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PAIN AssessmentPAIN Assessment
Najmeh Ajoodanian, MS, NICU
2014
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Pain Perception
• 28 week of gestation
• pain threshold that is 30% to 50% lower than that of adults
• lower pain tolerance than older children
• Premature infants are even more hypersensitive to nociceptive stimuli than full-term infants
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• As the fifth vital sign,
• pain needs to be monitored routinely
in the clinical practice
• infants cannot speak and advocate
Pain . . .
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Pain . . .
• Pain assessment and measurement are the cornerstones of pain management
• The purpose of this review pain measures in both preterm and full term newborns by introducing a conceptual framework
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The International Association for the Study of Pain
(IASP)
“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described
in terms of such damage.”
“Pain is subjective”
defines pain
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FRAMEWORK FOR MEASUREMENT OF NEONATAL PAIN
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Neonatal Pain Responses
• Behavioral
• Physiologic
• Autonomic
• Biochemical
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Behavioral Pain Responses
• Facial expression cleaning the heel or changing diapers
• Facial expression include:
• facial grimacing, brows bulged and furrowed
• eye squeezed, nasolabial furrowing,
• lips opened and pursed, cupped tongue, quivering chin
• agitation.
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Crying is a common response to pain in infants
preterm and acutely ill infants may not audibly cry during heel sticks and other painful procedures silent cry
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Observations of gross motor responses including:
• body movements of arms, legs and trunks,
• Whole body, finger splay and fisting,
• attempts to withdraw from a painful stimulus
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Observation sleep wake alterations
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Physiologic Responses
• increases in heart rate, respiratory rate, blood pressure
• increases intracranial pressure, and palmar sweating
• decreases in transcutaneous oxygen saturation, vagal tone, and peripheral blood flow
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Autonomic Responses
• changes in skin color, nausea, vomiting, gagging
• hiccoughing, diaphoresis, palmar sweating
• dilated pupils
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Biochemical Responses
• increased secretion of catecholamines (ie, norepinephrine and epinephrine), glucagon, and corticosteroids or cortisol
• decreased prolactin, insulin, and immune responses
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Infant Contextual Parameters inPain Assessment
• Age
• Previous pain experiences
• Gender
• Health status
• especially in preterm infants
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Health providers’ knowledge, ability, and
attitudes toward neonatal pain are
significant factors in observation, and using
appropriate pain tools to recognize a
neonate’s pain.
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PAIN ASSESSMENT TOOLS
1. Unidimensional Tools
2. Multidimensional Tools
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Unidimensional Infant Pain Measures
• Designed for measurement of acute/procedural pain
• MAX: Maximally Discriminative Facial Coding System
• NFCS: Neonatal Facial Coding System
• IBCS: Infant Body Coding System;
• DAN: Douleur Aiguë du
• BIIP: Behavioral Indicator of Infant Pain
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Unidimensional Infant Pain Measures
• Designed for measurement of postoperative pain
• CSS: Clinical Scoring System
• LIDS: Livepool Infant Distress Scale
• FLACC: Face, legs, activity, cry, consolability
• UWCH: University of Wisconsin Children’s Hospital Pain Scale
• CHIPPS: Children’s and Infant’s Postoperative
• Pain Scale
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Unidimensional Infant Pain Measures
Designed for measurement of prolonged pain
•BPS: Behavioral Pain Score
•EDIN: Echelle Douleur Inconfort Nouveau-Ne Neonatal Pain and Discomfort Scale
•COMFORTneo: modified from the COMFORT
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Multidimensional Infant Pain Measures
Designed for measurement of acute/procedural pain
•NIPS: Neonatal Infant Pain Scale;
•NPAT: Neonatal Pain Assessment Tool
•PIPP: Premature Infant Pain Profile
•DSVNI: Distress Scales for Ventilated Newborn
•Infants
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Multidimensional Infant Pain Measures
Designed for measurement of acute/procedural pain
•SUN: Scale for Use in Newborns
•PAIN: Pain Assessment in Neonates
•BPSN: Bernese Pain Scale for Neonates
•FANS: Faceless Acute Neonatal Pain Scale
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Multidimensional Infant Pain Measures
Designed for measurement of postoperative pain
•COMFORT Scale (not primarily developed for neonates
•PAT: Pain Assessment Tool
•CRIES
•MIPS: L Modified Infant Pain
•MAPS: Multidimensional Assessment Pain Scale;
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Multidimensional Infant Pain Measures
Designed for measurement of prolonged/ongoing pain
•N-PASS: Neonatal Pain, Agitation, and Sedation Scale
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Premature Infant Pain Profile
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CRIES scale
• C-crying
• R-requires O2
• I-increased VS
• E-expression
• S-sleepless
Simple and easy to use-uses a scale of 1-10, similar to APGAR scoring
score of 4 or greater requires intervention
objective and behavioral categories
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FLACC Scale
• F-face (expression)
• L-legs (tone)
• A-activity
• C-cry
• C-consolability
score is tallied, similar to APGAR (0,1, or 2 for each category)
greater than 4 is indicative of pain
behaviorally based
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Measure Age Level Indicator Pain Stimulus
CRIES
Preterm & Full- term Up to 60 Weeks gestation age
Crying, requires O2 for saturation, increased vital signs (HR and BP), expression, sleepless
Postoperative Pain
BPSN
Preterm & Full- term neonates Time to calm, skin color, eyebrow bulge with eye squeeze, posture, breathing pattern, heart rate, oxygen saturation
Procedural pain in neonates with or without ventilation
NIPS Preterm & Full- term neonates Facial expression, cry, breathing pattern, arms, legs, state of arousal
Procedural pain
PAT
Full- term neonates Posture, tone, sleep pattern, expression, color, cry, respiration, heart rate, oxygen saturation, blood pressure, nurses perception of infant pain
postoperative pain
PIPP
Preterm & Full- term neonates Gestational age, behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, nasolabial furrow
Procedural and postoperative pain
SUN
Preterm & Full- term infants Central nervous system state, breathing, movement, tone, face, heart rate, blood pressure
Procedural pain
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New Techniques for Pain Measurement
• Heart Rate Variability
• Skin Conductance
• Brain-Oriented Approach
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Thank you for your attention
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References
Cong X. Cusson RM. Pain Assessment and Measurement. Foundations in Newborn Care. 2013;379-395
Kenner C, Lott JW. Comprehensive Neonatal care an interdisciplinary approach chapter 17: Pain in the Newborn and Infant . 2010
Verklan MT, Walden M. Care curriculum for Neonatal intensive care unit 2010