Behavioral and Physiological Indicators of Procedural and Postoperative Pain in High‐Risk Infants

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CLINICAL ISSUES

Behavioral and Physiological Indicators of Procedural and Postoperative Pain in High-Risk Infants Pamela S. Beacham

Nurses play a critical role in the assessment and management of infant pain. In this article, infant pain assessment tools that are valid, reliable, clinically sensitive, and developmentally appropriate are discussed. Their purpose, use in acute pain, and applicability for premature and newborn infant populations are described. Behavioral and physiological indicators of pain, sleep-wake states, and infant development are discussed as important considerations in pain assessment. Recommendations for improving pain assessment practices are offered in conclusion. JOGNN, 33, 246-255; 2004. DOI: 10.1177/ 0884217504263267 Keywords: Acute pain—Behavioral indicators of infant pain—Infant pain—Neonatal pain—Pain assessment—Pain assessment tools—Physiological indicators of infant pain Accepted: June 2003 Nurses play a critical role in the assessment and management of infant pain. However, studies have consistently shown that nurses tend to underestimate and undermedicate infant pain (Barker & Rutter, 1995; Johnston, Collinge, Henderson, & Anand, 1997). Research indicates that nurses are inconsistent in their practices of assessing infant pain and in using available assessment tools (Twycross, 1999). In addition, nurses need education related to pain assessment, interpretation of pain behaviors, and evaluation of the effectiveness of pain management (Abu-Saad, Bours, Stevens, & Hamers, 1998; Franck, Greenberg, & Stevens, 2000; Hudson-Barr, Duffey, Holditch-Davis, Funk, & Frauman, 1998; McCaffery & Ferrell, 1997; Stevens, Johnston, & Gibbons, 1998). 246 JOGNN

Choosing a pain assessment tool or a set of pain indicators is the first step in implementing a consistent approach to pain assessment in neonates. Nurses need to make informed decisions about pain assessment in infants and to select tools that meet guideline specifications for psychometric soundness, clinical sensitivity, and developmental appropriateness. They must know the indicators that have demonstrated the strongest relationship to pain in infants and must consider the conditions (type of pain, such as surgical, procedural, or chronic pain) and the neonatal population (gestational age groups) in which the indicators have been used. To guide decisions regarding pain assessment, nurses also need to know about the development of the infant’s pain response system. In this article, we describe how individual pain indicators have been defined and measured in assessment of acute procedural pain and postoperative pain and summarize what is known about the indicators commonly used in multidimensional pain assessment tools for neonates and infants. In addition, questions are identified that need to be asked when evaluating assessment tools for clinical use and strategies are presented for achieving a developmental approach to pain assessment in high-risk infants.

Review of the Literature The indicators used in pain assessment tools for neonates have been generated from the literature; from nurses and physicians working with infants; and from direct observations of full-term infants undergoing procedures such as heel-sticks, immunizations, and circumcisions (Porter & Anand, 1998). Similarly, acute procedural pain has been Volume 33, Number 2

TABLE 1

Behavioral and Physiological Indicators of Infant Pain

Indicators

Definitions

Change With Pain

I. Physiological indicators Vital signs (heart rate, Measure of change from baseline respiratory rate, blood pressure) (% increase or change, or mean change) Oxygen saturation Measure of % decrease or change from acceptable baseline II. Behavioral indicators Facial expression Negative facial expression (frown) or discrete facial actions (e.g., grimace, brow bulge, eye squeeze, nasolabial furrow) Cry Fundamental frequency; change in mean spectral energy (MSE) or latency to cry; duration and total cry time

Body movements

Movement (squirming, kicking); protective (guarding); postures (arching, rigid, tense); changes in muscle tone

studied extensively in premature infants (Franck, Greenberg, & Stevens, 2000; Franck & Miaskowsi, 1997; Stevens, Gibbins, & Franck, 2000). However, postoperative pain and chronic pain in neonates have received considerably less attention. Common indicators of pain are summarized in Table 1. It is critical to understand that pain indicators may vary in their usefulness and applicability across various types of pain. For example, an overall increase in respiratory rate may be an appropriate indicator of procedural pain, whereas changes in respiratory pattern (rate, including depth and other characteristics) may be a more useful indicator for postoperative pain. Conversely, respiratory rate has generally not been included as an indicator on measures of chronic pain.

Physiological Indicators Procedural Pain Physiological indicators used in the assessment of acute procedural pain in infants include heart rate, heart rate variability (or vagal tone), oxygen saturation, arterial PaO2, respiratory rate, intracranial pressure, blood pressure, and palmar sweat. Physiological indicators have been reported in studies evaluating the neonate’s response to such aversive but routine aspects of care as nasopharangeal and endotracheal suctioning (Blauer & Gerstmann, 1998; Pokela, 1994), and during procedures such as heel-stick, percutaneous catheter placement, arterial March/April 2004

Increased Decreased

Increased

Factors That Influence Response Age, behavioral state, health Behavioral state Pulmonary status Age, behavioral state, severity of illness, prior pain experience, possibly gender Age, behavioral state, severity of illness, prior pain experience

Increase in MSE and frequencies, decreased latency, increased duration and total cry time Changes from baseline Age, behavioral state, severity of illness, medications

venopuncture (Laarson, Tannfeldt, Lagecrantz, & Olsson, 1998), and lumbar puncture (Porter, Miller, Cole, & Marshall, 1998). In general, heart rate, respiratory rate, intracranial pressure, blood pressure, and palmar sweat increase with pain and decrease in response to either anesthesia or analgesia or both, whereas the converse is true of oxygen saturation, arterial PaO2, and heart rate variability (Craig, Hadjistavropoulos, Grunau, & Whitfield, 1994; Craig, Whitfield, Grunau, Linton, & Hadjistavropoulos, 1993; Harpin & Rutter, 1982; Johnston, Stevens, Yang, & Horton, 1995; Marshall, Deeder, Pai, Berkowitz, & Austin, 1984; Maxwell, Yaster, Wetzel, & Niebyl, 1987). Of these indicators, vital signs and oxygen saturation are the most accessible and easiest to monitor at the bedside. Virtually all infants, including the smallest and sickest, have demonstrated an ability to mount an acute physiological response to painful and aversive stimuli. However, the magnitude of vital sign changes reported differs from study to study, from infant to infant, and from noninvasive to invasive phases of specific procedures such as the swab to cleanse and lance phases of heel sticks. Because vital sign changes are not specific to pain (Barr, Rotman, Yaremko, Leduc, & Francoeur, 1992; Gunnar, Connors, Isensee, & Wall, 1988), they should be used in conjunction with other behavioral and contextual indicators to measure procedural pain (Craig et al., 1993; Grunau & Craig, 1987; Johnston, Stevens, Craig, & Grunau, 1993).

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Postoperative Pain Physiological indicators used in the assessment of postoperative pain in infants include heart rate, heart rate variability (or vagal tone), oxygen saturation, respiratory rate, and blood pressure. Physiological changes have been reported by researchers, who evaluated responses to circumcision and the effectiveness of various anesthetic techniques and analgesics. Most researchers have reported significant mean increases in heart rate and blood pressure and decreases in heart rate variability and oxygen saturation, regardless of anesthetic techniques. However, the combined use of dorsal penile nerve block and local anesthetics resulted in the most significant attenuation in physiological response (Benini, Johnston, Faucher, & Aranda, 1993; Kirya & Werthermann, 1978; Marchette, Main, Redick, Bagg, & Leatherland, 1991; Williamson & Williamson, 1983). Physiological changes are also attenuated with analgesia. Physiological and hormonal indicators (such as cortisol, epinephrine, and blood glucose) have been used to evaluate the effectiveness of both anesthesia and analgesia in premature and full-term infants undergoing cardiothoracic surgery (Anand & Hickey, 1992; Anand, Sippell, & Ansley-Green, 1987). These studies documented the infant’s capacity for a profound metabolic and endocrine response to major surgery but cardiorespiratory changes (heart rate, respiratory rate, blood pressure, and oxygen saturation) were not reported. In a more recent study, Franck, Boyce, Gregory, et al. (2000) reported that measures of heart rate, respiratory rate, and blood pressure were confounded by severity of illness and the administration of anesthesia and neuromuscular blockade in extremely premature infants in the immediate postoperative period following ligation of the patent ductus arteriosus. Similarly, Buttner and Finke (2000) concluded that physiological indicators such as blood pressure, heart rate, and respiratory rate were unreliable in predicting postoperative analgesic demand in newborns and infants undergoing a variety of nonemergent surgeries.

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ain assessment in preterm infants should include both behavioral and physiological indicators of pain.

These findings are congruent with studies in older children that showed that vital sign changes are not sustained in protracted acute pain (such as postoperative pain) or chronic pain (Buttner & Finke, 2000; McGrath, 1991). However, physiological measures may be the sole method 248 JOGNN

of assessing pain in infants who are paralyzed for surgery. In addition, some infant pain researchers advocate measuring physiological parameters in conjunction with behavioral measures in infants in the neonatal intensivecare unit (NICU) because exaggerated and protracted stress may be as harmful, or more harmful, than pain (Anand, 1998). Therefore, additional research is needed to determine the reliability of these measures for postoperative pain.

Behavioral Indicators Behavioral indicators are important markers of pain in infants. Three categories of behaviors, facial expression, vocalizations, and motor activity, have been consistently identified in the evaluation of pain for all infants, including premature infants (Hudson-Barr et al., 1998; Stevens, Johnston, & Gibbons, 1998). In addition, sleep-wake states and infant development have been identified as important contextual factors in infant pain.

Facial Expression Procedural Pain. Negative facial expressions have been described as indicators of procedural pain in infants, have been included on most procedural pain assessment tools (Craig et al., 1993; Stevens & Johnston, 1994; Taddio, Katz, Ilersich, & Koren, 1997), and have proved the most sensitive and reliable behavioral measures of infant pain (Craig et al., 1993; Grunau & Craig, 1987; Grunau, Johnston, & Craig, 1990; Stevens & Johnston, 1994). For instance, significant increases in individual facial actions were reported between baseline and the tissue-damaging phases of heel-sticks and circumcisions in both full-term and premature infants (Johnston, 1994; Taddio, Goldbach, Ipp, Stevens, & Koren, 1995; Taddio et al., 1997). In addition, facial expression has discriminated between real and sham heel-sticks (Johnston, Stevens, Yang, & Horton, 1996). Predictably, facial activity is reduced with analgesia (Scott et al., 1999). The facial expression indicator is generally included on a pain scale either as a global measure (that is, facial expression such as frown, grimace, or changes in the level of tension in facial muscles) or as a molecular measure (i.e., discrete facial muscle changes such as brow bulge, eye squeeze, and nasolabial furrow). The Neonatal Facial Coding Scale (NFCS; Grunau & Craig, 1987) scores 10 discrete facial muscle changes, whereas the Premature Infant Pain Profile (PIPP; Stevens, Johnston, Petryshen, & Taddio, 1996) uses 3 of these 10 specific facial actions to code facial expression. The Scale for Use in Newborns Tool (SUN; Blauer & Gerstmann, 1998) scores facial muscle tension. Other tools such as the CRIES (Krenchel & Bildner, 1995), the Pain Assessment Tool (PAT; Hodgkinson, Bear, Thorn, & Van Blaricum, 1994), the Volume 33, Number 2

Neonatal Infant Pain Scale (NIPS; Lawrence et al., 1993), and the Neonatal Pain Assessment Tool (NPAT; Friedrichs, Young, Gallagher, Keller, & Kimura, 1995) use the global measure of facial expression. The molecular measure of facial expression is probably the more sensitive indicator and has been reported to distinguish gender differences in pain expression in infants (Guinsburg et al., 2000). However, coding discrete facial actions requires extensive training for observers and may be difficult to score at the bedside by nurses. Therefore, the global measure of facial activity is the more practical measure for clinical pain assessment. Postoperative Pain. Postoperative pain has not received the research attention that procedural pain has in infants. Therefore, we know very little about facial expression as an indicator for postoperative pain. On most postoperative pain assessment tools for neonates, negative facial expression is included as a global measure, such as frown and grimace. However, each tool differs somewhat in how the indicator is defined and weighted. For example, on the CRIES, the PAT, and the NIPS, facial expression changes the total score by 1 to 2 points. For the CRIES and the PAT, this means that all the indicators on the tool are weighted equally. However, on the NIPS and the PIPP, cry is weighted more heavily. On the PIPP, facial expression changes the total scores between 3 and 9 points. Weighting becomes a potentially important issue when one considers the infant who “shuts down” in severe pain and does not respond to pain with facial expression changes. This infant’s maximum pain scores never truly reflect the degree of pain he or she experiences, which may lead to undertreatment of pain.

Crying Procedural Pain. Cry has also been suggested as another behavioral indicator of infant pain. The cry in response to procedural pain has been characterized as an intense, high-energy (more energy in high frequencies of the sound spectrum), and often high-pitched, response of urgency. It occurs immediately or very shortly after the impact of painful stimuli (short latency) and can be differentiated from cries due to hunger, anger, and tiredness (Fuller, 1991; Johnston & O’Shaughnessy, 1988). Differences in cry responses to procedural pain due to gender, state, illness, and postnatal age have also been reported, and responses vary widely among infants (Grunau & Craig, 1987; Johnston & Strada, 1986). For example, more robust cries have been reported in infants who are near full-term, relatively healthy, and who are awake when a procedure occurs, compared with premature, sleeping, or sicker infants (Grunau & Craig, 1987; Hadjistavropoulos, Craig, Grunau, & Whitfield, 1997). In the case of the extremely premature or critically ill

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infant, cry may not be a valid indicator of pain (Johnston, Stevens, Yang, et al., 1996; Johnston, Sherrard, et al., 1999). Extremely premature infants often require mechanical ventilation and therefore cannot verbalize their cry (Johnston et al., 1993). In these situations, facial expression (cry face/grimace) would prove the more valid indicator. Postoperative Pain. Cry has also been measured as an indicator of postoperative pain in full-term and premature infants. The effects of analgesia and anesthesia on postcircumcision pain have been evaluated using cry as an indicator (Benini et al., 1993; Kirya & Werthermann, 1978; Marchette et al., 1991; Williamson & Williamson, 1983). In these studies, crying time and latency to cry have been used as indicators of pain intensity and have been reported as longer and occurring with shorter latency in nonanesthetized controls, when compared with infants who received dorsal penile nerve block with local anesthetics (Benini et al., 1993; Kirya & Werthermann, 1978). In addition, crying time was reduced in infants receiving topical analgesia (Johnston et al., 1993; Taddio et al., 1995, 1997).

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epeated painful stimulation may have substantially greater biological and clinical importance for premature infants than previously realized.

Cry has been included as an indicator on most postoperative pain tools and has been defined and measured in various ways. For example, on the CRIES tool, cry is scored as no cry, high-pitched cry, or inconsolable cry, and higher degrees of crying are indicative of more pain. On the PAT, crying is scored as present or absent. In general, premature infants reportedly cry less frequently and for shorter periods of time due to limited energy reserves (Craig et al., 1993; Johnston, 1994). It follows that sick infants in pain might not cry because they do not have the energy to do so. Therefore, the absence of crying in these infants must be evaluated with caution. Nurses must not assume that the absence of crying indicates an absence of pain.

Body Movements Procedural Pain. Body movements have been studied as indicators of pain in older infants and include such behaviors as kicking; thrashing; trunk, arm, and leg rigidity; and withdrawal of the affected extremity (Craig et al.,

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1993; Franck, 1986). Healthier and more mature infants demonstrate well-defined and purposeful withdrawal of the affected extremity in procedures such as heel-stick and intravenous catheter insertion (Craig et al., 1993; Franck, 1986). Premature infants, reported as hypersensitive to pain, respond to heel-stick with large jerky movements in the affected leg that spread to the other leg and upper extremities (Andrews & Fitzgerald, 1994). Body movements have been included as indicators of pain in several procedural pain assessment tools and characterized as gradations of posture and tone or as degrees of generalized motor activity. Descriptors include relaxed, restless, exaggerated, or flexed and extended. As with cry, the rating of gross motor movements requires nursing judgment. With the introduction of the Neonatal Individualized Developmental Care and Assessment Programs (NIDCAP) in many nurseries, motor behaviors such as startles, twitches, tremors, fluctuations in muscle tone, arching, squirming, and fingersplay have been identified as common behaviors of premature infants under stress (Als, 1982). Recently, Grunau, Holsti, Whitfield, and Ling (2000) evaluated these behaviors as potential indicators of pain and concluded that none of the behaviors were specific to pain. Rather, it is likely that these behaviors reflect the behavioral organization of the infant and are likely to be influenced by illness, environment, and gestational age. Grunau and colleagues (2000) concluded that further use of these behaviors in pain assessment is discouraged until more research is completed. Similarly, Walden et al. (2001) found that none of the NIDCAP motor behaviors were sensitive or specific to pain in premature infants. Postoperative Pain. Body movements are included on postoperative pain assessment tools developed for newborns and older infants. For example, body movements are included as an indicator on the PAT and are measured as posture and tone. In general, body movements have not been studied to the same extent that other behavioral measures have, so little is known about the significance of this constellation of indicators as measures of postoperative pain. Extremely premature infants typically cannot maintain muscle tone and posture when critically ill, becoming limp and flaccid (Johnston, Stevens, Yang, & Horton, 1995). This may result in lower pain scores as these indicators are currently conceptualized. In postoperative or procedure-related situations in which there is high likelihood that the infant is experiencing pain, pain should be assumed and interventions should be maximized to eliminate pain despite the absence of expected behavior. Newer tools such as the Neonatal Pain, Agitation, and Sedation Scale (Hummel & Puchalski, 2000) and the Distress Scale for Ventilated Newborn Infants (Sparshot, 250 JOGNN

1996) have incorporated these behavioral extremes and may prove to be more sensitive as indicators for critically ill and extremely premature infants. However, these tools are in the initial phases of psychometric testing.

I

nfant state affects infant pain response and must be considered for accurate pain assessment.

Effect of Infant State on Pain Response Sleep-wake state is of critical importance in the assessment of pain in all infants because state influences the infant’s ability to respond to stimulation (Holditch-Davis & Hudson, 1995; Prechtl, 1974). Therefore, regardless of whether state is included on the pain assessment tool, nurses need to be cognizant of infant state to make accurate assessments about behavior and to interpret the infant’s response to noxious events correctly. For this reason, state is often referred to as the most important contextual variable in infant assessment (Stevens, Johnston, & Horton, 1994).

Procedural Pain Sleep-wake state affects the infant’s response to pain, and state has been reported to change in response to pain (Gladman & Criswick, 1990). Infants are most receptive to environmental stimulation when alert. Therefore, response to painful stimuli is most vigorous when an infant is awake and alert. Premature infants’ blunted response to pain may be partially explained by the fact that they are rarely alert (Columbo & Horowitz, 1987) and are more likely to slip into deep sleep after painful procedures (Holditch-Davis & Caldwell, 1989). In contrast, full-term infants are more likely to remain awake after painful procedures (Anders & Chalemain, 1974).

Postoperative Pain Postoperative pain has also been reported to alter sleep in infants (Gedaly-Duff & Huff-Slankard, 1998). For example, full-term and premature infants who shut down in response to severe pain experience prolonged periods of non-REM sleep (Emde, Harmon, Metcalf, Koenig, & Wagonfeld, 1971). Some authors refer to the prolonged periods of non-REM sleep as stress sleep (Thoman, 1990). This labeling serves to remind caregivers that this sleep is not synonymous with restful, restorative sleep, nor indicative of a pain-free condition.

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Postoperative newborns experiencing moderate to severe pain have been reported as being awake more than 50% of the time and as having only occasional periods of quiet sleep (Attia, Amiel-Tison, Mayer, Shnider, & Barrier, 1987; Barrier, Attia, Mayer, Amiel-Tison, & Shnider, 1989; Elander, Hellstrom, & Qvarnstrom, 1993). However, the impact of surgical pain in infants has not been well studied. In studies of adults and older children who experience sleep deprivation as a result of acute pain, when the pain was adequately alleviated, normal sleep patterns were restored (Roth & Roehrs, 2000). This may not hold true for premature infants who spend months in the NICU and experience postoperative pain superimposed on more chronic forms of noxious procedural pain and environmental stimulation.

Effect of Infant Development on Pain Responses By 20 weeks gestation, the neural pathways for pain in newborns may be traced from the sensory receptors in the skin to the dorsal horn of the spinal cord and on to the cerebral cortex, implying the capacity for pain at birth, even when born prematurely (Anand, Phil, & Carr, 1989). Although full-term newborns have the same sensitivity to pain as older infants and children, there are several lines of evidence to suggest that premature infants may have a greater sensitivity to pain than full-term infants or older children (Fitzgerald & Beggs, 2001). The most compelling reason is that the inhibitory pathways responsible for the modulation of pain are not mature until after birth (Anand, Phil, & Carr, 1989). This inability to modulate noxious events leads to prolonged periods of hypersensitivity and decreases the infant’s pain threshold, so that even nonnoxious stimuli (i.e., handling) is perceived as noxious (Evans, Vogelpohl, & Bourguignan, 1997). This threshold is further reduced by repetitive pain or local tissue injury (Anand, 1998; Reynolds & Fitzgerald, 1995). Recent evidence suggests that the neuronal expression of new genes that provide the basis for neuronal sensitization and remodeling occurs within 20 minutes of injury and results in lasting changes in pain system response (Carr & Goudas, 1999). Therefore, repeated painful stimulation may have substantially greater biological and clinical importance for premature infants than previously realized (Anand, 1998). Researchers have begun to look at the effects of early pain experiences on children who were born prematurely. Interestingly, when premature infants are compared to full-term infants of the same gestational age (GA), they exhibit less behavioral and greater physiological responses to pain (Grunau, Whitfield, & Petrie, 1994; Johnston & Stevens, 1996). This same pattern of response is seen in very premature infants who have experienced higher numbers of painful experiences (Johnston, Sherrard, March/April 2004

et al., 1999; Johnston, et al., 1999a, 1999b). This is a particularly disturbing finding because caregivers rely heavily on infant behavior when making judgments about pain. It is critical that nurses understand these contradictions and take them into consideration when assessing infant pain.

Recommendations for Practice Several guidelines have recently been developed to improve pain assessment in infants. Included are the National Association for Neonatal Nurses published assessment guidelines for neonates titled Pain Assessment and Management: Guidelines for Practice (Walden, 2001), the joint statement of the American Academy of Pediatrics (AAP) and the Canadian Pain Society (CPS) titled Prevention and Management of Pain and Stress in the Neonate (2001), and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) guidelines for pain assessment in infants and children (1999). Current recommendations for pain assessment in infants includes the use of reliable, valid, sensitive, and developmentally appropriate tools that include both physiological and behavioral indicators of pain. Seven composite tools meeting these guidelines are summarized in Table 2. Each tool was designed with a specific purpose and infant population in mind; these issues should be taken into consideration when choosing a tool for clinical use. For example, procedural assessment tools should not be used to measure postoperative pain until pilot studies have been conducted or other research is available to support use of the tool in that context. Similarly, tools that were developed to assess pain in premature infants may not be considered age-appropriate for a 15-month-old infant.

Procedural Pain Tools Three of the tools, the NIPS, PIPP, and SUN, have been developed as research tools to measure premature and full-term newborns’ responses to acute pain. All three tools have been successfully used in premature and fullterm infants between 28 and 42 weeks gestational age. Of the three tools, the PIPP has been most widely studied across gestational age groups and across the continuum of acute pain (procedural and postoperative). However, because PIPP total scores are adjusted for the gestational age of the infant (i.e., allows points to be added to the total score for younger, more premature infants), pain scores may appear inflated. Because it is possible to obtain a total score of 7 to 8 points in infants who are sleeping quietly, some practitioners have used a “not in pain” designation for these infants, whereas others have adjusted the score cutoff range to 6 points instead of 3 for infants less than 32 weeks gestational age (D. C. HudsonBarr, personal communication, 2003).

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TABLE 2

Multidimensional Pain Assessment Tools for Premature and High-Risk Infants Tool Acronym Name

First Author, Date

Physiological Indicators

NIPS

Neonatal Infant Pain Scale

Lawrence 1993

Breathing

CRIES

CRIES

Krenchel 1995

PAT

Pain Assessment Tool

Hodgkinson 1994

PIPP

Premature Infant Pain Profile

Stevens 1996

Requires O2 to keep saturation > 95% Increases in vital signs Respirations Heart rate O2 saturation Blood pressure Heart rate O2 saturation

DSNVI Distress Scale for Ventilated Newborn Infants

Sparshot 1996

NPAT

Friedrichs 1995

SUN

Neonatal Pain Assessment Tool Scale for Use in Newborns

Blauer 1998

Color Heart rate Blood pressure O2 saturation Temperature (skin, toe) Heart rate Blood pressure Respiratory rate Breathing Heart rate Mean BP

Behavioral Indicators

Facial expression None Cry Arm & leg posture State Cry None Facial expression

Cry Facial expression Sleepless Posture/tone Facial expression (3 discrete facial action codes) Behavioral state Facial expression Body movement

Cry Activity State CNS state Body movement Body tone Facial tone

The Distress Scale for Ventilated Newborn Infants (DSVNI) was developed as a clinical tool to measure distress in mechanically ventilated infants; distress is defined as pain or trauma caused by procedures (heel-stick, intravenous insertion, intubation) and invasive care (endotracheal suctioning) (Sparshot, 1996). The tool has been used in premature infants between 26 and 35 weeks gestational age. This tool has not been extensively tested but was included in our review because of its unique focus on the extremely premature and critically ill infant.

Postoperative Pain Tools The CRIES and the PAT tools have been developed for the clinical assessment of postoperative pain; both were developed for neonates. The CRIES has been used successfully in premature infants as young as 32 weeks gestation and in infants from birth to 15 months of age. The PAT has been used primarily in preterm infants between the ages of 27 and 40 gestational weeks.

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Other Indicators

Context for Use

Age Group

Procedural

Neonates 3240 weeks

Postoperative

Premature infants > 32 weeks, infants to 15 months

Nurse perception of pain

Postoperative

Premature infants 27-40 weeks

Gestational age (points added if < 35 weeks)

Procedural & Postoperative

Premature and term infants 28 to 42 weeks

Procedural

Ventilated and critically ill premature infants 26 to 35 weeks

Clinical data Procedural & (time since Postoperative medication, etc.) Procedural

Premature infants 25 weeks to infants 12 months Premature infants 25-40 weeks

Although most clinicians want to identify one pain assessment tool or a single set of pain indicators that can be used to measure all types of pain in all infants, such composite tools currently do not exist. No single tool stands out as the best for all situations. At present, the most promising measures for clinical practice appear to be the CRIES tool for postoperative pain and the PIPP for procedural pain (Stevens, 1998). The most valid behavioral indicator of acute pain is facial expression, and the most accessible physiological indicators are heart rate and oxygen saturation (Craig, 1998; McGrath, 1998). The DSVNI may prove very useful for assessing pain in ventilated infants but warrants additional psychometric testing. None of the tools presented in Table 2 have successfully captured the pain experience of the extremely premature infant or the critically ill newborn. More research is needed to identify appropriate pain indicators for these infants. In conclusion, infants respond to pain with behavioral and physiological indicators that can be observed by careVolume 33, Number 2

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Marshall, T. A., Deeder, R., Pai, S., Berkowitz, G. P., & Austin, T. L. (1984). Physiologic changes associated with endotracheal intubation in preterm infants. Critical Care Medicine, 12(6), 501-503. Maxwell, L. G., Yaster, M., Wetzel, R. C., & Niebyl, J. R. (1987). Penile nerve block for newborn circumcision. Obstetrics and Gynecology, 70(3, Pt. 1), 415-419. McCaffery, M., & Ferrell, B. R. (1997). Nurses’ knowledge of pain assessment and management: How much progress have we made? Journal of Pain & Symptom Management, 14(3), 175-188. McGrath, P. J. (1991). Multi-centre trials in pain research. Clinical Journal of Pain, 7(4), 262. McGrath, P. J. (1998). Behavioral measures of pain. In G. A. Finley & P. J. McGrath (Eds.), Measurement of pain in infants and children, progress in pain research and management (Vol. 10, pp. 83-102). Seattle: IASP Press. Pokela, M. J. (1994). Pain relief can reduce hypoxemia in distressed neonates during procedures. Pediatrics, 93, 379383. Porter, F. L., & Anand, K. J. S. (1998). Epidemiology of pain in neonates. In K. J. S. Anand (Ed.), Vol. 20(4). England: Wells Medical. Porter, F. L., Miller, J. P., Cole, F. S., & Marshall, R. E. (1998). A controlled clinical trial of local anesthetic for lumbar puncture in newborns. Pediatrics, 66(1), 1-13. Prechtl, H. F. (1974). The behavioural states of the newborn infant (a review). Brain Research, 76(2), 185-212. Reynolds, M. L., & Fitzgerald, M. (1995). Long-term sensory hyperinnervation following neonatal skin wounds. Journal of Comparative Neurology, 358(4), 487-498. Roth, T., & Roehrs, T. (2000). Sleep organization and regulation. Neurology, 54(5 Suppl 1), S2-S7. Scott, C. S., Riggs, K. W., Ling, E. W., Fitzgerald, C. E., Hill, M. L., Grunau, R. V., et al. (1999). Morphine pharmacokinetics and pain assessment in premature newborns. Journal of Pediatrics, 135(4), 423-429. Sparshot, M. (1996). The development of a clinical distress scale for ventilated newborn infants: Identification of pain and distress based on validated behavioral scores. Journal of Neonatal Nursing. Stevens, B. (1996). Pain management in newborns: How far have we progressed in research and practice? Birth, 23(4), 229-235. Stevens, B. (1998). Composite measures of pain. In G. A. Finley & P. J. McGrath (Eds.), Progress in pain research and therapy (pp. 161-177). Seattle: IASP Press.

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Pamela S. Beacham, RNC, MSN, NNP, is a doctoral student, School of Nursing, University of North Carolina at Chapel Hill. Address for correspondence: Pamela S. Beacham, RNC, MSN, NNP, School of Nursing, University of North Carolina at Chapel Hill, CB #7640 Carrington Hall, Chapel Hill, NC 27599-7640. E-mail: [email protected].

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