Clinical Guidelines (Nursing)

Neonatal Pain Assessment

  • Introduction 

    Definition of Pain 

    Definition of Terms

    Aim

    Definition of Terms

    The Modified Pain Assessment Tool (PAT)

    • How to complete the mPAT Score
    • Special Considerations when Completing the mPAT Score
    • Frequency of Pain Assessment
    • Documentation
    • Interpreting the mPAT Score

    Nursing Comfort Measures

    Companion Documents

    Family Centered Care

    Links

    References

    Evidence Table 

    Introduction

    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.

    Definition of Pain

     “…an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 1989)

    Definition of Terms

    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.  

    Aim

    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 Modified Pain Assessment Tool  

    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 ( Table 1).
    • 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)

    mPAT table1

    Adapted from O’Sullivan et al. (2016)

    How to complete the mPAT Score

      • Observe neonate and score the following items: behavioural state, colour and facial expression.
      • Then gently touch the neonate’s limb to assess muscle tone.
      • Score the neonate for each of the physiological and behavioural parameters, and for the nurse’s perception of pain.
      • Each item is scored from 0 to 2, and added to generate a total score out of 20 (the higher the score, the higher the level of pain).
      • If a baby is muscle-relaxed the total score is out of 10, since a muscle-relaxed neonate can only be scored on the physiological indicators of pain, not the behavioural indicators of pain.

      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.

      Special Considerations when Completing the mPAT Score 

      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.

      • Preterm infants have a hypersensitivity to sensory stimuli. This may be demonstrated by an exaggerated response to painful stimuli, such as during adhesive tape removal or during moving/handling.
        • A higher baseline heart rate and respiration rate may be normal for premature neonates. 
        • Fluctuating heart rates and oxygen saturations also may be normal for premature neonates.
        • This needs to be taken into consideration for the premature neonate, however, if there are variations from what is normal for the individual premature neonate, then this needs to be accounted for in the mPAT score.
      • Neonates with neurological impairment may exhibit altered processing and modulation of pain. These patients may not display the usual behavioural and physiological responses to pain. E.g. during a heel lance procedure a neonate with neurological impairment may not exhibit facial grimace and change in heart rate.  
      • Neonates who are receiving inotropic support may have an altered heart rate and blood pressure, which will affect the outcome of the mPAT score.
        • These altered baseline heart rate and blood pressures need to be accounted for in the mPAT score, and any changes from this new baseline needs to be documented in the mPAT score accordingly.
      • Neonates may appear pale/blue/grey/mottled/dusky for a variety of reasons including; low haemoglobin levels, congenital heart disease, or other disease processes. This abnormal colour may be normal for the neonate. This should be accounted for in the mPAT score, however, variations from the neonate’s normal should also be accounted for in the mPAT score.
      • Intubated and ventilated neonates can still cry, although it will be a silent cry, this should be accounted for in the mPAT score.
      • Vulnerable neonates may learn to become helpless in order to restore energy, especially when constant attempts to communicate pain are unrecognised.  E.g. a neonate, who has frequently been exposed to painful stimuli, does not respond to a nasogastric tube insertion or heel lance procedure or nappy change.  This does not mean that they are not experiencing pain, but they have learnt this behaviour in order to conserve their energy.
      • Patients who are receiving muscle-relaxants can only have a score based on physiological changes; hence the mPAT score becomes a maximum of 10. Adequate analgesia and sedation needs to administered before muscle-relaxing a neonate.
      • Sedation may mask the neonate’s response to painful stimuli. Sedation does not provide pain relief. Sedation should be combined with analgesia.

      Frequency of Pain Assessment 

      Frequency of pain assessment will depend on the clinical situation.  If pain is a concern then frequency of scoring can be increased. 

      • Baseline mPAT scores should be completed at least once per shift for all neonates.
      • Score immediately post-op and continue hourly mPAT scores until stabilised and analgesia optimal. 
      • Minimum 4 hourly mPAT scores should then be recorded for a minimum of 48 hours post-op or until analgesia is ceased for 48 hours.
      • mPAT scores should be completed prior to and following any invasive procedures.
      • Score ½ hour after any analgesic interventions to establish effectiveness
      • Neonates who are ventilated or receiving analgesia should have mPAT scores recorded at a minimum of 4 hourly.
      • Long-term ventilated patients should have at least one mPAT score at commencement of each shift.

      Documentation 

      • After completing the mPAT score, the number should be documented on the EMR (Electronic Medical Records) observation flowsheet.
      • Document the correct time the mPAT score was taken, and the context of the score during this time, for example, awake or asleep or heavily sedated.
      • Document any special considerations that were taken when completing the mPAT score within EMR.
      • Hand over these special considerations to the next shift to ensure consistency in pain assessment.
      • Document interventions and effectiveness of interventions in the appropriate location within the EMR.

      Interpreting the mPAT Score

      Pain management must be individual to each patient and situation, however, RCH recommends: 

      • mPAT scores should provide a trend for each patient, allowing analgesia to be titrated as required.
      • Nursing comfort measures should be provided as a first step of management and in addition to any analgesia required.
      • A stepped approach should be used for pain management:
        • Non-opioid analgesia should be considered for mild to moderate pain.
        • Opioid analgesia in combination of non-opioid analgesia is reserved for moderate to severe pain.
        • The following is to be used as a guide only, clinical judgment and collaboration with the multidisciplinary team is advised (Table 2).

      Table 2:

      mPAT Score Intervention
      <5 Nursing Comfort Measures (NCM)
      >5 Paracetamol/Clonidine/Other Non-Opioid Analgesia with NCM
      >10 Opioids with Non-Opioid Analgesia/Analgesia Dose Adjustment with NCM


      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.

      • mPAT scores should be discussed as part of both nursing and medical handovers.
      • Nurses can also initiate more frequent pain assessment scoring if they believe a neonate is in pain.
      • If mPAT scores are consistently low then weaning analgesia should be considered. However, a low mPAT score does not mean that a neonate is ready for their analgesia to be weaned, it indicates that the
      • neonate has adequate analgesia for their current condition.
      • Likewise, a high mPAT score does not ‘justify’ the requirement for analgesia. It indicates that the current analgesia being provided is inadequate for the neonate’s current condition.
      • Clinical judgment and collaboration with the multidisciplinary team may also be used in conjunction with the mPAT scores to ensure adequate pain management.
      • mPAT scores should be reviewed by medical staff prior to weaning or increasing analgesia. 

      Nursing Comfort Measures

      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.

      • Breastfeeding by mother as appropriate
      • Repositioning - positioning the neonate, appropriate to their gestational maturation, supporting limbs/ trunk and taking care with any attached lines or equipment (i.e. supine or side lying). Rolls or position aids (or nests) can also be used.
      • Swaddling - neonates can be wrapped in a cloth or blanket, with their arms and legs tucked in, to make them feel secure.
      • Nesting - a positioning aid or roll that is placed around the neonate to help contain them and make them feel safe and secure by imitating a womb-like environment. It also helps keeps the neonates limbs in alignment when they cannot be wrapped or swaddled.
      • Facilitated tucking - holding a neonate so that their limbs are in close proximity to the trunk. The neonate is held side lying in a flexed position. This technique involves touch and positioning, and promotes a sense of control and security for the neonate.
      • Containment holding - the caregiver can use two hands to hold the baby and make them feel secure (i.e. one hand on the baby’s head and one on their feet).
      • Decreasing environmental sensors (noise/ light)
      • Tactile soothing - still gentle touch can be provided by caregivers placing their hand on the neonate’s head and abdomen/back.
      • Talking to neonate
      • Nappy change
      • Non-nutritive sucking - refers to the use of a dummy to promote sucking without breast milk or infant formula.
      • Allowing neonate to grasp a finger
      • Skin to skin care for the newborn (Kangaroo Care) - nursing of the neonate on the bare skin of their mother or father, upright at a 40-60 degree angle and covered by parent’s shirt/gown, with an additional blanket as required.
      • Clustering, developmental or cue based care - grouping care to minimise the number of times a neonate is handled. By reducing episodes of handling, periods of sleep can be protected and stress can be minimised. If neonates are displaying signs of stress (such as increased heart rate or facial expression), fewer procedures can be clustered on the next occasion and comfort measures can be provided.

      Also Consider

      Family Centered Care

      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.

      Companion Documents

      Links

      References

      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.

      Evidence Table

      Neonatal Pain Assessment Evidence Table 


      Please remember to  read the disclaimer


      The 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.