Neonatal Pain Assessment

Neonates are subjected to multiple, necessary, but often painful diagnostic and therapeutic procedures. Neonates cannot verbalize pain, leaving the assessment to physiological factors and the nurses’ judgment.

Adequate and consistent pain assessment can decrease the long term effects and consequences. Proper pain assessment done with every set of vital signs is the key to pain management.

Currently there is a need for evidence-based practice to be systematically applied to pain assessment in the neonatal intensive care unit (NICU),1 and through proper awareness and education, improved outcomes can be achieved.

The Neonate
The neonate is an infant aged from birth through the first 28 days of life.2 A pre-term neonate has been born before 37 weeks gestation. A full-term neonate has been born between 37 and 42 weeks. A post-term neonate has been born past 42 weeks.

While the pre-term, full-term and post-term neonate have different and specific nursing needs, they all feel pain and require proper pain assessment and management.

Neonatal Pain
Term neonates experience pain during routine procedures after birth, such as circumcision, heel sticks and vaccinations. Those in the intensive care unit are often exposed to many more therapeutic and diagnostic procedures that cause pain.3 Preterm infants respond to pain in different ways than their more mature counterpartsand it can be more difficult to assess because the response maybe be diminished or absent.

It was once believed that infants did not feel pain due to an immature central nervous system.4 While few, there are some nurses who do not believe that preterm infants feel pain at all.1 There are other nurses who are unsure of whether neonates can feel pain. Research shows that neonates feel pain, and perhaps feel it more intensely due to an under-functioning pain modulation system.4,5

Inadequate pain management, numerous painful procedures and incessant pain cause disturbances in the development of the immature nervous system, which can cause both short and long term consequences.

Some consequences include reduced pain thresholds and lengthened duration of crying. As childhood progresses, there is an increased occurrence of somatization. Blunting – pain insensitivity as a defense mechanism – has been observed in older children who have been exposed to pain and had a NICU stay.6 While displaying blunting during painful procedures, the children often show an increase in cortisol with routine tasks, indicating a higher stress level.

Other long-term effects of undermanaged pain include decreased pain sensitivity, stress disorders, self-destructive behaviors, impaired social and cognitive skills and attention deficit disorder.3

Pain causes physiological changes involving metabolism, coagulation and the cardiovascular, respiratory, endocrine and immune systems. Pain causes an increase in heart rate, blood pressure and respirations. Sweating, flushing and lower oxygen saturation are also indicative of pain.

A pain response in any infant can be displayed through crying, inconsolability and irritability. As mentioned before, preterm infants communicate pain differently than older babies and children.

Because they are underdeveloped they may exhibit a lessened response. Nurses may miss these cues because they are looking for a typical presentation. A stressed facial expression (eyes squeezed closed, furrowed and bulging brow, mouth open, widened, bulging nose and raised cheeks) and flexion of extremities are indicative of some level of pain.7

Knowing what to assess and assessing consistently is imperative in managing the pain.

Pain Assessment
Pain assessment is often listed as the fifth vital sign.3 Pain assessment in the neonate should be performed at least every three hours and before, during and after procedures.

There are over forty neonatal pain assessment scales that can be utilized by registered nurses. In a Northeast Florida study, the following assessment tools were rated for preference among NICU nurses:3

• Premature Infant Pain Profile (PIPP)
The PIPP assesses points for gestational age, alertness, heart rate, oxygen saturation and facial expression. A score of 0-6 demonstrates minimal to no pain, 7 to 12 reflects mild to moderate pain and a score greater than 12 indicates moderate to severe pain.

• Neonatal Pain, Agitation and Sedation Scale (N-PASS)
The N-PASS evaluates crying/irritability, behavior state, facial expression, tone of extremities and vital signs (heart rate, respiration, blood pressure and oxygen saturation) to assess pain. If the neonate is less than 30 weeks gestation, one extra point is added. A score greater than 3 indicates that treatment is needed. This tool can also be used to assess sedation. Among the NICU nurses surveyed there was no statistical difference in the preference for either tool. The N-PASS was chosen as the standard at the facility due to its comprehensiveness and the sedation component.3

Pain Management
Pain management in neonates can be achieved through several different methods depending on the procedure and type of pain experienced. Non-pharmacological methods include the five S’s – swaddle, suck, shush, swing, side/stomach position – breastfeeding, sweet solution, kangaroo care and massage.

Oral sweet solutions produce an analgesic affect by promoting the release of endorphins.5 A pacifier, for nonnutritive sucking, may be offered after the solution has been administered to increase the effectiveness. Pain reduction with this intervention typically lasts up to ten minutes. Nonnutritive sucking without sweet solutions is offered most to neonates, even when evidence shows that the sucking with sweet solutions provides better pain reduction.4

Evidence suggests that breastfeeding produces similar pain reduction and offers the greatest relief when used in conjunction with a sweet solution and nonnutritive sucking. Breastfeeding also releases endorphins via oxytocin secretion.

Swaddling, skin-to-skin contact and kangaroo care stimulate the proprioceptive system, have a calming effect, and exhibit a markedly reduced physiological response.5 Massage would offer similar relief.

Pharmacologically, topical anesthetics, non-opioid, opioid and blocks such as an epidural can be administered.

Lewis and Murata (2012) compared non-pharmacological methods of pain relief in children receiving vaccinations. Compared to the control group, which only received water and parental comfort, the other groups’ (water/five S’s, sucrose/five S’s, sucrose/parental comfort) pain ratings were significantly lower. There is very little evidence in literature to support the use of pharmacological pain relief, such as acetaminophen, post-vaccine.9

Conclusion
There is a lack of consistency when it comes to pain assessment and pain management for the neonate in the NICU, and a standard of care should be established and utilized consistently to provide better outcomes to the neonates and their families.

Neonates, who undergo numerous painful procedures during their stay in the NICU, can feel pain intensely. If they are assessed properly and the pain is managed appropriately, there should be a reduction of both short and long term negative consequences.

It is imperative to implement evidence-based care in nursing practice. Nurses should utilize solid research to provide increasingly exceptional care.

Nadine R. White graduated from the University of North Florida in August 2012; Julie Baker-Townsend, WHNP B-C, and Judy Comeaux, DNP, ARNP/PNP are professors at University of North Florida.

References
1. P”lkki, T., Korhonen, A., Laukkala, H., Saarela, T., Vehvil„inen-Julkunen, K., & Pietil, A. (2010). Nurses’ attitudes and perceptions of pain assessment in neonatal intensive care. Scandinavian Journal of Caring Sciences, 24(1), 49-55. doi:10.1111/j.1471-6712.2008.00683.x
2. Ward, S. L., & Hisley, S. M. (2009). Maternal-child nursing care: Optimizing outcomes for mothers, children and families. Philadelphia, PA: F. A. Davis Company.
3. Gyland, E. A. (2011). Infant pain assessment: A quality improvement project in a level III neonatal intensive care unit in northeast Florida. Newborn And Infant Nursing Reviews. doi:10.1053/j.nainr.2011.12.007
4. Codipietro, L., Bailo, E., Nangeroni, M., Ponzone, A., & Grazia, G. (2011). Original articles: Analgesic techniques in minor painful procedures in neonatal units: A survey in northern Italy. Pain Practice, 11, 154-159. doi:10.1111/j.1533-2500.2010.00406.x
5. Parry, S. (2011). Neonatal: Acute pain management in the neonate. Anaesthesia & Intensive Care Medicine, 12(Neonatal / Pharmacology), 121-125. doi:10.1016/j.mpaic.2010.12.011
6. Johnston, C. C., Fernandes, A. M., & Campbell-Yeo, C. (2011). Review: Pain in neonates is different. Pain, 152, S65-S73. doi:10.1016/j.pain.2010.10.008
7. Hummel, P. (2009). N-PASS: Neonatal pain, agitation, and sedation scale. Retrieved from http://www.n-pass.com/assesment_table.html
8. Stevens, B., Johnston, C., Petryshen, P., & Taddio, A. (1996). Premature infant pain profile: Development and initial validation. The Clinical Journal of Pain 12(1), 13-22
9. Lewis, R., & Murata, P. (2012). Physical intervention alleviates pain in infants receiving vaccinations. Medscape Education Clinical Briefs. Retrieved from http://www.medscape.org.