The effect of pain on infant behaviors

Vocal pain expression augmentation for a robopatient

Abdominal palpation is one of the basic but important physical examination methods used by physicians. Visual, auditory, and haptic feedback from the patients are known to be the main sources of feedback they use in the diagnosis. However, learning to interpret this feedback and making accurate diagnosis require several years of training. Many abdominal palpation training simulators have been proposed to date, but very limited attempts have been reported in integrating vocal pain expressions into physical abdominal palpation simulators. Here, we present a vocal pain expression augmentation for a robopatient. The proposed robopatient is capable of providing real-time facial and vocal pain expressions based on the exerted palpation force and position on the abdominal phantom of the robopatient. A pilot study is conducted to test the proposed system, and we show the potential of integrating vocal pain expressions to the robopatient. The platform has also been tested by two clinical experts with prior experience in abdominal palpation. Their evaluations on functionality and suggestions for improvements are presented. We highlight the advantages of the proposed robopatient with real-time vocal and facial pain expressions as a controllable simulator platform for abdominal palpation training studies. Finally, we discuss the limitations of the proposed approach and suggest several future directions for improvements.

Video and audio processing in paediatrics: a review

OBJECTIVE

Video and sound acquisition and processing technologies have seen great improvements in recent decades, with many applications in the biomedical area. The aim of this paper is to review the overall state of the art of advances within these topics in paediatrics and to evaluate their potential application for monitoring in the neonatal intensive care unit (NICU).

APPROACH

For this purpose, more than 150 papers dealing with video and audio processing were reviewed. For both topics, clinical applications are described according to the considered cohorts-full-term newborns, infants and toddlers or preterm newborns. Then, processing methods are presented, in terms of data acquisition, feature extraction and characterization.

MAIN RESULTS

The paper first focuses on the exploitation of video recordings; these began to be automatically processed in the 2000s and we show that they have mainly been used to characterize infant motion. Other applications, including respiration and heart rate estimation and facial analysis, are also presented. Audio processing is then reviewed, with a focus on the analysis of crying. The first studies in this field focused on induced-pain cries and the newest ones deal with spontaneous cries; the analyses are mainly based on frequency features. Then, some papers dealing with non-cry signals are also discussed.

SIGNIFICANCE

Finally, we show that even if recent improvements in digital video and signal processing allow for increased automation of processing, the context of the NICU makes a fully automated analysis of long recordings problematic. A few proposals for overcoming some of the limitations are given.

Acoustic estimates of respiration in the pain cries of newborns

OBJECTIVE

The purpose of the present study was to examine the temporal features of pain-elicited crying demonstrated by healthy full term infants to estimate (1) the respiratory rate during cry and (2) the inspiratory and expiratory phase composition of the cry respiratory cycle.

PATIENTS AND METHODS

The pain-elicited cries of 12 newborn infants were recorded within the first 2 weeks following birth. A complete crying episode was analyzed for each infant and acoustically measured for the number and duration of inspiratory and expiratory cry components. These components were then used to estimate the respiratory rate of infant crying, as well as the inspiratory and expiratory phase composition of the cry respiratory cycles.

RESULTS

Acoustic analysis revealed that the average rate of crying was 57 breaths min⁻¹ with the inspiratory phase contributing 27% to the overall respiratory cycle. However, considerable variability was found across infants with distinct patterns of respiration associated with high versus low respiratory rates.

CONCLUSIONS

The respiratory patterns associated with pain cries is highly variable and may be associated with variations in stress-arousal, strength of emotional expression, and overall fitness. This study supports the notion that the respiratory activity surrounding newborn infant crying is unique to the type of cry sampled.

The effect of positioning on infant cries: implications for sudden infant death syndrome

OBJECTIVE

A definitive cause for sudden infant death syndrome (SIDS) has not yet been identified, but some theories point to laryngeal or respiratory causes, in addition to theories of reduced arousal or reduced autonomic response. The occurrence of SIDS has dropped since the movement to place newborns to sleep in the supine position; however, some research has found a respiratory disadvantage for infants in this position. The current paper studied acoustic characteristics of infant pain cries to determine the potential differences related to prone versus supine positioning.

METHODS

Fifty-one newborn infant cries were recorded during and following a blood draw screening procedure, with infants placed either in the supine or prone position. All infants were healthy, full-term infants. Complete crying episodes were audio-recorded, and results were based on compositional analysis and long-time average spectrum analysis across each crying episode.

RESULTS

Spectral analysis revealed acoustic differences related to infant positioning, and acoustic analysis also revealed that there were no respiratory differences between supine-positioned and prone-positioned infants. Overall, the acoustic differences suggest decreased arousal and/or a decreased response to pain for healthy infants recorded in the prone position.

CONCLUSIONS

As decreased arousal and prone positioning have been seen as possible causative factors for SIDS, the current results are seen as a successful step in evaluating the possibility of using acoustic analysis of infant cries as a means of evaluating SIDS risk for healthy infants.

Pain assessment in the nonverbal patient: position statement with clinical practice recommendations

The article presents the position statement and clinical practice recommendations for pain assessment in the nonverbal patient developed by an appointed Task Force and approved by the ASPMN Board of Directors.

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).

Prevention and treatment of postoperative pain with particular reference to children

Pain therapy is an important aspect of medical practice for patients of all ages, to optimize care, to obtain an adequate quality of life and to improve their general conditions. Pain is among the most prevalent symptoms experienced by patients undergoing surgery. The success of postoperative pain therapy depends on the ability of the clinician to assess the presenting problems, identify and evaluate pain syndromes and formulate a plan for comprehensive continuing care. The prevalence of acute pain has led to the need to develop techniques for the assessment and management of this symptom in order to focus the attention on an interdisciplinary therapeutic approach (including pharmacologic, cognitive-behavioral, psychologic and physical treatment) and on the timing of different interventions (pre and postoperative). In this chapter we describe the principal therapeutic approaches to control pain in post-operative patients, such as non-opioid, opioid and adjuvant analgesics with particular attention in paediatric age. Moreover we report the principal scales to assess the pain intensity in the post-operative period. The need of a multidisciplinatory team and of a pre and postoperative pain management program represents an important goal in order to obtain effective pain relief and optimize pediatric care and rapid recovery. The introduction of a perioperative team service will improve the approach to pain management programs and it is considered the most important challenge for future.

The challenges of pain measurement in critically ill young children: A comprehensive review

This article addresses the issues in measuring pain in critically ill children, provides a comprehensive review of the pain measures for children aged between 0 and 3 years, and discusses their applicability to this group of children. When children are critically ill, pain can only exacerbate the stress response that already exists, to the extent that homeostasis cannot be maintained. Severity of illness is thus likely to affect physiologic and behavioural pain responses that would normally be demonstrated in healthy children. The problem of differentiating pain from other constructs adds to the complexity of assessing pain in non-verbal children. A pain measure to be useful clinically must be adapted to the developmental age of the target population. Search of electronic databases and other electronic sources was supplemented by hand review of relevant journals to identify published and unpublished pain measures for use in children aged between 0 and 3 years. Twenty eight pain measures were identified in the literature; 11 for neonates only, 11 for children aged between 0 and 3 years, and six for children more than 12 months. These measures vary in relation to their psychometric properties, clinical utility and the context in which the study was performed. These measures may not be suitable for the critically ill young child, because the items included were derived from observations of healthy or moderately sick children, and may not reflect pain behaviour in those who are critically ill. It is therefore recommended to develop new pain scales for this population of compromised children.

Nursing assessment of infant pain

This study compared how nurses perceived their assessment of infant pain and how the pain was actually assessed in an intensive care unit. A descriptive design was used to collect data about nurses beliefs and documentation practices related to pain assessment in infants. An anonymous subset of the unit nurses (n = 24) responded to a questionnaire regarding infant pain assessment. Pain assessment documentation of the unit nurses was examined in a retrospective chart review (n = 107). Results showed an inconsistency between what nurses believe about infant pain as sessment and the documentation practice in the unit. According to the questionnaire, the nurses believed that pain assessment was important to providing effective pain relief and that nurses are capable of assessing infant pain. However, it was not evident in the documentation that nurses used pain tools or other means to document their evaluations of infant pain or the infant's response to pain medication interventions.

CONCLUSION

Greater consistency of nurses in documenting pain assessment, thereby improving care provider communication of an infant's pain experience, is needed to improve the standard of care in managing infant pain.

Physiologic correlates of comfort in healthy children

Pain assessment is particularly challenging when children are unable or unwilling to provide a self-report. Although clinicians frequently use vital signs as an adjunct to pain assessment, little evidence exists to support this practice. The purpose of this study was to explore the ability of selected physiologic variables (peripheral skin temperature, heart rate, skin conductance activity [SCA], respiratory rate, electromyogram [EMG] of the frontalis and right forearm muscles, and systolic and diastolic blood pressure [BP]) to detect changes in children's autonomic arousal from baseline. A one-group, repeated measures, randomized crossover design guided the study. Chosen from a convenience sample, 100 healthy children (ages 8-17 years) served as their own controls while undergoing two levels of intervention: cold pressor pain and guided imagery. Although most physiologic responses showed changes in the expected direction, EMG, SCA, and heart rate decreased slightly during cold pressor. Few significant intercorrelations were demonstrated among the physiologic variables. SCA, forehead EMG, respiratory rate, systolic and diastolic BP detected significant changes in arousal across measures. Notably, heart rate failed to detect changes for any of the measures. Results emphasize the need for caution in interpreting heart rate as an index of comfort. Further research is needed to examine the effects of clinical pain on physiologic indices and to further examine age and sex influences. To be relevant for assessment of acute established pain, physiologic variables must also be tested for their sensitivity beyond the immediate period of autonomic arousal.

Validation of the Pain Assessment in Neonates (PAIN) scale with the Neonatal Infant Pain Scale (NIPS)

PURPOSE

To establish the validity and clinical usefulness of a modified pain assessment scale, the Pain Assessment in Neonates (PAIN) scale.

DESIGN

Correlational design to compare scores obtained on the PAIN with scores obtained on the Neonatal Infant Pain Scale (NIPS).

SAMPLE

A convenience sample of 196 neonates from an NICU and a step-down unit with gestational ages of 26 to 47 weeks.

METHOD

Bedside nurses observed the neonates for two minutes and then scored their responses on both scales. The scales were scored sequentially and in a randomized order.

MAIN OUTCOME VARIABLE

Correlation of individual item scores and total scores on the PAIN and the NIPS.

RESULTS

The scores for individual items on the PAIN were significantly associated with scores obtained on the NIPS. Overall correlation between the scales was 0.93. These associations suggest that the PAIN is a valid scale for assessment of neonatal pain.

Infant gender differences regarding acute established pain

The purpose of this study was to ascertain if any gender differences existed in the behaviors of infants experiencing different levels of acute established pain and different levels of arousal within each level of pain. To do this, the behaviors of 152 two-week- to 12-month-old infants were videotaped and compared. Levels of pain were assessed by a panel of expert pediatric nurses. Results indicated that female 2-week- to 6-month-old infants performed more generally broadcast crying than did males and that the cries of female 7- to 12-month-old infants were of higher pitch than those of males. There was no gender difference in any facial or other bodily behavior. One cannot interpolate from these results that there are any gender differences in pain thresholds, only that there seem to be gender differences in behavioral responses to acute established pain.

Infant behaviors as indicators of established acute pain

ISSUES AND PURPOSE

Many infant pain assessment tools use infant behaviors indicative of increased arousal. These tools were developed and tested using clinical situations involving acute immediate pain responses. Are these behaviors valid, clinical indicators of acute established pain (non-procedurally caused) pain? Can these tools be used to assess acute established infant pain? This article explores research findings to answer these questions.

CONCLUSIONS

Findings suggest that behaviors indicative of increased arousal (e.g., crying, facial expressions that accompany crying) are nonspecific indicators of distress rather than independent indicators of established acute pain. Thus, the use of behaviors representing acute immediate pain responses to assess acute established pain, or the use of tools that incorporate these behaviors, can be misleading.

PRACTICE IMPLICATIONS

Always use acute immediate pain behavioral responses (behaviors indicative of increased arousal) in conjunction with clinical data concerning "likelihood of pain" and consolability.

Fluctuations in established infant pain behaviors

This study compares behaviors that differed across levels of established (e.g., nonprocedural) infant pain with those that differed between periods of greater and lesser distress within any level of infant pain. Sixty-four videotaped infants of two ages (0 to 3 months and 7 to 12 months) and four levels of established infant pain (none, mild, moderate, and severe) were used. Pain was from medical or surgical causes. Behaviors were compared between the most distressed (HI) and the least distressed (LO) video segments per infant and across the four levels of infant pain using a two-level (distress and level of pain) MANOVA. Many behaviors were indicative of high levels of established pain and greater distress. Others increased with greater distress but lower levels of pain. Findings suggest that many behaviors indicative of high distress that constitute the immediate infant pain response are not good indicators of levels of established infant pain.

Validity and reliability of a practice-based infant pain assessment instrument

The purpose of this study was to determine the validity and reliability of an infantpain assessment instrument. This instrument is an algorithm derived from a model of infant pain assessment that emerged from interviews with pediatric nurses and includes methods for evaluating clinical data that suggest the Iikelihood of pain. Unlike other instruments, this instrument is not restricted to use in clinical situations where the likelihood of pain is evident. This instrument determines the three levels of pain that guide subsequent nursing interventions: no pain, mild pain (discomfort), and severe pain. Content validity was determined by obtaining and incorporating feedback from a focus group of practicing pediatric nurses on various developmental stages of the instrument. Criterion-like validity was excellent: Mean Pearson correlations between the pain ratings of 18 videotaped infants by 24 nursing students using the instrument with ratings performed by a panel of 5 expert nurses not using any instrument was 0.96. Test-retest reliability, as measured by Pearson correlations between pain ratings 3 months apart, was also excellent (r = 0.91).

Techniques to comfort children during stressful procedures

Medical procedures can be unpleasant experiences for children, their parents, and health care providers. We present this model of working with children having invasive procedures with the aim of helping to increase the comfort of infants and children and also parents and medical staff. The model has five parts: (1) Preparing the child and parent for the procedure and for their role during the procedure; (2) inviting the parent/caregiver to be present; (3) utilizing the treatment room for stressful procedures; (4) positioning the child in a comforting manner; and (5) maintaining a calm, positive atmosphere.

Assessment of pain and agitation in critically ill infants

Critically ill infants are subjected to many painful experiences that, if inadequately treated, can have severe physiological and psychological consequences. Optimal management of pain relies on the adequacy of nurses' assessment; this, however, is complicated by another common condition, agitation. A multidimensional assessment is therefore necessary to adequately identify pain and agitation. The aim of this descriptive study was to identify the cues that nurses caring for critically ill infants use to assess pain and agitation. A questionnaire, developed from the literature, was distributed to all registered nurses (85) working in the neonatal and paediatric intensive care units of an Australian teaching hospital. Questionnaires were completed by 41 nurses (a 57 per cent response rate). Results revealed that, except for diagnosis, there were no significant differences between the cues participants used to assess pain and those to assess agitation. Nurses used numerous cues from various sources: most importantly, their own judgement (99 per cent); the parents' judgement (90 per cent); the infant's environment; documentation (78 per cent), and the infant's cues (70 per cent). These findings demonstrate the relevance of the nurse's role in assessment of pain and agitation in critically ill infants. Nurses used cues specific to the critically ill rather than the less sick infant. Results of this study also show the difficulty of differentiating between pain and agitation. Further research on ways of distinguishing between the construct of pain and agitation needs to be undertaken.

Acoustic examination of preterm and full-term infant cries: the long-time average spectrum

The acoustic characteristics of crying behavior displayed in 2 groups of newborn infants are reported. The crying episodes of 10 full-term and 10 preterm infants were audio recorded and analyzed with regard to the long-time average spectrum (LTAS) characteristics. An LTAS display was created for each infant's non-partitioned crying episode, as well as for 3 equidurational partitions of the crying episode. Measures of first spectral peak, mean spectral energy, and spectral tilt were revealing of differences between full-term and preterm infants' non-partitioned crying episodes. In addition, the full-term infants demonstrated significant changes in their crying behavior across partitions, whereas the preterm infants changed little across the crying episode. Discussion focuses on possible differences between full-term and preterm infants in their neurophysiological maturity, and the subsequent impact on their speech development. The importance of examining entire crying episodes when evaluating the crying behavior of infants is also discussed.

The influence of background clinical data on infant pain assessments

The purpose of this study was to determine the importance of knowledge of clinical background data on nursing assessments of infant pain. In a quasi-experimental design, the infant pain assessments of two groups of pediatric nurses were compared. Both groups assessed the levels of pain of the same videotaped infants. One group also read clinical background data about each infant; the other group did not. The group who read clinical background data evidenced higher mean levels of assessed pain per videotaped infant than did the group who only viewed the videotapes. Findings underscore the importance of clinical data and clinical context in the process of assessing infant pain and the risk of underestimating pain when all factors are not considered.

Preverbal, Early Verbal Pediatric Pain Scale (PEPPS): development and early psychometric testing

The Pre-Verbal, Early Verbal Pediatric Pain Scale (PEPPS) is conceptualized to measure the established pain response in toddlers, a pediatric group void of pain assessment scales. It consists of seven categories, each with weighted indicators. Scores can range from 0 to 26. Using a blinded, cross-sectional design, 40 children, aged 12 to 24 months, were videotaped throughout their postoperative stay in the postanesthesia care unit. Vignettes were randomly selected and viewed by four experienced pediatric nurses. Results indicated that the PEPPS was easy to use and demonstrated acceptable inter-rater and intrarater reliability. Early evidence of construct validity was established by statistically significant differences in premedication and postmedication pain scores.

An ethical investigation into the provision of pain relief in infants

This article examines issues relating to the pain experienced by infants and the nursing care they receive in the context of universal ethical principles. The intention is to show that ethics is not a remote intellectual pursuit but has the potential to directly affect and enhance the care given to infants in pain. The author maintains that the consequence of using an ethical approach is that the relationship between infant and carer is infused with improved communication and greater self-awareness.

Symptom management outcomes. Do they reflect variations in care delivery systems?

OBJECTIVES

Symptom management is increasingly recognized as a critical element of patient care, particularly in managing chronic illness. However, research on outcomes related to symptom management is in its infancy, except for the symptom of pain. This symptom was therefore chosen as a prototype to review the state of the science regarding relations between organizational variables and symptom management outcomes and to illustrate the issues regardless of the symptom managed. This article discusses pain outcome measures appropriate for acute and cancer pain, proposes attributes of the care delivery system that may affect outcome measures, and identifies challenges associated with this type of research.

METHODS

Review of quality assurance studies raises issues concerning the adequacy of currently used outcomes for pain and satisfaction with pain management. Although considerable effort has been expended in developing pain measurement in adults and children, critical issues for examining pain management outcomes include deciding what perspectives should be used as the most valid indicator of the pain outcome and when the measures should be obtained.

RESULTS

Critical concerns are raised about the measure of satisfaction with pain management and its appropriateness as the end-result outcome. A key issue is whether respondents actually disentangle satisfaction with pain management from satisfaction with other aspects of care, including caring dispositions of health-care providers. Finally, the question is raised: Are pain outcomes affected by organizational context?

CONCLUSIONS

Although the answer to this question is unknown, a few research studies suggest that organizational context is likely to influence pain outcomes. It is clear, however, from ongoing work that until several conceptual, methodological, and analytic challenges are resolved, research is unlikely to capture the influence of variations in care delivery systems on symptom management outcomes.

The influence of length of pediatric nursing experience on key cues used to assess infant pain

This study examined (1) the influence of continuing education and length of pediatric nursing experience on infant pain assessments, (2) length of pediatric nursing experience on the cues used in making these assessments, and (3) the relationships between cues and assessed levels of pain. The convenience sample consisted of 20 nurses with less than 1 year of pediatric nursing experience, 20 nurses with more than 1 year of pediatric nursing experience but less than 5 years, and 24 nurses with more than 5 years pediatric nursing experience. All had at least a Bachelor of Science in Nursing degree. Participants assessed videotaped infants in varying degrees of pain, as determined by an expert panel. Results fit with, and provide some quantitative illustration for, the model of clinical nursing development as described by Benner and coworkers. More experienced nurse participants agreed more with the expert panel on levels of assessed pain than the other nurse participants. Similarities and differences in the relationship between key cues and level of assessed pain among nurse participants with differing lengths of pediatric nursing experience are presented and discussed.

Modes of thought, feeling, and action in infant pain assessment by pediatric nurses

The components of the assessment process are identified and compared from an ethnography of the methods used by 65 pediatric nurses to assess the level of pain in a sample of infants younger than 1 year of age. Nine different modes of thought, feeling, and action were referenced in reaching judgments about pain levels. The five predominant modes were: deductive, clinical, inductive, testing, and knowing the infant. Over time, the participants had developed a preference for particular combinations of the elements which constitute these modes: repeated use of these preferred assessment methods gave more experienced pediatric nurses distinctive styles of pain assessment. Nurses demonstrated a wider "repertoire" of knowledge about how to assess pain than they customarily used: the selection of particular repertoire items varied by nurses' initial estimates, experience level, and personal assessment style. Findings support the proposition that an understanding of the infant pain assessment process must include nurses' selection and customary use of knowledge and data available to them, as well as the intrinsic nature of that information.

Meanings of discomfort and fussy-irritable in infant pain assessment

The purpose of this study was to describe the clinical meaning and customary use of the terms discomfort and fussy-irritable by pediatric nurses. This descriptive study used a purposive sample of 60 pediatric nurse participants who had a Bachelor of Science in Nursing degree and different lengths of pediatric nursing experience. Participants were interviewed as they assessed pain levels of videotaped infants. Interviews were analyzed with both qualitative and quantitative descriptive methods. Qualitative findings suggest that for participants, "discomfort" meant noxious sensations for which narcotic analgesics would not be appropriate management, and "pain" implied noxious sensations for which narcotic analgesics were warranted. "Fussy-irritable" meant mild infant arousal that did not demand urgent attention. Quantitative findings showed that: (a) assessments of fussy-irritable were consistent with qualitative findings, but assessments of discomfort were not, and (b) pediatric nurses are socialized concerning the clinical meanings of these terms between their first and fifth year of pediatric practice. This study identifies clinical meanings implicit in the assessment terms of "discomfort," "pain," and "fussy-irritable" and shows that individual participants did not always use terms in the same way. Inconsistent meanings and use of such terms can confound communication among nurses and hamper the learning of infant pain assessment by novices.

Distribution of cues across assessed levels of infant pain

A convenience sample of 24 more experienced, 20 less experienced, and 20 novice nurses assessed videotaped infants in varying degrees of pain (none, mild, moderate, and severe), as determined by an expert panel. Participants identified all information they used in making an assessment (All cues) and that subset they deemed most important (Key cues). Data were analyzed using a two-level analysis of variance (level of assessed pain and pediatric nursing experience). Forty-five of the 62 cues mentioned by participants did not differ across levels of pain. Eleven All cues and 11 Key cues differed between infants in pain and not in pain, suggesting that these cues may be potentially useful as predictors of the presence/absence of pain. Three All cues differed both between pain and no pain as well as between levels of pain, which suggests that participants' awareness of subtle leveling might be used in the discrimination of a wider range of pain levels. Differences in cue utilization among the more experienced, less experienced, and novice participants are discussed.

Relationship of cues to assessed infant pain level

Cues that 46 pediatric nurses with a BS in Nursing reported as key to their pain assessments of 88 videotaped infants, ages 0 to 12 months, are identified. Frequencies with which these cues were used for infants of different ages and the relationships between key cues and assessed levels of pain are described. Greater pain was strongly associated with tears, stiff posture, guarding, and fisting. Greater pain was moderately associated with inadequate type or dosage of analgesia, more recent surgery, inconsolability, difficult to distract, does not focus on surroundings, frown, grimace, wrinkled face, flushed face, pain cry, and increased arousal in response to touch of sore area. Internurse variability in cue use was sizable. Most of the often-used cues had weak or no association with assessed pain level. Only consolability, pain cry, grimace, and stiff posture were frequently used and correlated > .51 with assessed level of pain.