n = 155) or a novel print brochure (n = 155) as an educational intervention, both developed to deliver educational information about the verbal numeric pain scale and its use. Participants initially rated their pain on a scale from 0 to 10 and then were administered the educational intervention. Following the educational intervention, participants completed a survey that included demographic information, postinterventional pain score, prior pain experience, and subjective rating of the helpfulness of the educational intervention. Fifty-five consecutive participants were enrolled as controls and received no educational intervention but gave a self-reported triage pain score and a second pain score at an equivalent time interval. Clinical significance was defined as a decrease in pain of 2 or more points following the education.

RESULTS

Following the educational interventions, there were statistically significant, although not clinically significant, decreases in mean pain scores within each intervention group (video: mean change, 1 point [95% confidence interval [CI] = 0.7 to 1.2]; printed brochure: mean change, 0.6 points [95% CI = 0.4 to 0.8]). For participants in the control group (no intervention), there was no significant change (mean change, 0.2 points [95% CI = -0.2 to 0.5]). A clinically significant decrease in pain was seen in 28% of the video group, 23% of the brochure group, and 5% of controls. Most patients had no change (71% of the video group, 73% of the brochure group, and 89% of controls). Participants rated the helpfulness of the video educational intervention as 7.1 (95% CI = 6.7 to 7.5) and the print educational intervention as 6.7 (95% CI = 6.2 to 7.1) on a scale from 0 (least effective) to 10 (most helpful).

CONCLUSIONS

Among ED participants with pain, both educational interventions (video and printed brochure) resulted in statistically and clinically significant decreased self-reported pain scores by 2 or more points in 26% of participants compared with 5% of controls. The educational interventions were rated as helpful by participants, with no appreciable difference between the two intervention groups.

Summary proceedings from the neonatal pain-control group

Recent advances in neurobiology and clinical medicine have established that the fetus and newborn may experience acute, established, and chronic pain. They respond to such noxious stimuli by a series of complex biochemical, physiologic, and behavioral alterations. Studies have concluded that controlling pain experience is beneficial with respect to short-term and perhaps long-term outcomes. Yet, pain-control measures are adopted infrequently because of unresolved scientific issues and lack of appreciation for the need for control of pain and its long-term sequelae during the critical phases of neurologic maturation in the preterm and term newborn. The neonatal pain-control group, as part of the Newborn Drug Development Initiative (NDDI) Workshop I, addressed these concerns. The specific issues addressed were (1) management of pain associated with invasive procedures, (2) provision of sedation and analgesia during mechanical ventilation, and (3) mitigation of pain and stress responses during and after surgery in the newborn infant. The cross-cutting themes addressed within each category included (1) clinical-trial designs, (2) drug prioritization, (3) ethical constraints, (4) gaps in our knowledge, and (5) future research needs. This article provides a summary of the discussions and deliberations. Full-length articles on procedural pain, sedation and analgesia for ventilated infants, perioperative pain, and study designs for neonatal pain research were published in Clinical Therapeutics (June 2005).

Capturing postoperative pain responses in critically ill infants aged 0 to 9 months

OBJECTIVES

The purpose of this study was to describe physiologic and behavioral pain behaviors in postoperative critically ill infants. A secondary aim was to identify how these pain responses vary over time.

DESIGN

This observational study was conducted in the pediatric intensive care unit at two tertiary referral hospitals. Using ethological methods of observation, video recordings of postoperative infants were viewed to depict different situations of pain and no pain and were then coded using a reliable checklist.

PATIENTS

A total of 803 recorded segments were generated from recordings of five critically ill infants aged between 0 and 9 months who had undergone major surgery.

MEASUREMENTS AND MAIN RESULTS

There was an 82% agreement between the two coders. Multivariate analyses showed that physiologic responses differed only when adjusted for time. Significant decreases in systolic and diastolic arterial pressure (p < .001 and p = .036, respectively) were associated with postoperative pain exacerbated by painful procedures on day 2. On day 3, however, heart rate, arterial pressure (systolic, diastolic, and mean), and central venous pressure significantly increased (p < .05) in response to postoperative pain. Indicators included vertical stretch of the mouth, hand twitching, and jerky leg movements for postoperative pain and increase in respiratory distress, frown, eyes tightly closed, angular stretch of the mouth, silent or weak cry, jerky head movements, fist, pulling knees up, and spreading feet for postoperative pain exacerbated by painful stimuli.

CONCLUSIONS

Findings support the ability to capture different intensities of postoperative pain in critically ill infants beyond neonatal age. These pain indicators can be used for the development of a pain assessment tool for this group of infants.

Pilot study of the systemic effects of three different screening methods used for retinopathy of prematurity

PURPOSE

This pilot study compared the physiological and behavioural changes in premature infants undergoing three different methods of screening for retinopathy of prematurity (ROP).

STUDY DESIGN

Prospective randomized cross-over pilot study.

SUBJECTS AND METHODS

Fifteen premature infants requiring screening for ROP were recruited, and physiological and behavioural responses produced by three different methods of screening were compared. The screening methods employed a RetCam 120 and an indirect ophthalmoscope with and without an eyelid speculum. Physiological indices (change in pulse, mean blood pressure and oxygen saturation) and facial responses to pain (brow bulge, eye squeeze, nasolabial fold, mouth opening and the presence of cry) were recorded at five points: before, during and immediately after screening and 10 and 30 min after examination.

RESULTS

Screening with the RetCam 120 and the indirect ophthalmoscope with a speculum both caused a greater change in pulse and mean blood pressure and an increase in facial responses to pain during and immediately after screening as compared to the indirect ophthalmoscope without the speculum. RetCam 120 screening caused greater desaturation than the other methods.

CONCLUSIONS

Although this was a small sample which limits absolute conclusions, the study showed that screening using a RetCam or a speculum and indirect ophthalmoscope caused more stress to the infant, as indicated by physiological and behavioural changes, than simply screening using an indirect ophthalmoscope without a speculum. These effects should be considered when deciding on the appropriate screening method for examining particularly sick infants.

Oral sucrose for procedural pain in sick hospitalized infants: a randomized-controlled trial

OBJECTIVE

To determine the efficacy of 25% oral sucrose in the reduction of pain during a heel lance procedure in sick hospitalized infants.

METHODOLOGY

In a blinded randomized- controlled trial, hospitalized infants were given either 1 mL 25% sucrose or 1 mL water 2 min prior to a heel lance procedure. Pain assessment comprised a four-point facial expression score, incidence and duration of crying, heart rate and oxygen saturation changes.

RESULTS

A total of 128 infants were included. Facial scores immediately upon heel lance, and at 1 and 2 min in the recovery period were reduced in the treatment (sucrose) group compared to the placebo (water) group (P < 0.05). At other observation points, the differences in facial scores between the two groups of infants did not reach statistical significance. Neither incidence nor duration of crying whilst the blood collection was in progress was significantly reduced by sucrose. In the 3-min recovery period following completion of the blood collection, incidence and duration of crying were significantly less in the treatment group of infants (P < 0.05). Physiological responses of heart rate and oxygen saturation were not attenuated by sucrose at any time point during or following the blood collection.

CONCLUSION

Oral sucrose was effective in reducing behavioural responses to pain upon heel lance and in the period following completion of a heel lance procedure in this group of sick hospitalized infants. This simple strategy can be promoted in institutions caring for sick babies, as a method of reducing behavioural responses to procedural pain.

Assessment and management of pain in infants

Infants, including newborn babies, experience pain similarly and probably more intensely than older children and adults. They are also at risk of adverse long term effects on behaviour and development, through inadequate attention towards pain relief in early life. However, the issue of analgesia in young babies has been largely neglected in most clinical settings, despite subjecting them to painful diagnostic and therapeutic procedures. Several therapeutic and preventive strategies, including systemic and local pharmacological and non-pharmacological interventions, are reported to be effective in relieving pain in infants. A judicious application of these interventions, backed by awareness and sensitivity to pain perception, on the part of the caregivers is likely to yield the best results. This article is a review of the mechanisms of pain perception, objective assessment, and management strategies of pain in infants.