Neonatal Pain Assessment

  • Introduction

    Neonates frequently experience pain during their hospital admission as a result of diagnostic or therapeutic interventions or as a result of a disease process. They 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 a 5th vital sign.


    This guideline aims to provide clinical staff an outline for pain assessment in neonates and infants up to 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). 

    Definition of Terms

    • Pain – “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (IASP, 2020)
    • 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 (60-80%) but then quickly resolve to baseline normal levels. They are usually self-limiting and require no intervention. Considered normal in premature neonates and unwell term 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 of systolic myocardial contraction to support the patient’s blood pressure.
    • Sedated – the neonate is kept calm and/or 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. 

    The Modified Pain Assessment Tool  

    It is recommended that the mPAT is used for all patients admitted to Butterfly Ward at RCH and can be utilised for both medical and surgical infants up to 6 months of age in other ward areas.

    The mPAT scale focuses on behavioural and physiological responses to painful stimuli, and includes a nurse’s perception indicator (Table 1).

    Table 1: The modified Pain Assessment Tool (mPAT)

    Posture/Tone Normal/Relaxed 0
    Extended 1
    Flexed and/or Tense 2
    Sleep Pattern Relaxed 0
    Easily Woken 1
    Agitated or Withdrawn 2
    Expression Normal/Relaxed 0
    Frown 1
    Grimace 2
    Cry No 0
    Yes, Consolable 1
    Yes 2
    Colour Pink/Normal 0
    Occasionally mottled/pale 1
    Pale/Dusky/Flushed 2
    Respirations Normal baseline rate 0
    Tachypnoea 1
    Apnoea/Splinting 2
    Heart Rate       Normal baseline rate 0
    Tachycardia 1
    Fluctuating 2
    Oxygen Saturation Normal 0
    Fleeting desaturation 1
    Desaturating 2
    Blood Pressure Normal 0
    Fluctuates with Handling 1
    Hypotensive/Hypertensive 2
    Nurses Perception No Pain 0
    Pain with Handling 1
    Yes Pain 2
    Total Score  

    Adapted from O’Sullivan et al. (2016)

    How to complete the mPAT Score

      a)        Observe neonate and score the following items: behavioural state, colour and facial expression.

      b)       Then gently touch the neonate’s limb to assess muscle tone.

      c)       Score the neonate for each of the physiological and behavioural parameters, and for the nurse’s perception of pain.

      d)       Each item is scored from 0 to 2, then added to generate a total score out of 20 (the higher the score, the higher the level of pain).

      e)       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 be given if the neonate is perceived to be in pain at the time of assessment. It should not be given for other factors that are anticipated to contribute to the neonate’s pain.

      A pain score completed by both medical and nursing staff together may be useful if there are any score discrepancies or concerns.

      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. 

      a) Baseline mPAT scores should be completed at least 8-12 hourly (once per shift) for all neonates

      b) Score immediately post-op and continue hourly mPAT scores until stabilised and analgesia optimal 

      c) 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

      d) mPAT scores should be completed prior to and following any invasive procedures

      e) Score ½ hour after any analgesic interventions to establish effectiveness

      f) Neonates who are ventilated or receiving analgesia should have mPAT scores recorded at a minimum of 4 hourly

      g) Long-term ventilated patients should have at least one mPAT score at commencement of each shift

      Interpreting the mPAT Score

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

      a) mPAT scores should provide a trend for each patient, allowing analgesia to be titrated as required

      b) Nursing comfort measures should be provided as a first step of management and in addition to any analgesia required. 

      c) A stepped approach should be used for pain management:

                i) Non-opioid analgesia should be considered for mild to moderate pain.

                ii) Opioid analgesia in combination of non-opioid analgesia is reserved for moderate to severe pain.

                iii) 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.

      a) mPAT scores should be discussed as part of both nursing and medical handovers

      b) Nurses can also initiate more frequent pain assessment scoring if they believe a neonate is in pai

      c) 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

      d) 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

      e) 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 and trending should be reviewed by medical staff prior to weaning or increasing analgesia. For more information on neonatal pain management please visit the Neonatal Pain Management in the NICU guideline.


      a) After completing the mPAT score, the number should be documented on the observation flowsheet

      b) 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

      c) Document any special considerations that were taken when completing the mPAT score 

      d) Hand over these special considerations to the next shift to ensure consistency in pain assessment

      e) Document interventions and effectiveness of interventions 

      Special Considerations 

      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.

      1. 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.
             i) A higher baseline heart rate and respiration rate is normal for premature neonates 
             ii) Fluctuating heart rates and oxygen saturations also may be normal for premature neonates
             iii) 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 scor
      2. 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. 
      3. Neonates who may be withdrawing from opioids or maternal substance use, may exhibit behaviours that are similar to pain, but are not pain. The WAT1 and NAS assessment tools may be more appropriate for assessing these neonates
      4. Neonates who may be experiencing delirium may also exhibit behaviours that are similar to pain but are not pain. The Butterfly ward is currently trialling the CAPD score for these neonates as a more appropriate assessment.
      5. 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.
      6. 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.
      7. Intubated and ventilated neonates can still cry, although it will be a silent cry, this should be accounted for in the mPAT score.
      8. 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.
      9. 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 MUST be administered before muscle-relaxing a neonate
      10. Sedation may mask the neonate’s response to painful stimuli. Sedation does not provide pain relief. Sedation should be combined with analgesia.

      Family Centred Care

      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.

      Also Consider

      • Invasive painful procedures should only be performed when necessary and clustered with other procedures and cares if appropriate
      • Time painful procedures with parents present (as desired), so they can provide comfort and soothing to their child
      • Ensure hands are not cold when handling neonates
      • Oral sucrose can also be used to support procedural pain management in neonates (Refer to  Sucrose (oral) for Procedural Pain Management in Infants)

      Companion Documents


      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 March 2024.  

      Evidence Table 


      Source of Evidence

      Key findings and considerations 
      De Clifford Faugère, G., Aita, M., Feeley, N., & Colson, S. (2022). Nurses' Perception of Preterm Infants' Pain and the Factors of Their Pain Assessment and Management. Journal of Perinatal & Neonatal Nursing, 36(3), 312-326. doi:10.1097/JPN.0000000000000676  Cross sectional study 

      The results of this study indicate that nurses’ attitudes and perceptions, assessment practices, and pain management interventions were related to contextual factors, such as country, level of care, and work shift, and individual factors, such as age, years of experience, level of education, and had a preterm infant. It is crucial that education and pain guidelines encourage the use of effective interventions, such as sucrose and skin-to-skin contact, improving nurses’ management of preterm infants’ pain. Since level of education influences nurses’ pain care, continuous training on pain assessment and management used in conjunction with skin-to-skin contact and family centred care could improve their management of preterm infants’ pain.  

        Devsam, B. U., & Kinney, S. (2021). The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates. Australian Critical Care, 34(4), 333-339. doi:10.1016/j.aucc.2020.09.005   
        Primary survey- descriptive exploratory  

        The clinical utility of the PAT is acceptable for minimally sedated neonates, however, it decreases the more sedated a neonate becomes, and the PAT’s usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate’s clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability and clinical utility research, particularly in critically ill and muscle-relaxed neonates.    

          Eriksson, M., & Campbell-Yeo, M. (2019). Assessment of pain in newborn infants. Seminars in Fetal & Neonatal Medicine, 24(4), 1-7. doi:10.1016/j.siny.2019.04.003  
           Expert opinion 

          Each unit should have a pain assessment tool that covers the patients that they are caring for and the types of pain that they are experiencing. Pain assessment should be recorded and reported regularly with clear action steps for each level of pain experienced. Continue to validate pain assessment tools that currently exist and gain a deeper understanding of the pain that is experienced by neonates. Health care professionals need to continually assess the uptake and consistency of pain assessment tools in clinical practice.  

            Giordano, V., Edobor, J., Deindl, P., Wildner, B., Goeral, K., Steinbauer, P., . . . Olischar, M. (2019). Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development: A Systematic Review. JAMA Pediatrics, 173(12), 1186-1197. doi:10.1001/jamapediatrics.2019.3351  
            Systematic review of descriptive and qualitative studies 
            According to the present systematic literature research results, various scales assessing pain or sedation have been published with different levels of validity and reliability. We suggest the use of scales that are validated for construct validity, internal consistency, and interrater reliability and further suggest choosing a particular scale based on the population of interest and the construct intended to measure. The PAT is validated to be used in preterm and term neonates for post-operative and prolonged pain.  

              Hodgkinson. K, Bear. M, Thorn. J, Blaricum. S.V, Measuring Pain in Neonates: Evaluating an Instrument and Developing a Common Language, the Australian Journal of Advanced Nursing, 1994, Vol.12, No.1 17-22  
              Systematic review 

              This article explains the development and evaluation of the pain assessment tool (PAT). The PAT scoring system explained as well as an explanation of the scoring terms. Pilot study was undertaken to evaluate the effectiveness of the tool. Article recommended the use of the PAT scoring system to evaluate pain in post-operative and other neonates. Tool was found to be useful and workable.  

                Ilhan, E., Pacey, V., Brown, L., Spence, K., Galea, C., Adams, R., & Hush, J. M. (2021). Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care. Clinical Journal of Pain, 37(6), 397-403. doi:10.1097/AJP.0000000000000931  
                 Systematic review 
                This study of the PAT scores demonstrates that pain in infants in the NICU can be represented by 2 factors, the behavioural pain measures, and physiological pain measures, and that there is a low-to-moderate correlation between these factors. This suggests that the PAT should be conceptualized as measuring 2 different measures of pain with behavioural parameters being more visible indicators of pain than physiological parameters. However, the 2 factors may reflect pain differently according to gestational age at birth and postmenstrual age assessment, indicating the importance of considering both in the assessment of pain in infants in the NICU.  

                   Muirhead, R., Ballard, E., Kynoch, K., Peacock, A., Birch, P., & Lewis, P. A. (2023). A survey of pain practices in the surgical neonate. An Australasian perspective. Journal of Neonatal Nursing, 29(6), 857-861. doi:10.1016/j.jnn.2023.07.010   Primary survey- descriptive exploratory 
                  An electronic survey was administered to one nursing and one medical representative at each of the 15 Australian and New Zealand neonatal surgical units. The Neonatal Pain Agitation and Sedation Scale (NPASS) was most frequently employed, with 39% of units utilizing this tool for pain assessment. The Premature Infant Pain Profile (PIPP) was utilized in 31% of units and the Pain Assessment Tool (PAT) and Modified Pain Assessment Tool (MPAT) were used in 23% of units respectively. The revised PIPP-R: Premature Infant Pain Profile-Revised was utilized in only one unit (8%), and two units (15%) indicated that two separate pain tools were utilized in practice depending on infant gestation. The FLACC (Face, Legs, Activity Cry and Consolability) and CRIES tools were not employed by any Australasian unit. For the two units that did not use a validated pain tool for pain assessment, nurse experience, clinical assessment and ward round discussion were reported as the methods of assessment utilized. The employment of a pain assessment tool in Australian and New Zealand NICUs is high.  
                    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  Primary research 

                    The original PAT has 10 undefined response options—1 for each of the 10 items. Therefore, minor additions were made to these items on the scale to help staff to complete the measure and to improve its consistency. The mPAT is a reliable and valid measure of acute pain in neonates as premature as 24 weeks gestation.