Pain assessment: Current status and challenges

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Summary

Neonatal pain assessment has received much attention over the past decade. Behavioural indicators of pain include facial action, body movement and tone, cry, state/sleep, and consolability. Physiological indicators of pain include increased heart rate, respiratory rate, and blood pressure, as well as decreased heart rate variability and oxygen desaturation. Pain assessment in neonates is difficult in neurologically compromised, chemically paralyzed, and non-responsive infants. Multiple pain assessment tools are summarized. Pain assessment and management protocols are delineated.

Introduction

Neonatal pain assessment, an essential component of neonatal care, has received increased attention over the past decade. Historically, neonatal care focused on survival; pain was not recognized or treated. Research studies from 1985 to 1992 by Anand and colleagues on pain and its effects in preterm neonates were instrumental in changing attitudes regarding neonatal pain.1, 2, 3 A survey in 1988 among English anaesthetists showed that 80% of respondents considered neonates capable of experiencing pain, but only 52% ordered opioids after surgery, highlighting the need for education and practice changes.4 A major contributor to non-treatment was the lack of objective pain assessment methods. A variety of valid and reliable pain assessment instruments have been developed over the past two decades. Yet, behavioural pain assessment remains challenging and controversial due to the lack of a gold standard for neonatal pain expression. Integration of pain assessment into daily practice remains problematic.

This paper describes behavioural, physiological and biological indicators for neonatal pain assessment and provides an overview of pain instruments and their content. The multiple challenges surrounding pain assessment and management in daily practice are delineated. The interactions between developmental care, pain assessment, and pain management are discussed.

Section snippets

Behavioural indicators

Facial expression is considered the most sensitive indicator of acute and short-term pain in neonates.5, 6, 7 Total facial activity and a cluster of specific facial features (brow bulge, eye squeeze, nasolabial furrow and open mouth) have been shown to be significantly associated with acute and postoperative pain.5, 8 An example of a unidimensional instrument focusing on facial expression is the Neonatal Facial Coding System (NFCS), which assesses ten discrete facial actions from either

Pain assessment instruments

Various pain assessment instruments have been developed, based on behavioural indicators of pain alone or a combination of behavioural and physiological indicators. Whereas combined instruments are multidimensional by nature, others tend to focus on one behavioural aspect, for instance facial expression in the NFCS.5 Most instruments have been reviewed extensively by other authors.23, 24, 25 Table 1 displays components of 16 different neonatal pain assessment instruments. There is considerable

Challenges in behavioural pain assessment

Pain assessment in the non-verbal patient of any age remains challenging despite recent progress. Physiological and behavioural pain cues might be exhibited with non-painful experiences, leading to clinical difficulties in interpreting the behaviour. Pain and agitation behaviours are difficult, if not often impossible, to differentiate. Some clinicians maintain that pain and agitation are two separate entities, and struggle to distinguish the two behaviourally. Agitation is a broad term, used

Difficulties in clinical pain assessment and management

Pain assessment in the NICU has become commonplace in the United States due to regulatory demands. However, the integration of assessment into practice remains problematic. Pain assessment is often accomplished by the bedside caregiver, usually the nurse, recorded on the medical record, but not acted on by the team. This might be partially due to the lack of evidence-based treatment protocols. Recommendations are more precise for procedural and postoperative pain than for pain in the ventilated

Concluding remarks

Clinicians are continually challenged by neonatal pain assessment and management. Currently, behavioural pain assessment is the cornerstone of pain management but scores should be tempered with common sense and sound judgement, as behavioural pain assessment remains difficult in some infants. The search for biological pain markers should continue. Research is needed to establish clinical utility and significance of existing pain tools. Pain management methods—pharmocological and

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