COVERS Neonatal Pain Scale: Development and Validation

Prongs or Mask for Nasal Continuous Positive Airway Pressure in Neonates: Which One Is More Comfortable?

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is a common mode of respiratory support in neonatal intensive care units. Our objective was to compare whether NCPAP given with nasal prongs compared with a nasal mask reduces the pain scores in preterm infants with respiratory distress.

METHODS

Preterm infants on NCPAP due to respiratory distress were included in the study. All infants received NCPAP via the Infant Flow SiPAP. The COVERS pain scale was used to score the infants' pain. Each infant was studied alternating between nasal prongs and a nasal mask. Heart rate, respiratory rate, oxygen saturation, and transcutaneous CO2 (tcCO2) were monitored. Blood pressure and the infants' pain scores were determined every 30 minutes and the average of measurements was taken.

RESULTS

The median (interquartile range) values of pain scores, respiratory rates, oxygen saturations, tcCO2 levels, and systolic blood pressures differed significantly and favored the nasal mask.

CONCLUSIONS

This study demonstrates that continuous positive airway pressure via a nasal mask leads to a significant reduction in pain scores without altering the respiratory parameters of babies. On the basis of this study, it is possible to conclude that NCPAP applied via nasal mask may be a good alternative to NCPAP applied via nasal prongs.

Face-based automatic pain assessment: challenges and perspectives in neonatal intensive care units

OBJECTIVE

To describe the challenges and perspectives of the automation of pain assessment in the Neonatal Intensive Care Unit.

DATA SOURCES

A search for scientific articles published in the last 10 years on automated neonatal pain assessment was conducted in the main Databases of the Health Area and Engineering Journal Portals, using the descriptors: Pain Measurement, Newborn, Artificial Intelligence, Computer Systems, Software, Automated Facial Recognition.

SUMMARY OF FINDINGS

Fifteen articles were selected and allowed a broad reflection on first, the literature search did not return the various automatic methods that exist to date, and those that exist are not effective enough to replace the human eye; second, computational methods are not yet able to automatically detect pain on partially covered faces and need to be tested during the natural movement of the neonate and with different light intensities; third, for research to advance in this area, databases are needed with more neonatal facial images available for the study of computational methods.

CONCLUSION

There is still a gap between computational methods developed for automated neonatal pain assessment and a practical application that can be used at the bedside in real-time, that is sensitive, specific, and with good accuracy. The studies reviewed described limitations that could be minimized with the development of a tool that identifies pain by analyzing only free facial regions, and the creation and feasibility of a synthetic database of neonatal facial images that is freely available to researchers.

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.

Assessment of neonatal pain: uni- and multidimensional evaluation scales

Neonatal pain is a problem that is easily overlooked. According to the status quo of neonatal pain management, commonly 9 scales are used for evaluation of neonatal pain; details of the specific indicators, such as the applicable neonatal gestational age range, score, and the type of pain, for the domestic references are provided so as to provide reference for the proper evaluation and standardized management of neonatal pain, as well as to promote the management level of neonatal pain.

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.

Psychometric Properties of the Turkish Version of the Neonatal Infant Acute Pain Assessment Scale

PURPOSE

Even the healthiest neonates experience pain during painful interventions (e.g. administration of Vitamin K, heel lance) in their first moments of life. This study aimed to examine the validity and reliability of the Turkish version of the Neonatal Infant Acute Pain Assessment Scale.

DESIGN AND METHODS

This methodological study was conducted with 100 newborns receiving treatment and care in a tertiary neonatal intensive care unit. The data were collected using the Neonate Demographic Form, the Neonatal Infant Acute Pain Assessment Scale, and the Premature Infant Pain Profile. The scale was analyzed in terms of validity, internal consistency, and interobserver reliability.

RESULTS

The content validity index of the scale was found to be between 0.87 and 1.00, while Cronbach's alpha coefficient was between 0.708 and 0.833. According to the item analysis results, item-total correlation values were high. A strong positive correlation was found between the scores of the two scales that were analyzed for concurrent validity.

CONCLUSIONS/PRACTICE IMPLICATIONS

The Turkish version of the Neonatal Infant Acute Pain Assessment Scale was determined to be valid and reliable. More studies should be done to accurately measure and effectively manage neonatal pain.

Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development: A Systematic Review

IMPORTANCE

Because children in a preverbal stage of development are unable to voice their feelings, they completely depend on their caregiving team for the interpretation and management of their pain and discomfort. Thus, accurately validated scales to assess pain and sedation levels are crucial.

OBJECTIVE

To provide clinicians a complete overview on the validity and reliability of the existing pain and sedation scales for different target populations (preterm infants, term infants, and toddlers) and in different clinical contexts.

EVIDENCE REVIEW

BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycCRITIQUES, PsycINFO, PSYNDEXplus Literature and Audiovisual Media, and PSYNDEXplus Tests were the databases screened from their inception to August 2018. All studies examining the validity or reliability of a given pain or sedation scale for patients in a preverbal stage of development were included in this systematic review. Those scales that were tested for at least construct validity, internal consistency, and interrater reliability were subsequently scored using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist.

FINDINGS

In total, 89 validation articles comprising 65 scales were included. Fifty-seven scales (88%) were useful for assessing pain, 13 scales (20%) for assessing sedation, and 4 scales (6%) for assessing both conditions. Forty-two (65%) were behavioral scales, and 23 (35%) were multidimensional scales. Eleven scales (17%) were validated for infants on mechanical ventilation. Thirty-seven scales (57%) were validated for preterm infants, 24 scales (37%) for term and preterm infants, 7 scales (11%) for term-born children, 7 scales (11%) for preterm infants, term infants, and toddlers, and 17 scales (26%) for term infants and toddlers. Twenty-eight scales (43%) considered construct validity, internal consistency, and interrater reliability.

CONCLUSIONS AND RELEVANCE

Clinicians should consider using scales that are validated for at least construct validity, internal consistency, and interrater reliability, combining this information with the population of interest and the construct the scale is intended to measure.

Measuring pain in dogs and cats using structured behavioural observation

The contemporary approach to pain measurement in people and animals seeks to measure the affective (emotional) component of the pain experience using structured questionnaires with formal scoring methodology. Chronic pain has wide-ranging impacts which affects the quality of life (QOL) of the individual, whether that is a person or an animal. Accordingly instruments to measure chronic pain are designed to measure its impact on QOL and are called health-related quality of life (HRQL) instruments. In veterinary science instruments to measure pain are based on behavioural observation by the veterinary surgeon/nurse in the case of acute pain and by the owner in the case of chronic pain. The development of HRQL instruments is an expanding field in veterinary science, not just for the measurement of pain, but for other chronic diseases, and it has a wide application in pharmaceutical research and clinical practice to improve patient care. This review highlights the challenges involved in creating such measures for dogs and cats, seeking to provide the reader with an understanding of their development process. It then provides an overview of the current status with regard to acute and chronic pain measurement.

Validation of Greek Versions of the Neonatal Infant Pain Scale and Premature Infant Pain Profile in Neonatal Intensive Care Unit

BACKGROUND

The Neonatal Infant Pain Scale and the Premature Infant Pain Profile have been used widely in neonatal intensive care units for pain assessment.

AIM

This study reports the evaluation and validation of these scales in full-term newborns who were hospitalized in two Greek neonatal intensive care units. Evaluation and validation of the Neonatal Infant Pain Scale and the Premature Infant Pain Profile in full-term newborns who were hospitalized in two Greek neonatal intensive care units.

MATERIALS AND METHODS

This is a cross-sectional study. Two neonatal intensive care units at a large General Children's Hospital in Greece. A total of 81 full-term newborns. This cross-sectional study was conducted in two neonatal intensive care units at a large General Children's Hospital in Greece. We studied 81 full-term newborns, who were exposed to various painful routine procedures. A single measurement was taken from each neonate. Two observers were present during each procedure and evaluated pain using both the Neonatal Infant Pain Scale and Premature Infant Pain Profile. Internal consistency coefficient Cronbach's α, internal class agreement coefficient, and κ factor were appropriately measured.

RESULTS

The weighting of the Neonatal Infant Pain Scale and Premature Infant Pain Profile pointed out an excellent coherence between the two scales and agreement among the researchers. The internal consistency coefficient Cronbach's α was >.8 and the internal class agreement coefficient was >.98 for both scales, which indicates an excellent consistency between scales. The κ factor for Neonatal Infant Pain Scale was >.73 and for the Premature Infant Pain Profile it was >.6, which indicates a significant agreement among investigators.

CONCLUSIONS

The Neonatal Infant Pain Scale and Premature Infant Pain Profile were successfully adjusted in Greek standards with reliability between the scales and among the researchers. Moreover, they constitute reliable tools for the evaluation of neonatal procedural pain in full-term newborns in Greece.

Prevention and Management of Procedural Pain in the Neonate: An Update

The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also 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 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. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures.

Neonatal Infant Pain Scale: Cross-Cultural Adaptation and Validation in Brazil

CONTEXT

The Neonatal Infant Pain Scale (NIPS), initially developed in Canada, has been previously used but not adequately adapted and validated for use in Brazil.

OBJECTIVES

The goal of the present study was to perform a cross-cultural adaptation and clinical validation of the NIPS for use in the Brazilian population.

METHODS

The instrument was adapted based on the method outlined by Beaton et al., including the production and combination of translated versions, back-translation, committee review, and pilot testing. The psychometric properties of the adapted instrument, including its validity, reliability, and internal consistency, were tested in a clinical validation study. The sample comprised 60 at-term newborns who were evaluated by six nurses as they experienced vaccination. Psychometric properties were evaluated using Student's t-tests, prevalence-adjusted and bias-adjusted kappa scores, the Bland-Altman method, and Cronbach's alpha coefficients.

RESULTS

The Brazilian version of the NIPS (Escala de Dor no Recém-Nascido [NIPS-Brazil]) demonstrated excellent interobserver and intraobserver reliability. Total NIPS-Brazil scores yielded prevalence-adjusted and bias-adjusted kappa scores of 0.93, whereas the Bland-Altman method revealed interobserver and intraobserver reliability values of 95% and 90%, respectively. The NIPS-Brazil had adequate internal consistency, as evidenced by a Cronbach's alpha of 0.762.

CONCLUSION

The NIPS was successfully adapted for use in Brazil and is now available for use in the assessment of acute pain in at-term newborns in Brazil.

Pain assessment and measurement in neonates: an updated review

Pain assessment and measurement are the cornerstones of pain management. Pain assessment connotes a comprehensive multidimensional description. Conversely, pain measurement provides a numeric quantitative description of each factor illustrating pain qualities. Pain scales provide a composite score used to guide practice and research. The type of infant pain instrument chosen is a significant factor in guiding pain management practice. The purpose of this review was to summarize current infant pain measures by introducing a conceptual framework for pain measurement. Although more than 40 infant pain instruments exist, many were devised solely for research purposes; several of the newly developed instruments largely overlap with existing instruments. Integration of pain management into daily practice remains problematic. Understanding how each instrument measures infant pain allows clinicians to make better decisions about what instrument to use with which infant and in what circumstances. In addition, novel new measurement techniques need further testing.

Palliative care for the newborn in the United Kingdom

Palliative care for the newborn is a developing area. There are more than 2000 estimated neonatal deaths each year in the UK from causes likely to benefit from palliative care. There is an increasing recognition that while the goals of care may be different for dying newborns, they deserve the same high standard of care as those babies who go on to survive. Recent neonatal palliative care guidance is available from the British Association for Perinatal Medicine (BAPM), the General Medical Council (GMC), and ACT (the U.K. association for children's palliative care). We attempt to answer the question: 'What does the provision of good neonatal palliative care look like?' by examining the factors important in the provision of such care.