In this section
Definition of Pain
Definition of Terms
The Modified Pain Assessment Tool (PAT)
Nursing Comfort Measures
Family Centered Care
Neonates frequently experience pain as a result of diagnostic or therapeutic interventions or as a result of a disease process. Neonates cannot verbalise their pain experience and depend on others to recognise, assess and manage their pain. Neonates may suffer immediate or long-term consequences of unrelieved pain. Accurate assessment of pain is essential to provide adequate management. Observation scales, which include physiological and behavioural responses to pain, are available to aid consistent pain management. Pain assessment is considered as the 5th vital sign.
“…an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 1989)
mPAT – modified Pain Assessment Tool; an updated and modified multidimensional observational scale used to assess or measure pain
PAT – Pain Assessment Tool; a multidimensional observational scale used to assess or measure pain
Fleeting desaturation – occurs when oxygen saturations drop to low levels (between the 60’s to 80’s percent) but then quickly increases again to normal levels. They are usually self-resolving, or self-limiting and require no intervention. Considered normal in premature neonates and occurs due to their immaturity.
Muscle Relaxant – a medication given to neonates to paralyse and stop all muscle movement. It is usually used in the NICU to reduce metabolic demand or to stop neonatal movement to protect an airway.
Inotropic support – a medication given as a continuous infusion, which alters the force or energy of systolic myocardial contraction to support the patient’s blood pressure.
Sedated – the neonate is kept calm and put to sleep using a sedative drug, such as midazolam.
Heavily Sedated – the neonate is very sedated, and not easily rousable or unrousable.
COCOON – ‘Circle Of Care Optimising Outcomes for Newborns’ is a model of care on Butterfly Ward to improve the experience of families whose babies are cared for on Butterfly Ward, and subsequently improve neonatal health outcomes.
This guideline is aimed at both nursing and medical staff, and provides an outline for assessing pain in neonates and infants 3-6 months of age, admitted to the Royal Children’s Hospital (RCH) to ensure effective and consistent pain assessment. This guideline focuses on the use of the modified Pain Assessment Tool (mPAT) that is currently used to assess pain for all patients admitted to the RCH Butterfly Ward, Neonatal Intensive Care (NICU).
The mPAT is an observational scale designed to assess neonatal pain. The mPAT is a modification of the original Pain Assessment Tool (PAT) scale that was first developed and piloted on the Butterfly Ward by Hodgkinson, Bear, Thorn & Blaricum (1994). The mPAT scale was modified by O’Sullivan, Rowley, Ellis, Faasse, & Petrie (2016) and piloted at The National Women’s Newborn Intensive Care Unit at Auckland City Hospital, New Zealand. It is a multidimensional pain assessment tool that was specifically designed for neonates undergoing surgical intervention. The mPAT has been validated for surgical and non-surgical neonates, from 24 weeks gestation to full term, up to 6 months old.
It is recommended that mPAT is used for all patients admitted to Butterfly Ward at RCH and can be utilised for both medical and surgical infants 3-6 months of age in other ward areas.
The mPAT scale focuses on the following behavioural and physiological responses to painful stimuli, and includes a nurse’s perception indicator (
• Behavioural signs of pain: posture/tone, sleep pattern, facial expression, colour and cry
• Physiological signs of pain: respirations, heart rate, saturations and blood pressure
Table 1: The Modified Pain Assessment Tool (mPAT)
Adapted from O’Sullivan et al. (2016)
A score of 2 for the ‘nurse’s perception of pain’ should not be given for other factors that are contributing to the neonate’s pain (for example, the presence of an ETT, day 1 post-op, the type of surgery, presence of a chest drain etc). This score should be given however, if the neonate is currently perceived to be in pain as a result of those other factors.
The following considerations present challenges in pain assessment. Continue to use the mPAT score and be mindful of these contextual matters when making changes to analgesia provided.
Frequency of pain assessment will depend on the clinical situation. If pain is a concern then frequency of scoring can be increased.
Pain management must be individual to each patient and situation, however, RCH recommends:
The mPAT score for muscle-relaxed neonates is out of 10, so the threshold to intervene is lower. The threshold to intervene is also lower for heavily sedated neonates.
Nursing comfort measures are non-pharmacological interventions that are very relevant to neonatal and infant pain management. Both healthcare professionals and parents can implement nursing comfort measures prior to or alongside analgesic interventions.
Sometimes it can be difficult for parents to feel involved in the care of their baby, especially in an intensive care or high dependency environment. When completing a pain assessment, healthcare professionals can gain information from the parents about any particular behavioural cues that their baby may be displaying. Healthcare professionals can provide explanations to parents regarding rationales for pain observations and interventions. Parents can be involved and given the opportunity to comfort their child appropriately. This can be achieved by teaching them about cues of distress for their baby and how they can provide developmental care. More information is available on the
COCOON website and via the MyRCH app. This will help improve their confidence as a parent and enable them to be more involved in the care and comfort of their baby.
1. Anand, K.J.S, Stevens, B.J, McGrath (2007) Pain research and clinical management- pain in neonates and infants, Third Edition, Elsevier, pp 19 and 87-90.
2. Australian and New Zealand Neonatal Network (ANZNN), (September 2007) Best Practice Clinical Guideline- Assessment and management of neonatal pain.
3. Australia and new Zealand Collage of Anaesthetics and Faculty of Pain Medicine (ANZCA). (2015) Acute pain management: Scientific Evidence, fourth edition, pp 413-414
4. American Academy of Pediatrics, (February 2016, Policy Statement- Prevention and Management of Procedural Pain in the Neonate: An Update, Pediatrics, Vol 137 (2), pp 1-13.
5. Britto.C.D (2014) Pain- Perception and assessment of painful procedures in the NICU. Journal of Tropical Paediatrics, Vol. 60, No. 6.
6. Burton, J., & MacKinnon, R. (2007). Selection of a tool to assess postoperative pain on a neonatal surgical unit. Infant, 3(5), 188-196. Retrieved from http://www.infantgrapevine.co.uk/default.html
7. Canadian Paeditric Society Statement (January/ February 2000) Prevention and management of pain and stress in the neonate, Paediatric Child Health, Vol 5, No 1, pp 31-38.
8. Cong. X, McGrath. J.M, Cusson. R.M, (2013) Pain assessment and measurement in neonates- an updated review, Advances in Neonatal care, Vol 13, No. 6, pp 379-395.
9. Devsam, B. U., & Kinney, S. (2017). Nurses' Utilisation of the Pain Assessment Tool (PAT) Score when assessing pain in ventilated, sedated and/or muscle-relaxed neonates. Unpublished Manuscript. Royal Children's Hospital, Victoria, Australia.
10. Ehandbook: (2015) http://www.health.vic.gov.au/neonatalhandbook/procedures/developmental-care.htm
11. Gray. L. et al (March 2015) Sucrose and warmth for analgesia in healthy newborns. Pediatrics, Vol. 135, No. 3.
12. Gibbins, S., & Stevens, B. (2001). State of the Art: Pain Assessment and Management in High-Risk Infants. Newborn and Infant Nursing Reviews, 1(2), 85-96. doi:10.1053/nbin.2001.24558
13. Hall R.W, Kanwaljeet J.S, Anand (2014) Pain management in newborns, Clinical Perinatology 41: pp 895-924.
14. Hodgkinson. K, Bear. M, Thorn. J, Blaricum. S.V, (1994) Measuring pain in neonates: evaluating an instrument and developing a common language, the Australian Journal of Advanced Nursing, Vol.12, No.1 pp 17-22.
15. IASP http://www.iasp-pain.org/Taxonomy
16. Lopez.O, Subramanian. P, Rahmat. N, Theam. L. C, Chinna. K and Rosli. R, (2014) The effect of facilitated tucking on procedural pain control among premature babies, Journal of Clinical Nursing, 24, pp 183-191.
17. Merskey. H, (1979) “Pain Terms: A List of definitions and notes on sage” Pain. Vol 6, pp 249-252.
18. O’Sullivan, A. T., Rowley, S., Ellis, S., Faasse, K., & Petrie, K. J. (2016). The Validity and Clinical Utility of the COVERS Scale and Pain Assessment Tool for Assessing Pain in Neonates Admitted to an Intensive Care Unit. The Clinical Journal of Pain, 32(1), 51-57. doi:10.1097/AJP.0000000000000228
19. Twycross. A, Dowden. S, Stinson. J, (2014) Managing pain in children: A clinical guide for nurses and healthcare professionals, Second Edition, Wiley Blackwell.
20. Ranger.M, Johnston.C, and Anand.K.J.S, (2007) Current controversies regarding pain assessment in neonates. Seminars in Perinatology, 31: pp 283-288.
21. Reavey D.A et al (2014) Improving pain assessment in the NICU- A Quality improvement project, Advances in Neonatal Care. Vol.14, No.3, pp. 144-153.
22. Rohan, A.J (2015) Efficacy of Current practices for pain assessment in premature ventilated infants in the NICU exposed to a high number of pain-associated procedures, The American Journal of Maternal/Child Nursing, Vol 40 (6) pp 367-372.
23. Royal Australasian College of Physicians, (2005) Guideline Statement: Management of procedure-related pain in neonates.
24. Royal Prince Alfred Hospital (2005) Newborn care protocol book- Neonatal pain policy- sited 9/11/2005.
25. Spence K. et al (January/ February 2005) A reliable pain assessment tool for clinical assessment in the Neonatal Intensive Care Unit, Journal of Obstetric, Gynecologic and Neonatal Nursing, pp80-86.
26. Twycross. A, Dowden. S, Stinson. J, (2014) Managing pain in children: a clinical guide for nurses and healthcare professionals, Second Edition, Wiley Blackwell.
27. Walker, S.M (2014) Neonatal pain, Pediatric Anaesthesia 24, pp 39-48.
28. Whitted. K. and Vael. A, (Nov-Dec 2014) An educational intervention to improve pain assessment in preverbal children, Paediatric Nursing. Vol. 40, No.6.
Neonatal Pain Assessment Evidence Table
Please remember to
read the disclaimer.
development of this nursing guideline was coordinated by Bianca Devsam, Clinical Nurse Specialist, Butterfly Ward, Neonatal Intensive Care Unit,
and approved by the Nursing Clinical Effectiveness Committee. Updated October 2017.