In this section
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.
“…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 aims to provide nursing, medical & allied health 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).
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 behavioural and physiological responses to painful stimuli, and includes a nurse’s perception indicator (Table 1).
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.
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.
mPAT scores should be reviewed by
medical staff prior to weaning or increasing analgesia.
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.
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.
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.
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 December 2020.