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Pain management in newborns can be quite complex. These patients are non-verbal and are lacking the cognitive skill set to identify pain to a healthcare provider or caretaker. While this communication between those under the age of 1 and others is unable to be established, the assessment and management of pain should still be a priority. When pain is left untreated it has the potential to create both short and long-term negative outcomes with physiologic, behavioral, and hormonal consequences (1).  

Introduction   

When we hear the word pain, most people immediately have a negative association. Pain can illuminate fear, anxiety, and discomfort in each patient that we care for. Pain not managed can produce short- and long-term effects [14]. There are multiple systems that pain can affect, including metabolic, hormonal, behavioral, and physiological changes in the newborn and infant population [9]. When nurses and healthcare professionals are managing pain in newborns and infants, it is important to note that these are critical stages of their life development. The short and long-term effects can be detrimental to the progression of neurodevelopment.  

Defining Pain

To effectively provide proper pain management in newborns, it is essential to understand and review basic knowledge of pain as well as each of this population’s developmental stages. Fostering this knowledge will initiate your success in the overall recognition and treatment of pain in the newborn and pediatric population.  

• Pain is defined as an unpleasant association with stimuli caused by tissue damage, illness, injury, or environmental factors [6]. 

• Stress occurs when a disruption in the equilibrium of the environment occurs. Factors such as physical, chemical, or emotional can contribute to stress [6]. 

According to the American College of Obstetricians and Gynecologists, below are the definitions of pregnancy term by weeks of gestation [2]: 

• Preterm: <37 weeks 
• Early Term: 37 0/7 to 38 6/7 weeks 
• Full Term: 39 0/7 to 40 6/7 weeks 
• Late Term: 41 0/7 to 41 6/7 weeks 
• Post-term: 42 0/7 weeks or greater 

Development

Ages: 1-3 months

• Smile or cry to identify a need 
• Move head side to side 
• Respond to external stimuli 
• See close objects 
• Repetitive movements for brain growth and memory 
• Learns to be comforted by caregivers and starts becoming attached 

Ages: 3-6 months

• Control head movements  
• Follows objects with eyes 
• Starts recognizing faces 
• Different cry tones for different needs 
• Brings hands together  
• Respond to love and affection 
• Props up on arms when on the belly 

Ages: 6-9 months

• Sit without support 
• Babble 
• Respond to their name 
• Understands “no”

Ages: 9-12 months

• Crawling 
• Standing without support 
• Can pick up objects 
• May be upset when separated from caregivers 
• Begins to pull up to stand 

[4, 10]

Identifying Pain

Proper identification, assessment, and treatment of pain can provide significant relief to any patient. Pain assessments are typically utilized to establish location and intensity in verbal patients or patients that can specify the location of a pain source. What about our non-verbal patients, such as infants and newborns?  

Throughout our nursing career, whether one is a newbie or a veteran, we have been instilled with the statement that pain is subjective. When considering pain management in newborns and infants, our objective assessment will be used to identify, locate, and place measurable data for guided treatment. There are a variety of pain scales that are widely used for infants and newborns; these will also be dependent on your facility’s protocols. Each pain scale may be dependent on age, term or preterm newborns, and the causative factor of pain. Knowledge of each of the available pain scales will benefit you in understanding when each would apply to your patient. 

Utilizing assessment and observational data in this age group will indicate physiological and behavioral changes that reflect pain. Understanding the general newborn and infant behavior patterns, medical history, and in conjunction with a proper physical assessment, will guide you in the decision to determine a response to pain, discomfort, or stress.  

Taking all these assessment items into account is critical because adults, newborns, and infants respond to pain differently. Some newborns may remain still when they are in pain to prevent more pain, some may guard a painful site, some will cry loudly, and some may remain silent [9]. Most newborn and infant pain assessment scales rely on behavioral or physiological observations, which can include the following [8]. 

Behavioral:

Crying, facial expressions, body movements, muscle tone, sleep patterns, behavior changes from baseline, ability to be consoled 

Physiologic:

Heart rate, respiratory rate and pattern, blood pressure, oxygen saturation, palmar sweating, skin color, pupil size 

Assessment Tools

NFCS (Neonatal Facial Coding System): 

NFCS is an assessment tool that can be used in preterm, term, and those up to 18 months of age. Units for observation include brow bulge, eyes squeezed shut, deepening of the nasolabial furrow, open lips, vertical mouth stretch, horizontal mouth stretch, taut tongue, chin quiver, lip pursing, and tongue protrusion.  

This is a very straightforward assessment tool with a score of 1 for yes or 0 for no. The higher the score, the increased the likelihood of pain [8].  

EVENDOL (Evaluation Enfant Douleur): 

The pain assessment tool is used for emergency settings and postoperative pain for those ages 0-7. Each unit is given a score of 0, 1, 2, or 3 and includes vocal or verbal expression, facial expression, movements, body postures, or interaction with the environment. According to the scale, usually, the treatment threshold is a total score of 4/15 [3]. 

NPDS (Neonatal Pain and Discomfort Scale): 

Pain assessment tools are primarily used for prolonged pain, discomfort, and stress. This assessment is used for both preterm and term newborns. NPDS requires knowledge of the newborn before the use of the assessment to establish a baseline. The scale assesses facial activity, sleep quality, body movements, consolability, and nurse contact [13].  

CHIPPS (Children and Infants Postoperative Pain Scale): 

This scale is used for newborns up to 18 months of age. Each unit is measured from 0–5-year-olds and includes cry, facial, torso, touch, and leg assessment data [13]. 

PIPP (Premature Infant Pain Profile): 

This assessment scale is utilized in both term and preterm newborns for acute and procedural-induced pain. This pain assessment uses gestation age at birth, behavioral state, heart rate, oxygen saturation, brow bulging, eye squeeze, and nasolabial furrow. Scores of 0, 1, 2, or 3 are given based on the assessed data listed [13]. 

N-PASS (Neonatal Pain, Agitation, and Sedation Scale):  

This pain scale measures acute and chronic pain and uses assessment criteria such as crying/irritability, behavioral state, facial expression, tone of extremities, and variation of vital signs from the patient’s baseline. Each category is rated a -2, -1, 0, 1, or 2 based on the criteria in each section. The age recommendation is for premature newborns to the first 100 days of life [8]. 

NIPS (Neonatal Infant Pain Scale): 

When utilizing the NIPS assessment tool, the nurse measures facial expressions, cry, breathing patterns, arm and leg movements, and state of arousal with a point of 0, 1, or 2. This pain assessment is beneficial for preterm newborns, term newborns, and infants until the age of 1 year [13]. 

FLACC (Face, Legs, Activity, Cry, Consolability): 

The FLACC scale measures acute pain and is often used in critical care settings and for cognitively impaired children. If the patient is awake, a 2–5-minute assessment is indicated, while 5 minutes of assessment data should be collected when a patient is sleeping. Data was collected from facial expressions, leg movements, activity, cry, and ability to be consoled. Each of these assessed units is then rated on a scale of 0, 1, or 2. The FLACC scale is applicable for ages between 6 months and 5 years old [13]. 

CRIES (Crying, Requires increased oxygen administration, Increased vital signs, Expression, and Sleeplessness): 

Data captured from this assessment includes items for assessment, including crying, oxygenation, vital signs, facial expression, and sleepiness, with scores of 0, 1, or 2. This pain scale is used primarily for those 6 months and younger (6). 

COMFORT: 

The COMFORT pain assessment tools can be used for ages 0-7 and have been shown useful in the postoperative period. It’s especially useful for sedated and unconscious pediatric patients. Assessment units measured include alertness, calmness, respiratory distress, crying, physical movement, muscle tone, facial tension, blood pressure, and heart rate. Each item within this assessment is given a score for data assessed ranging from a 1 to a 5 [13]. 

mPAT (Modified Pain Assessment Tool):  

This pain management in newborns scale has been used for patients at 24 weeks gestation to full term, as well as infants up to 6 months of age. Each unit is given a score of 0, 1, or 2, with a total maximum score of 20. The higher the score, the higher the level of pain. The observational units include posture/tone, sleep pattern, expression, cry, color, respiration, heart rate, oxygen saturation, blood pressure, and nurse’s perception. [1] 

Neonatal Infant Parasympathetic Evaluation (NIPE) 

This objective scale measures pain levels by continuous assessment of parasympathetic activity and is typically used during the postoperative period. It’s a relatively new way to measure pain and is measured every 5 minutes through a machine that monitors the patient’s respiratory pattern and other physiological parameters. Therefore, human scoring is not necessary [7]. 

Causative Factors

There is a multitude of causative factors that could create neonatal discomfort, stress, or pain. These can be induced by simple or complex tasks and interventions, such as increased noise or bright lights [5]. Birth injuries will also potentially inflict a pain response during a physical exam, especially when the injured area is touched. Since newborns and infants cannot communicate with examiners, relying on our assessment skills, knowledge of pain management in newborns, and having a sound understanding of medical history is crucial.  

Newborns that are experiencing withdrawals from nicotine or other substances will be very irritable and can be easily mistaken for pain if you don’t have all the relevant information. Once pain is identified, determining the causative factor, and classifying it as acute versus chronic is the next step in providing proper pain management in newborns [11].  

Below are some factors that can contribute to pain [5,11,15]. 

Daily Discomforts:

• Changing diapers  
• Wet or dirty diapers 
• Physical assessment  
• Placement into a car seat 
• Itchy clothing 
• Tight shoes/bows 

Routine Procedures:

• NG tube 
• Foley catheters 
• IV removal 
• Bulb suction 
• Dressing change or removal 

Moderately Invasive Procedures:

• Suctioning with a Delee 
• Heel Stick 
• Phlebotomy 
• IV placements 
• Frenotomy 
• Digit Removal 

Invasive Procedures:

• Surgery 
• Chest tube placement 
• Circumcision 
• Immunization 
• Mechanical Ventilation 

Condition/Disease Acute Pain:

• Constipation 
• Birth trauma/injury 
• UTI 

Chronic Pain:

• Sickle Cell Anemia 
• GERD 
• Necrotizing enterocolitis 
• Epidermolysis bullosa 

Treatment

When pain is identified, providing prompt corrective action for that pain is the next step. For newborns and infants, there is a wide range of treatment options. When applicable, starting with non-pharmacological therapies is typically the first line of treatment. 

 Non-pharmacological treatment options include (12):

– Non-nutritive sucking  

– Holding  

– Rocking 

– Swaddling 

– Kangaroo care 

– Breastfeeding 

– Touching and massage 

– Soothing sounds 

Pharmacological treatments can include (12):

– Oral sucrose

– Topical Ointments

– EMLA

– Tectacaine gel

– Opioids including morphine or fentanyl 

– Oral, IV, or rectal Acetaminophen 

– Subcutaneous lidocaine 

– Deep Sedation or general anesthesia 

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is not recommended in newborns due to potential adverse effects [12]. Each of the established treatment options is typically managed through established protocols within your facility for dosing and frequency of administration. 

Having a clear understanding of these protocols will provide you with the most effective treatment and preventative approach.  

Untreated Pain

When pain is not properly identified and is left untreated, it can result in both short and long-term effects that could be potentially detrimental. 

Repeated pain occurrences have been linked to cognitive development impairments, difficulty with neurocognitive processing, decreased cortical thickness, and hypothalamic-pituitary-adrenal axis dysfunction [14]. Also, leaving pain untreated can lead to mistrust between the caregiver and nurse to provide this to their loved one.  

Newborns and infants with persistent unmanaged pain have also shown increased pain sensitivity, lower immune responses, increased infection susceptibility, decreased wound healing, increased avoidance behavior, and social hypervigilance [11].  

There is ongoing research being done to gain insight into the understanding, but there are still many unanswered questions. These unanswered questions can be due to the non-verbal or undeveloped cognitive skills of this patient population when considering pain management in newborns. This could also be from varying factors that potentially alter responses in these patients from social, medical, gestational age, or delivery history and those historical influences on pain perception.  

While there are so many unanswered questions, there is still proven knowledge of both short and long-term effects of unresolved pain. For nurses, the ability to utilize these assessment tools and treatment options to provide proper pain management in newborns is critical. 

Prevention & Goals

Nursing is one of the most respected professions. Nurses can wear multiple hats and one of the most important is showing compassion for others. A large portion of a nurse’s responsibilities is to identify, measure, and treat pain. Compassion drives nurses to set goals to prevent pain, protect the patient from pain, and educate about pain.  

The frequency in which these pain assessment tools for pain management in newborns are established by evidence-based research to guide and manage pain. Conducting these assessments throughout the shift per your healthcare facilities’ protocols in addition to when we observe changes from our patient’s baseline are keys to effective pain management.  

Educating caregivers on newborn and infant pain and discomfort causative agents, behavioral and psychological indicators, and treatment will help prevent and protect these patients from pain.  

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