Pain Final

Pain Assessment
and Management
G u i d e l i n e
f o r
Marlene Walden, PhD RNC NNP CCNS

Sharyn Gibbins, PhD RN NNP
P r a c t i c e ,
n d
E d i t i o n
Pain Assessment and Management

Guideline for Practice, 2nd Edition
This guideline is an outline of the pain assessment and
management practices that currently are accepted and
documented by experts in the field of neonatal care. In
addition, it summarizes and recommends pain assessment and management practices based on the best
evidence for the nursing care of infants. This guideline
does not preclude the use of manufacturers recommendations or other acceptable methods of assessing and
managing pain in infants. The use of other practices
known to improve the quality of neonatal care is encouraged and not restricted by this document.
The National Association of Neonatal Nurses (NANN)
developed this guideline in response to members
requests. Broad in scope, it can provide a foundation
for specific nursing protocols, policies, and procedures
developed by individual institutions.
Authors
Marlene Walden, PhD RNC NNP CCNS
Sharyn Gibbins, PhD RN NNP
Reviewers
Daniel Batton, MD, American Academy of Pediatrics
Sandra Sundquist Beauman, MSN RNC
Jim Couto, MA, American Academy of Pediatrics
Mary Ann Gibbons, BSN RN
Melinda Porter, RNC CNS NNP
Ann Stark, MD FAAP, Chair of AAP Committee on
Fetus and Newborn
Carol Wallman, RNC NNP MS, NANN/AWHONN
Liaison to AAP Committee on Fetus and Newborn
Development and Acknowledgments

This guideline was written by two NANN members with
established expertise in pain assessment and management.
It was modified based on thoughtful comments and editing suggestions of volunteer reviewers.
NANN especially thanks Abbott Nutrition and Childrens
Medical Ventures for providing educational grants for the
publication of this guideline. Abbott Nutrition and Childrens
Medical Ventures had no prior substantive review rights
or input into the content of the guideline.
The following contributors and reviewers are recognized
for their assistance.
4700 W. Lake Avenue

Glenview, IL 60025-1485
800/451-3795
Fax 888/477-6266
www.NANN.org
Publishers note: The product is provided on an as-is basis. National Association of Neonatal Nurses, the authors
and editors neither represent nor guarantee that the content will, if followed, ensure safe and effective patient care.
NANN, the authors and editors assume no liability or responsibility in connection with the content. The content reflects
NANNs judgment regarding the state of general knowledge and practice in this field as of the date of publication and
is subject to change based on the availability of new scientific information. The content is not intended to be a substitute for professional medical judgment, diagnosis, or treatment.
Copyright 2001, 2008 National Association of Neonatal Nurses. All rights reserved. First edition 2001
Second edition 2008
Reproduction, distribution, or translation of this publication without the express written permission of NANN is
strictly prohibited.
ISBN 0-9787636-2-9.
Pain Assessment and Management: Guideline for Practice

Newborn infants, particularly those born preterm, regularly are subjected to a multitude of diagnostic and
therapeutic procedures that are painful but medically necessary to their care (Gibbins et al., 2006; Stevens et al.,
2007). Simons and colleagues (2003) found that infants
born at 2542 weeks gestation experienced an average
of 14 painful procedures per day during the first 2 weeks
of life. The most frequently performed procedures were
nasal, endotracheal, and nasopharyngeal suctioning followed by heelstick and intravenous and nasogastric tube
insertions. The number of procedures encountered by
infants in the neonatal intensive care unit (NICU) is partially due to a substantial number of failed attempts. In
the Simons et al. study, the failure rate for placement of
central venous catheters, peripheral arterial catheters, and
intravenous cannulae were 45.6%, 37.5%, and 30.9%,
respectively. Although most of the procedures performed in this study were rated by physicians and nurses
to be painful (>4 on a 10-point scale), very few infants
received any pharmacologic or nonpharmacologic procedural pain management.
Evidence suggests that the cumulative effects of
repeated painful medical procedures on the developing
brain may be of significant biological and clinical importance (Anand, 1998). Pain can place increased demands
on the cardiorespiratory system (Craig, Whitfield,
Grunau, Linton, & Hadjistavropoulos, 1993; McIntosh, Van Veen, & Brameyer, 1994; Stevens & Johnston,
1994; Stevens, Johnston, & Horton, 1993). In addition,
pain can lead to an elevation in intracranial pressure,
theoretically increasing the risk of intraventricular hemorrhage (Stevens & Johnston; Stevens et al., 1993). Pain
in infants contributes to adverse long-term developmental outcomes, such as decreased sensitivity to common
childhood pain, and a higher incidence of somatic complaints (i.e., physical complaints of unknown origin;
Fitzgerald & Shortland, 1988; Grunau, Whitfield, &
Petrie,1994; Grunau, Whitfield, Petrie, & Fryer, 1994).
This practice guideline, which presents the evidence
for the assessment and management of pain in infants,
is based on scientific literature and clinical recommendations from professional and accrediting organizations
such as the Agency for Health Care Policy and Research
(AHCPR [now the Agency for Healthcare Research and
Quality], 1992), National Association of Neonatal Nurses (NANN, 2001), Joint Commission on Accreditation of
Healthcare Organizations (JCAHO [now The Joint Commission], 2001), American Academy of Pediatrics (AAP,
1999), American Academy of Pediatrics/Canadian Paediatric Society (AAP/CPS, 2000, 2006), the American
Society for Pain Management Nursing (Herr et al., 2006),
and the International Association for the Study of Pain
(IASP, 2005).
Infant pain assessment and management is often inadequate despite the availability of assessment instruments
and safe, effective pharmacologic and nonpharmacologic interventions to prevent or minimize pain and distress.
Although the prevention of pain in neonates should be
the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences,
if painful procedures are required, careful consideration
of safe and effective interventions should be provided
(AAP/CPS, 2006). The goal of this guideline is to provide the knowledge necessary to effectively assess and
manage postoperative, procedural, and disease-related
pain in hospitalized infants.
Definition of Pain
The International Association for the Study of Pain
(2004) defines pain as an unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage.
The inability to communicate verbally does not negate
the possibility that an individual is experiencing pain and
is in need of appropriate pain-relieving treatment. Applying this definition to infants, Anand & Craig (1996)
suggest that newborns display physiologic and behavioral
cues to signal tissue damage. Caregivers should use these
response cues as objective and valid indicators of pain in
infants.
Guideline I
Education and competency validation in pain assessment
and management shall be conducted during orientation
and at regularly defined intervals throughout employment
for all nurses delivering care to infants (AAP/CPS, 2000,
2006; IASP, 2005; JCAHO, 2001; NANN, 2001).
Key Points
A. Nurses shall demonstrate competency in neonatal
content areas including, but not limited to, the
following:
1. Anatomy and physiology of pain transmission,
modulation, and perception
2. Pain assessment
a. physiologic and behavioral indicators
b. valid and reliable instruments to measure
pain
c. contextual factors such as gestational
age or behavioral state that modify pain
expression in infants
3. Pain management
a. nonpharmacologic approaches (e.g.,
behavioral and environmental strategies)
b. pharmacologic interventions (e.g., nonsteroidal antiinflammatory drugs, opioids,
and adjuvant analgesics)
(1) side effects
(2) assessment and management of opioid
tolerance, dependence, and withdrawal
(3) local anesthetics and analgesics (e.g.,
EMLA [eutectic mixture of local anesthetics], lidocaine, Ametop creams)
c. special procedural techniques (e.g., venipuncture versus heelstick, spring-loaded
lancet versus straight lancet)
d. palliative and end-of-life care
4. Documentation of pain assessment, interventions, and response to pharmacologic and
nonpharmacologic interventions
5. Parental role in pain assessment and
management
6. Institutional pain-related policies and
procedures
B. Education to achieve competency shall be based on
the following:
1. Sufficient scope and duration to ensure continued competency
2. Current research findings related to pain assessment and management
3. Educational content identified by professional
or accrediting organizations
4. Identified or stated learning needs of the healthcare provider

5. Performance and findings from continuous

quality improvement activities
6. Input and involvement of the multidisciplinary
team and the support of unit nursing and medical leaders
7. Appropriate documentation in the providers
record or personnel file (i.e., the content and
scope of the program and the providers successful completion of required competency
activities)
C. Upon completion of educational activities, the nurse
shall be able to do the following:
1. Identify physiologic and behavioral responses
to pain
2. Consider gestational age and developmental
stage in evaluating infant pain
3. Select an age-appropriate instrument with published reliability and validity to assess infant
pain
4. Demonstrate the use of appropriate nonpharmacologic interventions for the infant experiencing
pain
5. Demonstrate knowledge of the mechanisms of
actions, duration, excretion, and appropriate
dosing of pain medications
6. Administer ordered medications safely
7. Recognize and report adverse side effects of
analgesics
8. List the equipment and personnel needed to
adequately monitor the infant after administering pain medication
9. Demonstrate critical-thinking skills and appropriate nursing interventions in the event of an
adverse reaction to pharmacologic therapy
10. Educate parents and families on pain assessment and management approaches being used
and enlist their assistance, as appropriate
11. Advocate for a well-rounded pain management
plan
12. Appropriately document
a. assessment and reassessment of pain status
b. nonpharmacologic interventions
c. pharmacologic therapy, including
medication, dose, route, and time of
administration
d. infants response to all interventions
e. education and involvement of the parent or
caregiver
13. Demonstrate appropriate interpersonal skills in
communicating with the physician and family
members regarding the infants pain status
Guideline II
Pain is assessed and reassessed at regular intervals
throughout the infants hospitalization (AHCPR, 1992;
AAP/CPS, 2000, 2006; IASP, 2005; JCAHO, 2001;
NANN, 2001).
Key Points
A. Pain assessment is an essential component of pain
management (AHCPR, 1992; AAP/CPS, 2000, 2006;
IASP, 2005; JCAHO, 2001; NANN, 2001).
B. Infants are unable to self-report pain; therefore, other
measures must be used to detect pain and evaluate
interventions. No single objective assessment strategy,
such as interpretation of behaviors, pathology, or
estimates of pain by others, is sufficient by itself.
C. Use the hierarchy of Pain Assessment Techniques
(Herr et al., 2006; McCaffery & Pasero, 1999).
1. Verbal self-report (not possible in infants)
2. Search for potential causes of pain
3. Observe patient behaviors, which are not
always accurate reflections of pain intensity,
and in some cases, indicate another source
of distress, such as physiologic or emotional
distress
4. Surrogate reporting of parents and caregivers
5. Attempt an analgesic trial if there are pathologic
conditions or procedures likely to cause pain
or if pain behaviors continue after attention to
basic needs and comfort measures
D. Frequency of pain assessments for postoperative,
procedural, and disease-related pain in hospitalized
infants should be based upon the expected intensity
and duration of the pain (AHCPR, 1992; IASP, 2005;
NANN, 2001).
E. Pain should be assessed upon admission and at regularly defined intervals throughout the infants
hospitalization (AAP/CPS, 2000; IASP, 2005;
JCAHO, 2001; NANN, 2001). For example, a policy may state that pain is assessed upon admission
and once every 8 hours, unless ongoing or recurrent
pain caused by surgery, disease, or therapy dictates
more frequent assessment. Some institutions adopt
pain assessment as the fifth vital sign (i.e., pain is
assessed with every vital sign assessment).
F. Institutions should develop policies for the assessment
of procedure-related, postoperative, and diseaserelated pain common among patients in the NICU.
G. A high index of suspicion should be utilized when
assessing infants for the presence, absence, or intensity of pain (AHCPR, 1992; NANN, 2001).
1. Developmental maturity, health status, and environmental factors contribute to an inconsistent,
less robust pattern of pain response among
preterm and term infants, even in the same
infant over a period of time and in different situations (Craig et al., 1993; Gibbins & Stevens,
2003; Grunau, Linhares, Holsti, Oberlander, &
Whitfield, 2004; Johnston, Stevens, Craig, &
Grunau, 1993; Shapiro, 1993).
2. The presence of pain should be presumed in all
situations considered to cause pain in adults and
children, even in the absence of behavioral or
physiologic signs (Franck, 1998).
H. A multidimensional approach that incorporates both
physiologic and behavioral indicators should be used
to assess pain (AHCPR, 1992; NANN, 2001).
1. Heart rate appears to be the most reliable physiological measure of pain (Sweet & McGrath,
1998). Three other frequently used physiological
measures of pain include oxygen saturation,
blood pressure, and breathing patterns. Other
physiological indicators such as intracranial
pressure and heart rate variability, although reliable, are clinically difficult to evaluate.
a. Research exploring brief, acute noxious
stimuli suggests that heart rate and blood
pressure generally increase during pain
while oxygen saturation decreases. Respiratory rate may either increase or decrease
during pain, but typically becomes more
rapid, shallow, or irregular (Hummel & van
Dijk, 2006; Sweet & McGrath, 1998).
b. Physiologic measures may be the sole
method of assessing pain in infants who are
pharmacologically paralyzed for mechanical
ventilation or who are severely neurologically impaired (Hummel & van Dijk,
2006). Observe for vital sign changes during handling; increases in heart rate and
blood pressure generally indicate the need
for more analgesia, sedation, or both in the
paralyzed infant. Variability in heart rate and
blood pressure decreases in a sedated infant.
c. When pain is prolonged, physiologic measures may not be valid indicators, as vital
sign changes cannot be maintained (Hummel
& van Dijk, 2006).
d. Physiologic measures reflect the bodys
nonspecific response to stress and may not
be specific to pain (Barr, 1992; Gunnar,
Connors, Isensee, & Wall, 1988). Therefore, physiologic measures should be used
along with behavioral measures that have
been demonstrated to be more consistent
and specific to pain in infants (Duhn &
Medves, 2004; NANN, 2001; Stevens,
Johnston, & Horton, 1994).
2. The most frequently studied behavioral responses

to pain in the neonate are facial activity, crying,
and body movements.
a. Facial activity (i.e., brow bulge, eye
squeeze, nasolabial furrow, and open
mouth) is the most specific indicator of
acute procedural pain (Gibbins & Stevens,
2003; Grunau & Craig, 1987; Grunau,
Johnston, & Craig, 1990; Hummel & van
Dijk, 2006; Stevens et al., 1993).
b. Acoustical and temporal characteristics of
pain cries have been demonstrated to be different from those of other types of cries, in
both preterm and full-term infants, but difficult to discriminate in the clinical setting
(Fuller, 1991; Grunau & Craig, 1987).
(1) Types of cries differ along a continuum of intensity according to graded
levels of noxious stimuli that correspond to adults judgments about the
urgency or severity of the infants distress (Fuller, 1991; Porter, Porges, &
Marshall, 1988).
(2) Although the presence of crying can provide valuable information about pain,
its absence should not be equated with
absence of pain (Johnston et al., 1999;
Johnston, Stevens, Yang, & Horton,
1995; Stevens et al., 1993; Stevens et
al., 1994). The absence of a response
may indicate the depletion of the
infants response capability, not a lack
of pain perception (Franck, 1998).
c. Franck (1986) demonstrated that healthy,
full-term newborns make swiping motions
toward a lanced foot with the unaffected
leg, as if trying to push away the noxious
stimulus.
d. Preterm infants may uniquely respond to
acute pain by increased flexion and extension of arms and toe and finger splay
(Grunau, Holsti, Whitfield, & Ling, 2000;
Holsti, Grunau, Oberlander, & Whitfield,
2004; Morison et al., 2003).
e. Extremely low-birthweight (ELBW) infants
have limited capacity to respond to pain.
ELBW infants have inadequate muscle
strength, posture, tone, and movement
compared to term infants; interpretation of
their pain responses is difficult (Gibbins &
Stevens, 2003). Responses to pain in this
high-risk population are currently under
investigation.
f. Cognitively impaired infants show similar

physiological and behavioral responses to
pain compared to healthy term infants, but
with decreased magnitude (Stevens et al.,
2007).
3. Expression of pain is altered by the contextual
factors surrounding the painful event (Johnston
& Stevens, 1996; Johnston et al., 1999; Stevens
et al., 1994).
a. Behavioral state has been shown to act as a
moderator of behavioral pain responses in
both full-term and preterm infants (Grunau
& Craig; 1987; Johnston et al., 1999; Stevens & Johnston, 1994; Stevens, Johnston,
Petryshen, & Taddio, 1996). Awake or alert
infants demonstrate a more robust reaction
to painful stimuli than sleeping infants.
b. Research examining both facial and body
activity has demonstrated that the more
premature the infant, the less vigorous and
robust the response (Craig et al., 1993;
Johnston et al., 1999; Johnston et al.,
1995). Craig and colleagues suggest that
the less vigorous response demonstrated by
preterm infants should be interpreted in
the context of the energy resources available to respond and the relative immaturity
of the musculoskeletal system (p. 296).
c. Evidence suggests that preterm infants in the
NICU with a history of painful experiences
have a diminished or less mature behavioral
response to subsequent painful procedures
(Johnston & Stevens, 1996).
d. Johnston and colleagues (1999) found that
preterm infants lack of response to a heelstick procedure was predicted by lower
gestational age at birth, postnatal age at the
time of the study, length of time since the
last painful procedure, and behavioral state.
e. Other contextual factors that alter infants
pain expression include severity of illness,
technician expertise, gender, environmental
stress, procedural modifiers, and initial
threshold and sensitization after repeated
stimulation (Craig et al., 1993; Grunau &
Craig, 1987; Johnston & Stevens, 1996;
Johnston et al., 1993; Johnston et al., 1995;
McIntosh et al., 1994; Stevens & Johnston,
1994; Stevens et al., 1993; Stevens et al.,
1994).
I. Reliable and valid multidimensional instruments
should be used to assess pain in infants (AHCPR,
1992; AAP/CPS, 2000, 2006; Anand & International
Evidence-Based Group for Neonatal Pain (IEBGNP),
2001; Duhn & Medves, 2004; IASP, 2005; NANN,

2001).
1. In choosing an instrument to use in assessing
pain in infants, caregivers should take into
consideration all published psychometric data,
including the aspects of validity, reliability, and
clinical utility. Caregivers should also consider
infant population, setting, and type of pain
experienced when choosing a pain instrument
(Duhn & Medves, 2004).
2. Total pain scores obtained by utilizing a behavioral pain assessment tool should be interpreted
cautiously, taking into consideration the presence of risk factors for pain and the infants
ability to exhibit pain behaviors (Hummel &
van Dijk, 2006). Numeric pain assessment scores
do not measure the infants actual pain; instead,
the infants response to pain is measured.
3. Few multidimensional pain measures have
established adequate psychometric properties
and clinical utility for use with infants. The most
commonly used published instruments that
demonstrate acceptable psychometric and clinical utility properties are the Premature Infant
Pain Profile (PIPP) developed by Stevens and
colleagues (1996), the CRIES tool (Bildner &
Krechel, 1996), and the Neonatal Infant Pain
Scale (NIPS) developed by Lawrence and colleagues (1993).
a. PIPP (see Figure 1)
(1) was tested in infants of 2840 weeks
gestational age with procedural pain
(2) incorporates contextual factors that
may modify the pain response
(3) includes two physiologic indicators of
pain (i.e., heart rate and oxygen saturation); three behavioral indicators
(i.e., brow bulge, eye squeeze, and
nasolabial furrow); and two contextual factors (i.e., gestational age and
behavioral state)
(4) uses a 4-point scale (03); scores on
the seven indicators are added for a
total pain score
(5) maximum attainable score depends on
the infants gestational age (younger
preterm infants can reach a maximum
PIPP score of 21, older infants can
attain a maximum score of 18)
(6) for all age groups, has a total pain
score that is interpreted as follows:
(a) 6 = minimal or no pain
(b) 712 = mild to moderate pain
(requires nonpharmacologic
comfort measures)
(c) >12 = moderate to severe pain
(most likely requires pharmacologic intervention in conjunction
with comfort measures)
b. CRIES (see Figure 2)
(1) assesses postoperative pain in preterm
and full-term infants
gestational age
(3) acronym is named for the five indicators
it measures, each of which is scored
on a 3-point scale (02): Crying,
Requires oxygen to maintain saturation greater than 95%, Increased vital
signs, Expression, and Sleepless
(4) has a total score that ranges from
0 to 10
(5) has a total pain score that is interpreted
as follows:
(a) 4 = mild pain (requires non
pharmacologic comfort measures)
(b) 5 = moderate to severe pain
(most likely requires pharmaco-
logic intervention in conjunction
with comfort measures)
c. NIPS (see Figure 3)
(1) was tested for validity and reliability
in preterm and full-term infants with
procedural pain
gestational age
(3) has a six-item scale; five items are
behavioral (i.e., facial expression, crying, arms, legs, and state of arousal)
and one is physiologic (i.e., breathing
pattern)
(4) each behavior other than crying has
descriptors for the two possible scores
(i.e., 0 and 1); crying is scored on a
3-point scale (02)
(5) has a total score that ranges from 0 to 7
d. Emerging pain assessment instruments
include the Pain Assessment Tool (PAT;
Hodgkinson, Bear, Thorn, & Van Blaricum,
1994) that was developed for postoperative pain, the Scale for Use in Newborns
(SUN; Blauer & Gerstmann, 1998) that
was developed for procedural pain, the
Bernese Pain Scale for Neonates (BPSN;
Cignacco, Mueller, Hamers, & Gessler,
2004) that was specifically developed to
assess the responses of preterm neonates or
those who require mechanical ventilation

to procedural pain, and the Neonatal Pain
Agitation and Sedation Scale (N-PASS;
Hummel, Puchalski, Weiss, & Creech, 2003)
that was developed to measure ongoing
and acute pain and sedation in preterm and

term neonates. More research to establish
reliability and validity of these measures is
needed.
Guideline III
Use both nonpharmacologic and pharmacologic therapies
to control or prevent pain (AHCPR, 1992; AAP/CPS, 2000,
2006; Anand & IEBGNP, 2001; IASP, 2005; NANN, 2001).
Key Points
A. Nonpharmacologic strategies to promote comfort
and stability are vitally important during all minor
to moderately painful procedures. Nonpharmacological interventions minimize the infants pain and
distress while maximizing the infants regulatory and
coping abilities. Pharmacologic therapies should
always be accompanied by nonpharmacologic comfort measures as these strategies provide additive or
synergistic benefits (Franck & Lawhon, 2000).
1. It is important, when possible, to reduce the
number of painful procedures performed on
infants (Franck & Lawhon, 2000; Leslie &
Marlow, 2006). This can be accomplished
by using noninvasive monitoring techniques
such as oxygen saturation monitors as well as
critically evaluating the need for all caregiving
practices, such as the number and grouping of
laboratory and diagnostic procedures, and by
scheduling clinical procedures on the basis of
medical necessity rather than routine.
2. Painful procedures should not be performed at
the same time as other, nonemergency routine
care (e.g., taking vital signs, changing a diaper).
Evidence suggests that after exposure to a painful stimulus, a preterm infants pain sensitivity is
accentuated by an increased excitability of nociceptive neurons in the dorsal horn of the spinal
cord (Fitzgerald, Millard, & McIntosh, 1989;
Fitzgerald, Shaw, & McIntosh, 1988; Holsti,
Grunau, Oberlander, & Whitfield, 2005). This
sensory hypersensitivity, referred to as the windup phenomenon, may exist for prolonged periods
after a painful stimulus. It can cause other,
nonnoxious stimuli (e.g., handling, physical
examination, nursing procedures) to be perceived
as painful because of heightened activity in nociceptive pathways. Stress cues must be the guide
for determining the timing of painful and other,
nonemergency clinical care activities.
3. Containment and positioning strategies can be
used to maintain midline flexion and facilitate
hand-to-mouth opportunities, thus helping infants
achieve self-regulation.
a. Handling and immobilization in preparation
for painful procedures can heighten activity
in nociceptive pathways and accentuate
infants pain responses (AAP, 1999; Porter,
Miller, Cole, & Marshall, 1991; Porter,
Wolf, & Miller, 1998). Every attempt should

be made to minimize handling before a
painful procedure.
b. Swaddling during and after a heelstick
reduces the physiological and behavioral
pain indicators in preterm neonates
(Cignacco et al., 2007; Fearon, Kisilevsky,
Hains, Muir, & Tranmer, 1997).
c. A hand-swaddling technique, known as
facilitated tucking (i.e., holding the infants
extremities flexed and contained close to the
trunk), during a painful procedure may significantly reduce pain responses in preterm
infants (Cignacco et al., 2007; Corff, Seideman, Venkataraman, Lutes, & Yates, 1995;
Ward-Larson, Horn, & Gosnell, 2004).
4. Excessive and unpredictable sound levels and
bright or continuous lighting levels in the NICU
have been associated with increased physiologic
and behavioral stress responses in preterm infants
(Long, Lucey, & Philips, 1980; Shiroiwa, Kamiya, & Uchiboi, 1986). Although research has not
systematically documented the effects of sound
and lighting levels on pain responses in preterm
infants, clinical experience suggests that light and
sound levels should be as low as possible during
painful procedures (Franck & Lawhon, 2000). A
consensus group on NICU design suggests that
light levels should not exceed 60 footcandles,
which is equivalent to soft room lighting. Task
lights and phototherapy lights can exceed 300
footcandles, and therefore caution should be
taken to protect infants eyes during the use of
these light sources.
5. Nonnutritive sucking (NNS) is the most widely
studied nonpharmacological approach to pain
management. The mechanisms of action are
thought to be related to the activation of nonopioid pathways as the infant sucks on the
pacifier. Pain-relieving effects of NNS cease after
the pacifier is removed from the mouth (Boyle
et al., 2006; Campos, 1989; Carbajal, Chauvet,
Couderc, & Olivier-Martin, 1999; Field & Goldson, 1984; Gibbins, Stevens, & Hodnett, 2002;
Marchette, Main, Redick, Bagg, & Leatherland,
1991; Miller & Anderson, 1993; Shiao, Chang,
Lannon, Yarandi, 1997; Stevens et al., 1999).
6. The safety and efficacy of sucrose for preterm
and term infants has been reported in many
studies. A systematic review of 21 randomized
controlled trials found that sucrose decreased
crying time, heart rate, facial action, and composite pain scores during heel lance and venipuncture
(Stevens, Yamada, & Ohlsson, 2004).
a. The most effective dose of sucrose remains

unclear, but ranges between 0.05 and 2 ml of
a 24% solution have been reported. Sucrose
is most effective when it is administered
approximately 2 minutes before the painful stimulus (Stevens, Taddio, Ohlsson, &
Einarson, 1997). This 2-minute time interval
is thought to coincide with the endogenous
opioid release triggered by the sweet taste
of sucrose (Stevens et al., 1999). Sucrose
is optimally administered to the tip of the
tongue where sweet receptors lie. No effect
is obtained when given by nasogastric (NG)
tube and may not be effective via bottle
or nipple when given to an infant with
an efficient suck, bypassing the tip of the
tongue.
b. There is less evidence for the safety and
efficacy of sucrose for infants less than 27
weeks gestation; therefore, its use must
be considered on an individual basis. A
study by Willis, Chabot, Radde, and Chance
(1977) suggests that the hyperosmolality of
a 20% sucrose solution (0.51 ml mixed
with calcium lactate) given 20 minutes
before feedings by NG may have contributed to a higher-than-normal incidence
of necrotizing enterocolitis (NEC) in
very-low-birthweight infants. The study
failed to consider other risk factors such
as immaturity, presence of umbilical lines,
administration via NG tube, or the hyperosmolar calcium solution administered
with the sucrose as causative factors for
NEC. Johnston and colleagues (2002)
compared motor development, alertness
and neurobehavioral outcomes in preterm
infants less than 31 weeks gestation who
received either sucrose or water for every
painful procedure during the first 7 days
of life. The study found a dose-related
response, with infants who received more
doses of sucrose having lower scores on
motor development tests at 36 and 40
weeks postconceptional age. A more recent
study by Stevens and colleagues (2005)
did not demonstrate any adverse events,
clinical outcomes, or neurobiological risk
status in infants greater than 26 weeks
gestation who received 24% sucrose plus
pacifier prior to all painful procedures in
the NICU during the first 28 days of life.
c. The long-term safety of repeated doses of
sucrose in neonates, particulary ELBW
infants, has not been established and further

research is needed (Stevens et al., 2004).
7. Breastfeeding or breast milk for procedural pain
in neonates has been well researched. A review
of the research recommends that, if available,
breastfeeding or breast milk should be used to
alleviate procedural pain in neonates undergoing a
single painful procedure, as compared to placebo,
positioning, or no intervention. Administration
of glucose or sucrose had similar effectiveness as breastfeeding for reducing pain. The
effectiveness of breast milk for repeated painful
procedures is not established and further research
is needed (Shah, Aliwalas, & Shah, 2006).
B. Opioid analgesics and local anesthetics are the most common pharmacologic interventions used with neonates.
1. The first goal of pharmacologic management is
to distinguish between the need for pain relief
and the need for sedation. Opioids are generally
used in clinical situations when severe pain is
assessed or anticipated (AHCPR, 1992; Simons
& Anand, 2006). Sedatives blunt behavioral
responses to noxious stimuli without providing
pain relief. Therefore, sedatives should not be
used unless pain has been ruled out (Hartley,
Franck, & Lundergan, 1989).
2. Intravenous opioids, particularly morphine and
fentanyl, remain the most common analgesics
administered in the NICU (Simons & Anand,
2006). There is little scientific evidence demonstrating the pharmacodynamics of opioid
usage in the neonatal population (Franck &
Miaskowski, 1998; Simons & Anand). However,
published dosing guidelines exist to guide the
safe administration of opioids in monitored
infants (see Table 1).
3. Most studies measure the pharmacokinetics of
opioids after a single intravenous dose or during a continuous intravenous infusion. Limited
data suggest that there is no substantial benefit
to administering a continuous infusion of
opioids over intermittent dosing in neonates
(Bouwmeester et al., 2001; Bouwmeester, van
den Anker, Hop, Anand, & Tibboel, 2003).
4. Infants less than 1 month old have been found
to have longer elimination half-lives and
delayed clearance of opioids compared with
adults or children older than 1 year (Franck &
Miaskowski, 1998). As a result, longer dosing
intervals are often indicated for neonates, compared with those for older infants and children.
5. Enterohepatic recirculation may contribute to
prolonged clearance and elimination in infants
(Franck & Miaskowski, 1998). As a result, higher
10
6.
7.
8.
9.
10.
11.
plasma concentrations of opioids for longer

periods of time have been demonstrated in both
preterm and full-term infants as compared with
older children. Therefore, monitoring should be
continued for several hours after opioids have
been discontinued (Franck & Miaskowski).
Variations in response to opioids between infants
and older children or adults may be due to
differences in the number and type of mu
receptors in the brain and spinal cord. Younger
infants may require significantly higher opioid
concentrations to achieve adequate analgesia than older children do (Dahlstrom, Bolme,
Feychting, Noack, & Paalzow, 1979; Lynn,
Opheim, & Tyler, 1984; Olkkola, Maunuksela,
Korpela, & Rosenberg, 1988).
Regular assessments are needed, using a valid
and reliable neonatal pain instrument, to ensure
the adequacy of opioid therapy.
Regular assessments also are needed to identify
the side effects associated with opioid therapy
(Franck & Miaskowski, 1998). Although opioids
are often withheld because of a fear of opioidinduced cardiorespiratory side effects, few data
are available to support this concern (Farrington,
McGuinness, Johnson, Erenberg, & Leff, 1993;
Franck & Miaskowski; Koren et al., 1985; Purcell-Jones, Dormon, & Sumner, 1987). Side
effects often can be minimized by administering
boluses slowly (Franck & Miaskowski; Gregory,
1994a, 1994b; Yaster & Deshpande, 1988).
Sedation level should also be assessed regularly,
monitoring for the attainment of desired sedation level or inadvertent over-sedation.
Recent research highlights the potential for
increased adverse neurologic outcomes in ventilated infants with morphine administration,
particularly in hypotensive infants (Anand et
al., 2004; Aranda et al., 2005; Hall, Kronsberg,
Barton, Kaiser, & Anand, 2005). Closely monitor
the infant for hypotension.
Neonates who require opioid therapy for more
than several days may develop physical dependence and then exhibit withdrawal symptoms
if the opioid is stopped abruptly or weaned too
rapidly. Withdrawal symptoms include neurologic excitability, gastrointestinal dysfunction,
and other signs such as poor weight gain. The
prevalence of opioid withdrawal is greater in
infants who have received fentanyl as opposed
to morphine. Similarly, infants who receive
higher total doses or longer duration of infusion
are significantly more likely to experience
withdrawal (Dominguez, Lomako, Katz, &
Kelly, 2003). Data are insufficient to determine

the optimal weaning rate of opioids to prevent
withdrawal symptoms in neonates on opioid
therapy. Ducharme, Carnevale, Clermont, and
Shea (2005) reported that adverse withdrawal
symptoms in children who received continuous
infusions of opioids or benzodiazepines could
be prevented when the daily rate of weaning
did not exceed 20% for children who received
opioids or benzodiazepines for 13 days; 13%
20% for 47 days; 8%13% for 814 days; 8%
for 1521 days; and 2%4% for more than 21
days, respectively. An opioid-weaning protocol
and behavioral withdrawal scale should be used
for infants weaning from prolonged opioid
therapy. The Neonatal Abstinence Syndrome
scale (Finnegan, Kron, Connoughton, & Emich,
1975) or other valid measures can be used to
guide rate of opioid weaning and monitor for
withdrawal symptoms.
12. Prolonged use of opioids may lead to analgesic
tolerance, requiring increased dosing to attain pain
relief. An infant who becomes tolerant to the current dosage may exhibit pain behaviors, increased
wakefulness, and increased sympathetic responses
such as high-pitched crying and tremors when
handled or disturbed (Suresh & Anand, 1998).
Tolerance to opioids is managed by increasing the
dosage, although the use of adjunctive analgesics
can be clinically beneficial (Anand & Ingraham,
1996; Franck & Vilardi, 1995).
C. Nonopioid analgesics
Acetaminophen is a nonopioid analgesic useful for
short-term management of mild to moderate pain
in neonates. Although acetaminophen has been
shown to signicantly reduce pain response during skin excision and reduce comfort scores at 6
hours following the circumcision procedure (Howard, Howard, & Weitzman, 1994), other studies have
failed to demonstrate efficacy resulting from acutetissue injury of heelstick and postoperative pain
relief after cadiac surgery (Shah, Taddio, & Ohlsson, 1998; van Lingen et al., 1999). The results from
these studies suggest that acetaminophen may be more
appropriate for mild-to-moderate dull, continuous pain
that results from inammatory conditions (Anand,
Menon, Narsinghani, & McIntosh, 2000).
D. Topical anesthetics
1. Eutectic Mixture of Local Anesthetics (EMLA)
cream, a eutectic mixture of lidocaine and
prilocaine, is approved for use in infants who
have a gestational age of 37 weeks or more
(AstraZeneca, 1999). EMLA cream requires
1 hour of skin contact for efficacy. A systematic
11
review of 11 studies of EMLA cream as a treatment for acute pain in infants was conducted by
Taddio, Ohlsson, Einarson, Stevens, and Koren
(1998). Data suggest that EMLA cream reduces
pain during circumcision, venipuncture, arterial
puncture, and percutaneous venous catheter
placement. The data, however, failed to support
the efficacy of EMLA cream in managing pain
from heelstick. The potential increased risk of
methemoglobinemia can be minimized if its use
is limited to no more than once daily on intact
skin only, and it should not be used with other
drugs known to cause methemoglobinemia such
as acetaminophen, phenytoin, phenobarbital,
or nitroprusside (Brisman, Ljung, Otterbom,
Larsson, & Andreasson, 1998).
2. Tetracaine 4% gel (Ametop) has also been relatively well investigated in neonates. Tetracaine
produces local anesthesia within 3045 minutes.
Ametop has been shown to be beneficial for
venipuncture, vaccination, and IV insertion
(OBrien, Taddio, Lyszkiewicz, & Koren,
2005), but it is ineffective for heelsticks and
peripherally inserted central catheters.
3. Liposomal lidocaine cream (LMX 4%) is a
relatively new topical anesthetic for use in newborns. Several studies in older children have
evaluated the efficacy of LMX and EMLA during peripheral intravenous catheter insertion and
found a 30-minute application of LMX to be as
effective as a 60-minute application of EMLA
for producing topical anesthesia for peripheral
intravenous access (Eichenfield, Funk, FallonFriedlander, & Cunningham, 2005; Kleiber,
Sorenson, Whiteside, Gronstal, & Tannous,
2002; Koh et al., 2004). Similar results were
found in a recent study in neonates in reducing
circumcision pain in term newborns (Lehr et
al., 2005). LMX may be a better choice than
EMLA because of its faster onset of action and
no risk of methemoglobinemia. Further studies
in neonates are needed to establish the safety
and efficacy of LMX for management of procedural pain in neonates.
E. Procedural pain is common in the NICU and should be
managed with a combination of nonpharmacologic
and pharmacologic interventions (AAP/CPS, 2006;
Anand & IEBGNP, 2001; Anand et al., 2005). Anand
and IEBGNP provide guidelines for preventing
and treating pain associated with commonly performed procedures in the NICU (Table 2).
1. Heelstick
a. The significant pain response to heelstick
can be explained by the painful nature of
the lancing procedure in combination with

the squeezing of the heel to obtain the
blood sample.
b. Although data are sparse, it appears reasonable to recommend that only spring-loaded
mechanical lancets be used for heelstick
procedures. The use of mechanical lancets
results in less bruising, less need for repeat
punctures, and fewer behavioral and physiologic distress responses (Harpin & Rutter,
1983; McIntosh et al., 1994). McIntosh and
colleagues reported that use of a mechanical lancet was more effective than EMLA
cream or tactile and vocal stimulation in
reducing infants pain response to the heelstick procedure.
c. Barker, Willetts, Cappendijk, and Rutter
(1996) found that heel warming had no
effect on infant responses to pain during a
heelstick procedure.
d. Evidence-based interventions to reduce
pain associated with heelsticks include
pacifier with sucrose, swaddling, containment, facilitated tucking, breastfeeding,
and skin-to-skin contact with the mother
(Anand & IEBGNP, 2001).
2. Circumcision
a. Although the procedure is not medically
necessary, some parents or caregivers
choose to have their infants circumcised.
Procedural analgesia should be provided
during circumcision (AAP, 1999).
b. Subcutaneous ring block appears to provide superior analgesia; however, the AAP
policy statement also endorses the use of
dorsal penile nerve blocks and EMLA cream
for pain associated with circumcision
(AAP, 1999).
c. Containment, facilitated tucking, hand-tomouth opportunities, and flexed positioning
should be used to decrease the infants distress from the procedure (AAP, 1999).
d. The use of a sucrose-dipped pacifier during
the procedure and acetaminophen administered before or immediately following can
supplement the above analgesic approaches
(AAP, 1999).
3. Venipuncture may be preferable to heelstick in
minimizing procedure-related pain in full-term
infants (Anand & IEBGNP, 2001). A systematic
review of four randomized, controlled trials of
full-term infants found that pain scores were
significantly lower with venipuncture as compared to heelstick (Shah & Ohlsson, 2004).
12
Another study by Ogawa and colleagues (2005)

demonstrated that pain scores during venipuncture were lower than scores during heelstick.
The researchers also reported that venipuncture
scores without sucrose were significantly lower
than the heelstick group with sucrose. However,
frequent venipuncture for blood sampling is not
feasible for most infants in the NICU, necessitating the continued use of heelsticks. Support
during venipuncture includes swaddling,
facilitated tucking, sucrose water, and topical
anesthetic cream in infants 37 weeks gestation.
4. Technician expertise, such as the skill of the operator, influences pain responses in infants (Grunau
& Craig, 1987). Ensuring staff competence to
perform required procedures may reduce the
number of painful procedures to which an infant
is exposed by reducing the number of failed
attempts (Simons et al., 2003). Competence levels
of the personnel performing procedures on hospitalized infants should be monitored.
F. Mechanical ventilation
Mechanical ventilation via an endotracheal tube is
described as painful and distressful by adults and
children, requiring analgesia and sedation. Historically, infants in the NICU, particularly preterm
infants, have received little or no treatment of pain
and distress while ventilated, with wide variations in
beliefs and practice. A recent, large, multicenter trial
of morphine drip versus placebo in ventilated infants
found no improvement in short-term neurologic outcomes and worse outcomes in some subgroups (Anand
et al., 2004; Aranda et al., 2005). A secondary analysis
by Hall and colleagues (2005) found that open-label
bolus morphine in preterm neonates with preexisting
hypotension who were receiving preemptive analgesia
was associated with severe intraventricular hemorrhage
and death. A systematic review of 13 randomized, controlled trials found that opioids reduced pain scores
but did not alter the risk of poor neurologic outcome,
with the conclusion that there is insufficient evidence
available to recommend the routine use of opioids
in mechanically ventilated neonates (Bellu, de Waal,
& Zanini, 2005).
G. Perioperative pain management
1. Operative anesthesia should be provided to all
infants by a competent professional.
2. Postoperative pain management
a. Opioids should be administered around the
clock or via continuous infusion. The duration of this administration is dependent upon
the type and invasiveness of the surgical
procedure, the infants status postoperatively, and pain assessment scoring.
b. Data are inconsistent on whether nonsteroidal antiinflammatory drugs and

acetaminophen provide clinically important
postoperative analgesia after minor or major
surgery in neonates. Data are also unclear
on whether these agents provide clinically
important opioid-sparing effects after surgery (Berde et al., 2005).
H. Pain management at end of life
1. Although it is common practice to administer
opioid agents to dying adults, opioids are not
routinely administered to critically ill or dying
infants when life support is being withdrawn or
withheld (Partridge & Wall, 1997).
2. Given the difficulty of accurate pain assessment in
neonates at the end of life (EOL), caregivers should
consider risk factors for pain and use physiologic
measures to guide pain management decisions
(Walden, Sudia-Robinson, & Carrier, 2001).
3. Continuous infusions of opioids are often
required to manage pain at EOL and should be
titrated to desired clinical response (analgesia;
Anand et al., 2000). Opioid doses well beyond
those described for standard analgesia are often
required for infants who are in severe pain or
who have developed tolerance after the prolonged
use of opioids (Partridge & Wall, 1997).
4. Physiologic comfort measures may palliate
pain and distress in infants at EOL and include
reduction of noxious stimuli, organization of
caregiving, and positioning and containment
strategies (Walden et al., 2001).
I. Long-term effects of pain
The long-term effects of pain in animals are clear, with
changes observed in pain thresholds, social behaviors,
stress responses, and pain responses to nonpainful stimuli (Fitzgerald & Anand, 1993; Plotsky, Bradley, &
Anand, 2000; Reynolds, Alvares, Middleton, &
Fitzgerald, 1997; Ruda, Ling, Hohmann, Peng, &
Tachibana, 2000). Preliminary human data suggest
early pain experiences may alter future pain responses.
Johnston and Stevens (1996) compared pain responses
of neonates who were born at 28 weeks of gestation and were hospitalized in a NICU for 4 weeks
(32 weeks postconceptional age) to neonates who
were born at 32 weeks of gestation. Heart rate, oxygen saturation, and three facial actions (brow bulge,
nasolabial furrow, and eye squeeze) were used as
individual pain indicators. Neonates were observed
during a routine heel lance. Neonates who had spent
4 weeks in the NICU (less mature) had decreased
behavioral response and significantly higher heart
and lower oxygen saturation at the time of the heel
lance than neonates born at 32 weeks. Taddio,
13
Goldbach, Ipp, Stevens, and Koren (1995) examined

the effectiveness of EMLA for relieving procedural pain associated with immunization in 4- and
6-month-old infants. Males circumcised within 2 days of birth had significantly longer crying
bouts (53 seconds versus 19 seconds, p = .02) and
higher pain intensity scores, as measured on the Visual Analogue Scale (VAS; 8 versus 6, p = .01), at
immunization at 4 or 6 months of age than males
who were not circumcised. This finding was confirmed in subsequent research (Taddio, Katz, Ilersich,
& Koren, 1997).
14
Guideline IV
A collaborative, interdisciplinary approach to pain control, including all members of the healthcare team and
infants family, should be used to develop a pain management plan. Include the input of all members of the
healthcare team as well as that of the infants family whenever possible (AHCPR, 1992; AAP, 1999; IASP, 2005;
JCAHO, 2001; NANN, 2001).
Key Points
A. Parents play a key role in assessing and managing
their infants pain.
1. Parents have many concerns and fears about
their infants pain and about the medications
used in the treatment of pain (Franck, Allen,
Cox, & Winter, 2005; Gale, Franck, Kools, &
Lynch, 2004). Parents may fear the effects of
pain on their childs development. They may
also fear that their infant may become addicted
to the analgesics (Franck et al., 2000).
2. According to Harrison (1993), a key principle of
family-centered neonatal care is that parents and
professionals must work together to acknowledge
and alleviate the pain of infants in intensive
care (p. 646). To accomplish this, parents and
healthcare professionals must talk openly and
honestly about acute and chronic pain associated
with medical diseases as well as about pain
associated with operative, diagnostic, and therapeutic procedures.
3. Parents should be informed that effective pain
relief is an important part of their infants care
in the NICU (AHCPR, 1992).
4. Healthcare providers are obligated to ensure

that parents receive accurate and unbiased
information about the risks and benefits
of (as well as alternatives to) analgesia and
anesthesia, so that they can make informed
treatment choices (Harrison, 1993).
5. Healthcare providers should explore parents
cultural and religious beliefs about pain. These
beliefs should be taken into account when
determining a pain-management plan.
6. Parents have the right to seek another medical
opinion or to refuse a burdensome course of
therapy (Harrison, 1993).
7. Parents should be taught to observe how their
infant expresses pain through physiologic and
behavioral cues.
8. Parents, in addition to making decisions about
analgesia and anesthesia options, often are ready,
willing, and able to help caregivers provide
nonpharmacologic pain relief during minor
painful procedures. Parents should be taught
individualized techniques that are comforting to
their infant.
9. Institutions are responsible for documenting
the degree of parents satisfaction with the
pain management their child is receiving in the
hospital (AHCPR, 1992; IASP, 2005; JCAHO,
2001; NANN, 2001).
15
Guideline V
Pain assessment and management practices should be
documented in a manner that facilitates regular reassessment and follow-up intervention (IASP, 2005; JCAHO,
2001).
Key Points
A. Pain has been termed the fifth vital sign (American
Pain Society [APS], 1995). An infants pain should
be assessed upon admission and at regularly defined
intervals throughout the hospitalization (AAP/CPS,
2000; APS; IASP, 2005; JCAHO, 2001).
B. Pain scores, interventions, and responses should be
documented in a way that facilitates high visibility and
regular review by members of the healthcare team.
Figure 4 shows a tool designed to accomplish this
objective.
C. Pain scores should be recorded on the nursing progress record, using a valid and reliable pain instrument
at time intervals defined in hospital policy.
D. Environmental factors that appear to reduce or exacerbate the infants pain should be documented.
E. Nonpharmacologic strategies used alone or in conjunction with pharmacologic therapy should be
documented.
F. Pharmacologic interventionsincluding the medication administered, as well as the time, dosage, route,
and side effectsshould be recorded on the nursing
progress or medication record, as dictated by hospital
policy.
G. Patient response to interventions, both pharmacologic
and nonpharmacologic, should be documented, using
valid and reliable assessment methods.
H. The level of parental involvement with and knowledge
of their infants pain cues and current pain management should be recorded.
16
Guideline VI
Policies and procedures that support and promote optimal pain assessment and management practices should
be established by institutions caring for infants (AHCPR,
1992; AAP/CPS, 2000; JCAHO, 2001).
Key Points
A. Policies and procedures related to pain assessment
and management should:
1. Define each multidisciplinary team members
responsibilities and scope of practice in assessing and managing pain
2. Outline an education and competency assessment program
3. List indications for baseline monitoring as well
as frequency of assessment for infants experiencing ongoing or recurrent pain caused by
surgery, disease, or diagnostic or therapeutic
procedures
4. List pain instruments approved for use with

infants. Although consistency of instrument use
is encouraged across hospital units, the needs of
the patient population should be the determining
factor in the selection of pain instruments. Specific instruments may be needed to assess pain
in special populations (e.g., extremely preterm
infants or infants who undergo prolonged hospitalization and experience chronic pain)
5. Detail approved nonpharmacologic pain relief
measures
6. Outline an approach to pharmacologic pain
management
7. Discuss the role of parents in pain assessment
and management
8. Describe documentation requirements
17
Guideline VII
Institutions caring for infants should collect data to monitor the appropriateness and effectiveness of their pain
management practices (AHCPR, 1992; IASP, 2005;
JCAHO, 2001).
Key Points
A. In addition to reviewing the current pain standards
of professional and accrediting organizations, institutions should perform an extensive review of the
literature to determine the evidence base on pain
assessment and management in infants. Based on this
review, institutional barriers to optimal pain assessment and management practices should be identified.
B. The creation of a multidisciplinary pain team should
be considered to address the identified barriers and
facilitate improvements in pain management practices
for infants. The teams objectives might include the
following:
1. Choose a pain assessment tool
2. Develop standardized documentation, including
pain score, interventions, and infant responses
to interventions
3. Develop policies or a protocol to assess and
manage pain in newborns
4. Create parent-education materials about pain
assessment and management
5. Identify outcome measures relating to pain
assessment and management
6. Educate nursing staff on the use of tools,
documentation, pain reporting, pain policies or
protocol, and appropriate intervention strategies
C. Outcome measures should be defined and baseline
data collected before and after recommended practice
changes are implemented so as to evaluate the effect
of these changes on patient outcomes. Outcome measures that might be monitored include:
1. Intervals of pain assessment

2. Types and appropriateness of pain medications
ordered
3. Congruence between medications ordered and
medications administered
4. Length of time between identification of pain
and intervention
5. Number and types of nonpharmacologic
interventions
6. Patient responses to interventions, including
side effects
7. Parent education about infant pain cues and
ways to provide comfort
8. Extent of parental involvement in comforting
their infant
9. Parental satisfaction with pain management for
their infant
Conclusion
Nurses play an essential role in optimizing pain assessment and management in the NICU. Nurses are in a
key position to observe infant response to painful procedures or clinical conditions, using valid and reliable
pain instruments. The nurse, in conjunction with the
healthcare team and the parents, uses assessment data
to effectively implement nonpharmacologic and pharmacologic pain management strategies. The nurse is an
advocate for the infant, minimizing pain and distress
throughout the infants hospital stay. Nurses also play a
role in measuring patient outcomes and participating in
interdisciplinary initiatives regarding pain assessment
and management. Finally, the nurse plays a role in ongoing research and education of the profession regarding
best practices on pain assessment and management in
neonates.
18
References
Agency for Health Care Policy and Research. (1992). Acute
pain management in infants, children, and adolescents:
Operative and medical procedures: Quick reference
guide for clinicians. Rockville, MD: U.S. Department of
Health and Human Services.
American Academy of Pediatrics/Canadian Paediatric Society.
(2000). Prevention and management of pain and stress in
the neonate. Pediatrics, 105, 454461.
American Academy of Pediatrics/Canadian Paediatric Society.
(2006). Prevention and management of pain and stress in
the neonate: An update. Pediatrics, 118, 22312241.
American Academy of Pediatrics, Task Force on
Circumcision. (1999). Circumcision policy statement.
Pediatrics, 103, 686693.
American Pain Society (1995). Pain: The fifth vital sign.
Retrieved September 9, 2000, from www.ampainsoc.org.
Anand, K. (1998). Clinical importance of pain and stress in
preterm infants. Biology of the Neonate, 73, 19.
Anand, K., & Craig, K. (1996). New perspectives on the definition of pain. Pain, 67, 36.
Anand, K., & Ingraham, J. (1996). Tolerance, dependence,
and strategies for compassionate withdrawal of analgesics and anxiolytics in the Pediatric ICU. Critical Care
Nurse, 16(6), 8793.
Anand, K. J., Hall, R. W., Desai, N., Shephard, B., Bergqvist,
L. L., Young, T. E., et al. (2004). Effects of morphine
analgesia in ventilated preterm neonates: Primary outcomes from the NEOPAIN randomised trial. Lancet,
363(9422), 16731682.
Anand K. J. S., & International Evidence-Based Group for
Neonatal Pain. (2001). Consensus statement for the
prevention and management of pain in the newborn.
Archives of Pediatric Adolescent Medicine, 155, 173
180.
Anand K. J. S., Johnston, C. C., Oberlander, T. F., Taddio, A.,
Tutag Lehr, V., & Walco, G. A. (2005). Analgesia and
local anesthesia during invasive procedures in the neonate. Clinical Therapeutics, 27(6), 844876.
Anand K. J. S., Menon, G., Narsinghani, U., & McIntosh, N.
(2000). Systemic analgesic therapy. In K. J. S. Anand, B.
J. Stevens, & P. J. McGrath (Eds.), Pain in infants (2nd
ed., pp. 159188). Amsterdam: Elsevier.
Aranda, J. V., Carlo, W., Hummel, P., Thomas, R., Lehr,
V. T., & Anand, K. J. S. (2005). Analgesia and sedation during mechanical ventilation in neonates. Clinical
Therapeutics, 27(6), 877899.
AstraZeneca (1999, May 21). FDA approves EMLA cream
for use in full-term neonates, supporting its use in newborn circumcision. Retrieved September 12, 2000, from
www.emla-usa.com/news/pr52199.htm.
Barker, D. P., Willetts, B., Cappendijk, V. C., & Rutter, N.
(1996). Capillary blood sampling: Should the heel be
warmed? Archives of Disease in Childhood. Fetal and
Neonatal Edition, 74(2), F139F140.
Barr, R. (1992). Is this infant in pain? Caveats from the clinical setting. APS Journal, 1, 187190.
Bellu, R., de Waal, K. A., & Zanini, R. (2005). Opioids for

neonates receiving mechanical ventilation. Cochrane
Database of Systematic Reviews, 1, CD004212.
Berde, B. B., Jaksic, T., Lynn, A. M., Maxwell, L. G.,
Soriano, S. G., & Tibboel, D. (2005). Anesthesia and
analgesia during and after surgery in neonates. Clinical
Therapeutics, 27(6), 900921.
Bildner, J., & Krechel, S. (1996). Increasing staff nurse
awareness of postoperative pain management in the
NICU. Neonatal Network, 15(1), 1116.
Blauer, T., & Gerstmann, D. (1998). A simultaneous comparison of three neonatal pain scales during common NICU
procedures. Clinical Journal of Pain, 1, 3947.
Bouwmeester, N. J., Anand, K. J., van Dijk, M., Hop, W.
C., Boomsma, F., & Tibboel, D. (2001). Hormonal and
metabolic stress responses after major surgery in children
aged 03 years: A double-blind, randomized trial comparing the effects of continuous versus intermittent morphine. British Journal of Anaesthesia 87(3), 390399.
Bouwmeester, N. J., van den Anker, J. N., Hop, W. C., Anand,
K. J., & Tibboel, D. (2003). Age- and therapy-related
effects on morphine requirements and plasma concentrations of morphine and its metabolites in postoperative
infants. British Journal of Anesthesia, 90(5), 642652.
Boyle, E. M., Freer, Y., Khan-Orakzai, Z., Watkinson, M.,
Wright, E., Ainsworth, J. R., et al. (2006). Sucrose and
non-nutritive sucking for the relief of pain in screening
for retinopathy of prematurity: A randomised controlled
trial. Archives of Disease in Childhood. Fetal and
Neonatal Edition, 91(3), F166F168.
Brisman, M., Ljung, B. M., Otterbom, I., Larsson, L. E., &
Andreasson, S. E. (1998). Methemoglobin formation
after the use of EMLA cream in term neonates. Acta
Paediatrica, 7(11), 11911194.
Campos, R. (1989). Soothing pain-elicited distress in infants with
swaddling and pacifiers. Child Development, 60, 781792.
Carbajal, R., Chauvet, X., Couderc, S., & Olivier-Martin, M.
(1999). Randomised trial of analgesic effects of sucrose,
glucose, and pacifiers in term neonates. British Medical
Journal, 319, 13931397.
Carrier, C., & Walden, M. (2001). Integrating research and
standards to improve pain management practices for newborns and infants. Newborn and Infant Nursing Reviews,
1(2), 122131.
Cignacco, E., Hamers, J. P., Stoffel, L., van Lingen, R. A.,
Gessler, P., McDougall, J., et al. (2007). The efficacy of
non-pharmacological interventions in the management of
procedural pain in preterm and term neonates: A systematic
literature review. European Journal of Pain, 11, 139152.
Cignacco, E., Mueller, R., Hamers, J. P., & Gessler, P. (2004).
Pain assessment in the neonate using the Bernese Pain
Scale for Neonates. Early Human Development, 78(2),
125131.
Corff, K., Seideman, R., Venkataraman, P., Lutes, L., & Yates,
B. (1995). Facilitated tucking: A nonpharmacologic
comfort measure for pain in preterm infants. Journal
of Obstetric, Gynecologic, and Neonatal Nursing, 24,
143147.
19
Craig, K., Whitfield, M., Grunau, R., Linton, J., &

Hadjistavropoulos, H. (1993). Pain in the preterm neonate: Behavioral and physiological indices. Pain, 52,
287299.
Dahlstrom, B., Bolme, P., Feychting, H., Noack, G., &
Paalzow, L. (1979). Morphine kinetics in children.
Clinical Pharmacology and Therapeutics, 26, 354365.
Dominguez, K. D., Lomako, D. M., Katz, R. W., & Kelly, H.
W. (2003). Opioid withdrawal in critically ill neonates.
Annals of Pharmacotherapy, 37(4), 473477.
Ducharme, C., Carnevale, F. A., Clermont, M. S., & Shea, S.
(2005). A prospective study of adverse reactions to the
weaning of opioids and benzodiazepines among critically
ill children. Intensive and Critical Care Nursing, 21(3),
179186.
Duhn, L., & Medves, J. (2004). A systematic integrative review
of infant pain assessment tools. Advances in Neonatal
Care: Official Journal of the National Association of
Neonatal Nurses, 4(3), 126140.
Eichenfield, L. F., Funk, A., Fallon-Friedlander, S., &
Cunningham, B. B. (2005). A clinical study to evaluate
the efficacy of ELA-Max as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics, 109(6), 10921099.
Farrington, E., McGuinness, G., Johnson, G., Erenberg, A.,
& Leff, R. D. (1993). Continuous intravenous morphine
infusion in postoperative newborn infants. American
Journal of Perinatology, 10(1), 8487.
Fearon, I., Kisilevsky, B. S., Hains, S. M., Muir D. W., &
Tranmer, J. (1997). Swaddling after heel lance: Agespecific effects on behavioral recovery in preterm infants.
Journal of Developmental and Behavioral Pediatrics,
18, 222232.
Field, T., & Goldson, E. (1984). Pacifying effects of nonnutritive sucking on term and preterm infants during heelstick
procedures. Pediatrics, 74, 10121015.
Finnegan, L. P., Kron, R. E., Connoughton, J. F., & Emich, J.
P. (1975). A scoring system for evaluation and treatment
of the neonatal abstinence syndrome: A new clinical and
research tool. In P. I. Morselli, S. Garatani, & F. Sereni
(Eds.), Basic and therapeutic aspects of perinatal pharmacology (pp. 139153). New York: Raven Press.
Fitzgerald, M., & Anand, K. J. S. (1993). Developmental neuroanatomy and neurophysiology of pain. In N. Schechter
& D. B. Berde (Eds.), Pain in infants, children and adolescents (pp. 1132). Baltimore: Wilkins.
Fitzgerald, M., Millard, C., & McIntosh, N. (1989).
Cutaneous hypersensitivity following peripheral tissue
damage in newborn infants and its reversal with topical
anaesthesia. Pain, 39, 3136.
Fitzgerald, M., Shaw, A., & McIntosh, N. (1988). The postnatal development of the cutaneous flexor reflex: A comparative study in premature infants and newborn rat pups.
Developmental Medicine and Child Neurology, 30, 520526.
Fitzgerald, M., & Shortland, P. (1988). The effect of neonatal peripheral nerve section on the somadendritic
growth of sensory projection cells in the rat spinal cord.
Developmental Brain Research, 42, 129136.
Franck, L. (1986). A new method to quantitatively describe

pain behavior in infants. Nursing Research, 35(1), 2831.
Franck, L. (1998). Identification, management, and prevention of pain in the neonate. In C. Kenner, J. Lott, & A.
Flandermeyer (Eds.), Comprehensive neonatal nursing: A physiologic perspective (2nd ed., pp. 778803).
Philadelphia: W. B. Saunders.
Franck, L., & Lawhon, G. (2000). Environmental and behavioral strategies to prevent and manage neonatal pain. In
K. J. S. Anand, B. J. Stevens, & P. J. McGrath (Eds.),
Pain in infants (2nd ed., pp. 203216). Amsterdam:
Elsevier.
Franck, L., & Miaskowski, C. (1998). The use of intravenous
opioids to provide analgesia in critically ill, premature infants: A research critique. Journal of Pain and
Symptom Management, 15(1), 4169.
Franck, L., & Vilardi, J. (1995). Assessment and management
of opioid withdrawal in ill infants. Neonatal Network,
14(2), 3948.
Franck, L. S., Allen, A., Cox, S., & Winter, I. (2005). Parents'
views about infant pain in neonatal intensive care.
Clinical Journal of Pain, 21(2), 133139.
Franck, L. S., Boyce, W. T., Gregory, G. A., Jemerin, J.,
Levine, J, & Miaskowski, C. (2000). Plasma norepinephrine levels, vagal tone index, and flexor reflex threshold
in premature neonates receiving intravenous morphine
during the postoperative period: A pilot study. Clinical
Journal of Pain, 16(2), 95104.
Fuller, B. (1991). Acoustic discrimination of three types of
infant cries. Nursing Research, 40, 156160.
Gale, G., Franck, L. S., Kools, S., & Lynch, M. (2004).
Parents perceptions of their infants pain experience in
the NICU. International Journal of Nursing Studies,
41(1), 5158.
Gibbins, S., Maddalena, P., Moulsdale, W., Garrard, F., jan
Mohamed, T., Nichols, A., et al. (2006). Pain assessment
and pharmacologic management for infants with NEC:
A retrospective chart audit. Neonatal Network, 25(5),
339345.
Gibbins, S., & Stevens, B. (2003). The influence of gestational age on the efficacy and short-term safety of
sucrose for procedural pain relief. Advances in Neonatal
Care: Official Journal of the National Association of
Neonatal Nurses, 3(5), 241249.
Gibbins, S., Stevens, B., & Hodnett, E. (2002). Efficacy and
safety of sucrose for procedural pain relief in preterm and
term neonates. Nursing Research, 51(6), 375382.
Gregory, G. (1994a). Anesthesia for premature infants. In
G.A. Gregory (Ed.), Pediatric anesthesia (3rd ed., pp.
351373). New York: Churchill Livingstone.
Gregory, G. (1994b). Pharmacology. In G. A. Gregory (Ed.),
Pediatric anesthesia (3rd ed., pp. 1345). New York:
Churchill Livingstone.
Grunau, R., & Craig, K. (1987). Pain expression in infants:
Facial action and cry. Pain, 28, 395410.
Grunau, R., Johnston, C., & Craig, K. (1990). Neonatal facial
and cry responses to invasive and non-invasive procedures. Pain, 42, 295305.
20
Grunau, R., Linhares, M. B., Holsti, L., Oberlander, T. F., &

Whitfield, M. F. (2004). Does prone or supine position
influence pain responses in preterm infants at 32 weeks
gestational age? Clinical Journal of Pain, 20(2), 7682.
Grunau, R., Whitfield, M., & Petrie, J. (1994). Pain sensitivity and
temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls. Pain, 58, 341346.
Grunau, R., Whitfield, M., Petrie, J., & Fryer, E. (1994).
Early pain experience, child and family factors, as precursors of somatization: A prospective study of extremely
premature and fullterm children. Pain, 56, 353359.
Grunau, R. E., Holsti, L., Whitfield, M. F., & Ling, E. (2000).
Are twitches, startles, and body movements pain indicators in extremely low birth weight infants? Clinical
Journal of Pain, 16(1), 3745.
Gunnar, M., Connors, J., Isensee, J., & Wall, L. (1988).
Adrenocortical activity and behavioral distress in human
newborns. Developmental Psychobiology, 21, 297310.
Hall, R. W., Kronsberg, S. S., Barton, B. A., Kaiser, J. R., &
Anand, K. J. (2005). Morphine, hypotension, and adverse
outcomes among preterm neonates: Whos to blame?
Secondary results from the NEOPAIN trial. Pediatrics,
115(5), 13511359.
Harpin, V., & Rutter, N. (1983). Making heel pricks less painful. Archives of Disease in Childhood, 58, 226228.
Harrison, H. (1993). The principles for family-centered neonatal care. Pediatrics, 92, 643650.
Hartley, S., Franck, L., & Lundergan, R. (1989). Maintenance
sedation of agitated infants in the NICU with chloral hydrate:
New concerns. Journal of Perinatology, 9, 162164.
Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M.,
Merkel, S., et al. (2006). Pain assessment in the nonverbal
patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 4452.
Hodgkinson, K., Bear, M., Thorn, J., & Van Blaricum, S.
(1994). Measuring pain in neonates: Evaluating an instrument and developing a common language. Australian
Journal of Advance Nursing, 12(1), 1722.
Holsti, L., Grunau, R. E., Oberlander, T. F., & Whitfield,
M. F. (2004). Specific Newborn Individualized
Developmental Care and Assessment Program movements are associated with acute pain in preterm infants
in the neonatal intensive care unit. Pediatrics, 114(1),
6572.
Holsti, L., Grunau, R. E., Oberlander, T. F., & Whitfield, M.
F. (2005). Prior pain induces heightened motor responses
during clustered care in preterm infants in the NICU.
Early Human Development, 81(3), 293302.
Howard, C. R., Howard, F. M., & Weitzman, M. L. (1994).
Acetaminophen analgesia in neonatal circumcision: The
effect on pain. Pediatrics, 93, 641646.
Hummel, P., Puchalski, M., Weiss, M., & Creech, S. (2003,
May). N-PASS: Neonatal pain agitation and sedation
scaleReliability & validity. Poster presentation at the
Pediatric Academic Societies Annual Meeting, Seattle, WA.
Hummel, P., & van Dijk, M. (2006). Pain assessment: Current
status and challenges. Seminars in Fetal and Neonatal
Medicine, 11, 237245.
International Association for the Study of Pain. (2004). IASP Pain

Terminology. Retrieved August 31, 2007, from www.iasppain.org/AM/Template.cfm?Section=Home&template=/CM/
HTMLDisplay.cfm&ContentID=3088.
International Association for the Study of Pain. (2005). Core
curriculum for professional education in pain [online].
Retrieved August 31, 2007, from www.iasp-pain.org/
AM/Template.cfm?Section=Home&template=/CM/
HTMLDisplay.cfm&ContentID=4223#TOC.
Johnston, C., Filion, R., Snider, L., Majnemer, A.,
Limperopoulos, C., Walker, C., et al. (2002). Routine
sucrose analgesia during the first week of life in neonates
younger than 31 weeks postconceptional age. Pediatrics,
110(3), 523528.
Johnston, C., & Stevens, B. (1996). Experience in a neonatal
intensive care unit affects pain response. Pediatrics, 98,
925930.
Johnston, C., Stevens, B., Craig, K., & Grunau, R. (1993).
Developmental changes in pain expression in premature,
full-term, two- and four-month-old infants. Pain, 52,
201208.
Johnston, C., Stevens, B., Franck, L., Jack, A., Stremler, R.,
& Platt, R. (1999). Factors explaining lack of response
to heel stick in preterm newborns. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 28, 587594.
Johnston, C., Stevens, B., Yang, F., & Horton, L. (1995).
Differential response to pain by very premature infants.
Pain, 61, 471479.
Joint Commission on Accreditation of Healthcare
Organizations. (2001). Pain management standards for
2001. Retrieved September 9, 2000, from www.jcaho.
org/standard/pm.html.
Kleiber, C., Sorenson, M., Whiteside, K., Gronstal, B. A., &
Tannous, R. (2002). Topical anesthetics for intravenous
insertion in children: A randomized equivalency study.
Pediatrics, 110(4), 758761.
Koh, J. L., Harrison, D., Myers, R., Dembinski, R., Turner,
H., & McGraw, T. (2004). A randomized, double-blind
comparison study of EMLA and ELA-Max for topical
anesthesia in children undergoing intravenous insertion.
Paediatric Anaesthesia, 14(12), 977982.
Koren, G., Butt, W., Chinyanga, H., Soldin, S., Tan, Y. K.,
& Pape, K. (1985). Post-operative morphine infusion in
newborn infants: Assessment of disposition characteristics and safety. Journal of Pediatrics, 107, 963967.
Lawrence, J., Alcock, D., McGrath, P., Kay, J., MacMurray,
S., & Dulberg, C. (1993). The development of a tool to
assess neonatal pain. Neonatal Network, 12(6), 5966.
Lehr, V. T., Cepeda, E., Frattarelli, D. A., Thomas, R.,
LaMothe, J., & Aranda, J. V. (2005). Lidocaine 4% cream
compared with lidocaine 2.5% and prilocaine 2.5% or
dorsal penile block for circumcision. American Journal
of Perinatology, 22(5), 231237.
Leslie, A., & Marlow, N. (2006). Non-pharmacological pain
relief. Seminars in Fetal and Neonatal Medicine, 11,
246250.
Long, J., Lucey, J., & Philips, A. (1980). Noise and hypoxemia
in the intensive care nursery. Pediatrics, 65, 143145.
21
Lynn, A. M., Opheim, K. E., & Tyler, D. C. (1984). Morphine

infusion after pediatric cardiac surgery. Critical Care
Medicine, 12(10), 863866.
Marchette, L., Main, R., Redick, E., Bagg, A., & Leatherland,
J. (1991). Pain reduction interventions during neonatal
circumcision. Nursing Research, 40, 241244.
McCaffery, M., & Pasero, C. (1999). Assessment: Underlying
complexities, misconceptions, and practical tools. In M.
McCaffery & C. Pasero (Eds.), Pain: Clinical manual
(2nd ed., pp. 35102). St. Louis: Mosby.
McIntosh, N., Van Veen, L., & Brameyer, H. (1994).
Alleviation of the pain of heel prick in preterm infants.
Archives of Disease in Childhood, 70, F177F181.
Miller, H., & Anderson, G. (1993). Nonnutritive sucking:
Effects on crying and heart rate in intubated infants
requiring assisted mechanical ventilation. Nursing
Research, 42, 305307.
Morison, S. J., Holsti, L., Grunau, R. E., Whitfield, M. F.,
Oberlander, T. F., Chan, H. W., et al. (2003). Are there
developmentally distinct motor indicators of pain in preterm infants? Early Human Development, 72(2), 131146.
National Association of Neonatal Nurses. (2001). Pain assessment and management: Guideline for practice. Des
Plaines, IL: Author.
OBrien, L., Taddio, A., Lyszkiewicz, D. A., & Koren, G. (2005).
A critical review of the topical local anesthetic amethocaine
(Ametop) for pediatric pain. Paediatric Drugs, 7(1), 4154.
Ogawa, S., Ogihara, T., Fujiwara, E., Ito, K., Nakano, M.,
Nakayama, S., et al. (2005). Venepuncture is preferable to heel lance for blood sampling in term neonates.
Archives of Disease in Childhood. Fetal and Neonatal
Edition, 90(5), F432F436.
Olkkola, K. T., Maunuksela, E. L., Korpela, R., & Rosenberg,
P. H. (1988). Kinetics and dynamics of postoperative intravenous morphine in children. Clinical
Pharmacology and Therapeutics, 44(2), 128136.
Partridge, J. C., & Wall, S. N. (1997). Analgesia for dying
infants whose life support is withdrawn or withheld.
Pediatrics, 99(1), 7679.
Plotsky, P., Bradley, C., & Anand, K. (2000). Behavioral and
neuroendocrine consequences of neonatal stress. In K. J.
S. Anand, B. J. Stevens, & P. J. McGrath (Eds.), Pain in
neonates (2nd rev. ed., pp. 77101). Amsterdam: Elsevier
Science B.V.
Porter, F., Miller, J., Cole, F., & Marshall, R. (1991). A controlled clinical trial of local anesthesia for lumbar puncture in newborns. Pediatrics, 88, 663669.
Porter, F., Porges, S., & Marshall, R. (1988). Newborn cries
and vagal tone: Parallel changes in response to circumcision. Child Development, 59, 495505.
Porter, F., Wolf, C., & Miller, J. (1998). The effect of handling and immobilization on the response to acute pain in
newborn infants. Pediatrics, 102, 13831389.
Purcell-Jones, G., Dormon, F., & Sumner, E. (1987). The use
of opioids in infants: A retrospective study of 933 cases.
Anaesthesia, 42, 13161320.
Reynolds, M., Alvares, D., Middleton, J., & Fitzgerald, M.

(1997). Neonatally wounded skin induces NGF-independent
sensory neurite outgrowth in vitro. Developmental Brain
Research, 102, 275283.
Ruda, M. A., Ling, Q. D., Hohmann, A. G., Peng, Y. B., &
Tachibana, T. (2000). Altered nociceptive neuronal circuits after neonatal peripheral inflammation. Science,
289, 628630.
Shah, P. S., Aliwalas, L. I., & Shah, V. (2006) Breastfeeding
or breast milk for procedural pain in neonates. Cochrane
Shah, V., & Ohlsson, A. (2004). Venepuncture versus heel
lance for blood sampling in term neonates. Cochrane
Shah, V., Taddio, A., & Ohlsson, A. (1998). Randomized
controlled trial of paracetamol for heel prick pain in
neonates. Archives of Disease in Childhood. Fetal and
Neonatal Edition, 79, F209F211.
Shapiro, C. (1993). Nurses judgments of pain in term and
preterm newborns. Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 22(1), 4147.
Shiao, S., Chang, Y., Lannon, H., & Yarandi, H. (1997). Metaanalysis of the effects of nonnutritive sucking on heart
rate and peripheral oxygenation: Research from the past
30 years. Issues in Comprehensive Pediatric Nursing, 20,
1124.
Shiroiwa, Y., Kamiya, Y., & Uchiboi, S. (1986). Activity,
cardiac and respiratory responses of blindfold preterm
infants in a neonatal intensive care unit. Early Human
Development, 14, 259265.
Simons, S. H., & Anand, K. J. S. (2006). Pain control: Opioid
dosing, population kinetics and side-effects. Seminars in
Fetal and Neonatal Medicine, 11, 260267.
Simons, S. H., van Dijk, M., Anand, K. S., Roofthooft, D.,
van Lingen, R. A., & Tibboel, D. (2003). Do we still
hurt newborn babies? A prospective study of procedural
pain and analgesia in neonates. Archives of Pediatric
Adolescent Medicine, 157, 10581064.
Stevens, B., & Johnston, C. (1994). Physiological responses
of premature infants to a painful stimulus. Nursing
Research, 43, 226231.
Stevens, B., Johnston, C., Franck, L., Petryshen, P., Jack, A.,
& Foster, G. (1999). The efficacy of developmentally
sensitive interventions and sucrose for relieving procedural pain in very low birth weight infants. Nursing
Research, 48(1), 3543.
Stevens, B., Johnston, C., & Horton, L. (1993). Multidimensional
pain assessment in premature infants: A pilot study. Journal
of Obstetric, Gynecologic, and Neonatal Nursing, 22,
531541.
Stevens, B., Johnston, C., Petryshen, P., & Taddio, A. (1996).
Premature infant pain profile: Development and initial
validation. Clinical Journal of Pain, 12, 1322.
Stevens, B., McGrath, P., Gibbins, S., Beyene, J., Breau, L.,
Camfield, C., et al. (2007). Determining behavioural and
physiological responses to pain in infants at risk for neurological impairment. Pain, 127(12), 94102.
22
Stevens, B., Taddio, A., Ohlsson, A., & Einarson, T. (1997).

The efficacy of sucrose for relieving procedural pain in
infants: A systematic review and meta-analysis. Acta
Paediatrica, 86, 837842.
Stevens, B., Yamada, J., Beyene, J., Gibbins, S., Petryshen,
P., Stinson, J., et al. (2005). Consistent management of
repeated procedural pain with sucrose in preterm neonates: Is it effective and safe for repeated use over time?
Clinical Journal of Pain, 21(6), 543548.
Stevens, B., Yamada, J., & Ohlsson, A. (2004). Sucrose for
analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews, 3,
CD001069.
Stevens, B. J., Johnston, C. C., & Horton, L. (1994). Factors
that influence the behavioral pain responses of premature
infants. Pain, 59(1), 101109.
Suresh, S., & Anand, K. (1998). Opioid tolerance in infants:
Mechanisms, diagnosis, assessment, and management.
Seminars in Perinatology, 22, 425433.
Sweet, S., & McGrath, P. (1998). Relative importance of
mothers versus medical staffs behavior in the prediction of infant immunization pain behavior. Journal of
Pediatric Psychology, 23(4), 249256.
Taddio, A., Goldbach, M., Ipp, M., Stevens, B., & Koren, G.
(1995). Effect of neonatal circumcision on pain responses
during vaccination in boys. Lancet, 345(1), 291292.
Taddio, A., Katz, J., Ilersich, A. L., & Koren, G. (1997) Effect
of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 349(9052), 599603.
Taddio, A., Ohlsson, A., Einarson, T., Stevens, B., & Koren,
G. (1998). A systematic review of lidocaine-prilocaine
cream (EMLA) in the treatment of acute pain in infants.
Pediatrics, 101(2), 299.
van Lingen, R. A., Deinum, J. T., Quak, J. M., Kuizenga,
A. J., van Dam, J. G., Anand, K. J., et al. (1999).
Pharmacokinetics and metabolism of rectally administered
paracetamol in preterm neonates. Archives of Disease in
Childhood. Fetal and Neonatal Edition, 80, F59F63.
Walden, M., Sudia-Robinson, T., & Carrier, C. (2001).
Comfort care for infants in the neonatal intensive care
unit at end of life. Newborn and Infant Nursing Reviews,
1, 97105.
Ward-Larson, C., Horn, R. A., & Gosnell, F. (2004). The
efficacy of facilitated tucking for relieving procedural
pain of endotracheal suctioning in very low birthweight
infants. MCN: The American Journal of Maternal
Child Nursing, 29(3), 151156.
Willis, D. M., Chabot, J., Radde, I. C., & Chance, G. W.
(1977). Unsuspected hyperosmolarity of oral solution
contributing to necrotizing enterocolitis in very low birth
weight infants. Pediatrics, 60, 535538.
Yaster, M., & Deshpande, J. (1988). Management of pediatric
pain with opioid analgesics. Journal of Pediatrics, 113,
421429.
Young, T., & Mangum, O. B. (2006). NeoFax (19th ed.).
Raleigh, NC: Acorn Publishing.
23
Figure 1.
Premature Infant Pain Profile (PIPP)

Description of Score
Process
Indicator
Chart
Gestational age
Score 15
seconds
before event
Behavioral
state
Record baseline
heart rate
(___);
Observe infant
30 seconds
after event
Maximum
heart rate
Record baseline
oxygen
saturation
(___);
Observe infant
30 seconds
after event
Minimum
oxygen
saturation
Observe infant
30 seconds
after event
Brow bulge
Observe infant
30 seconds
after event
Eye squeeze
Observe infant
30 seconds
after event
Nasolabial
furrow
32 weeks35
weeks 6 days
28 weeks31
weeks 6 days
28 weeks
Active/awake
Eyes open
Facial
movements
Quiet/awake
Eyes open
No facial
movements
Active/sleep
Eyes closed
Facial
movements
Quiet/sleep
Eyes closed
No facial
movements
04 beats/
minute
increase
514 beats/
minute
increase
1524 beats/
minute
increase
25 or more
beats/minute
increase
36 weeks
Score
____________
____________
____________
02.4%
decrease
2.5%4.9%
decrease
5%7.4%
decrease
7.5% or more
decrease
____________
None
(0%9%
of time)
Minimum
(10%39%
of time)
Moderate
(40%69%
of time)
Maximum
(70% or more
of time)
____________
None
(0%9%
of time)
Minimum
(10%39%
of time)
Moderate
(40%69%
of time)
Maximum
(70% or more
of time)
____________
None
(0%9%
of time)
Minimum
(10%39%
of time)
Moderate
(40%69%
of time)
Maximum
(70% or more
of time)
____________
Total score
____________
PIPP Scoring Guidelines

1. Score the correct gestational age before beginning.

2. Assess baseline heart rate and oxygen saturation.
a. For procedural pain, assess before the event.
b. If pain is already present, review the chart for earlier baseline.
3. Score behavioral state by observing the infant for 15 seconds immediately before the event.
4. Observe the infant for 30 seconds immediately after the event.
Note. From Premature Infant Pain Profile: Development and Initial Validation, by B. Stevens, C. Johnston, P. Petryshen, and A.
Taddio, 1996, Clinical Journal of Pain, 12, p. 22. Copyright 1996 by Lippincott Williams & Wilkins. Adapted with permission.
National Association of Neonatal Nurses
24
Figure 2.
CRIES: Neonatal Postoperative Pain Assessment Score

Scoring Criteria
Indicator
Crying
Requires oxygen for
saturation > 95%
Increased vital signs
No
No
High pitched
< 30%
Inconsolable
> 30%
Heart rate and blood pressure

within 10% of preoperative
value

11%20% higher than
preoperative value

21% or more above preoperative value
Expression
None
Grimace
Grimace/grunt
Sleeplessness
No
Wakes at frequent
intervals
Constantly awake
CRIES Scoring Guidelines

Crying
Score 0: No cry or cry not high pitched
Score 1: Cry high pitched, but consolable
Score 2: High-pitched cry, inconsolable
Requires oxygen for saturation > 95%
Score 0: No oxygen required from baseline
Score 1: Oxygen requirement < 30% from baseline
Score 2: Oxygen requirement > 30% from baseline
Increased vital signs
Score 0: Heart rate and blood pressure are both unchanged or
at less than baseline
Score 1: Heart rate or blood pressure is increased by < 20%
Score 2: Heart rate or blood pressure is increased by > 20%
Note: Measure blood pressure last so as not to wake the infant.
Expression
Score 0: No grimace
Score 1: Grimace only is present
Score 2: Grimace and nonaudible grunt present
Note: Grimace consists of lowered brow, eyes squeezed shut,
deepening nasolabial furrow, and open lips and mouth
Sleeplessness
Score 0: Continuously asleep
Score 1: Awakens at frequent intervals
Score 2: Awake constantly
Note: Based on infants state during preceding hour.
Note. From Increasing Staff Nurse Awareness of Postoperative Pain Management in the NICU, by J. Bildner and S. Krechel,
1996, Neonatal Network, 15(1), p. 16. Copyright 1996 by S. Krechel & J. Bildner. Developed at University of Missouri
Columbia. Reprinted with permission.
25
Figure 3.
Neonatal Infant Pain Scale (NIPS)

Facial expression
0: Relaxed muscles
1: Grimace
Cry
0: No cry
1: Whimper
2: Vigorous cry
Breathing patterns
0: Relaxed
1: Change in breathing
Arms
0: Relaxed/restrained
1: Flexed/extended
Legs
0: Relaxed/restrained
1: Flexed/extended
State of arousal
0: Sleeping/awake
1: Fussy
Before
During
After
1
2
1
2
3
4
5
1
2
3
minute minutes minute minutes minutes minutes minutes minute minutes minutes
Totalt
NIPSScoring Guidelines
Facial expression
Score 0: Relaxed muscles = Restful face, neutral expression
Score 1: Grimace = Tight facial muscles; furrowed brow,
chin, jaw; negative facial expression (nose, mouth, brow)
Cry
Score 0: No cry = Quiet, not crying
Score 1: Whimper = Mild moaning, intermittent
Score 2: Vigorous cry = Loud scream, rising, shrill, continuous
Note: Silent cry, as evidenced by obvious mouth and other
facial movement, may be scored if baby is intubated.
Breathing patterns
Score 0: Relaxed = Usual pattern for this baby
Score 1: Change in breathing = Indrawing, irregular, faster
than usual, gagging, breath holding
Arms
Score 0: Relaxed/restrained = No muscular rigidity, occasional
random movements of arms
Score 1: Flexed/extended = Tense, straight arms, rigid or
rapid extension, flexion
Legs
Score 0: Relaxed/restrained = No muscular rigidity, occasional
random movements of legs
Score 1: Flexed/extended = Tense, straight legs, rigid and/or
rapid extension, flexion
State of arousal
Score 0: Sleeping/awake = Quiet, peaceful, sleeping or alert
and settled
Score 1: Fussy: Alert, restless, thrashing
Note. From The Development of a Tool to Assess Neonatal Pain, by J. Lawrence, D. Alcock, D. P. McGrath, J. Kay, S.
MacMurray, and C. Dulberg, 1993, Neonatal Network, 12(6), p. 60. Copyright 1993 by the Childrens Hospital of Eastern
Ontario, Ottawa, ON, Canada. Reprinted with permission.
26
Figure 4.
Incorporating Pain Assessment into the Vital-Sign Record

Pain Intensity Graph (using CRIES [110] or PIPP [112])
Pain Incident Description
Pain Incident Description Codes

Pain type
Disease = D
Procedure = P
Surgery = S
Treatment = T
Other (see nursing notes) = O
Intervention
Reduction of environmental stimuli = 1
Hand containment = 2
Swaddling/boundary nest = 3
Holding = 4
Position change = 5
Pacifier = 6
Sucrose pacifier = 7
Medication = 8
Other (see nursing notes) = 9
Family involvement
Comfort following procedure = C
Education (see nursing notes) = E
Support during procedure = S
Other = O
Note. From Integrating Research and Standards to Improve Pain Management Practices for Newborns and Infants, by C. Carrier and
M. Walden, 2001, Newborn and Infant Nursing Reviews, 1(2), p. 128. Copyright 2001 by Elsevier. Reprinted with permission.
27
Table 1.
Analgesic Medications, Routes of Administration, and Recommended

Dosages for Neonates
Drug
Routes
Dose
Administration Notes
Opioid Analgesics
Morphine
Fentanyl
Methadone
Intermittent intravenous
(IV), intramuscular,
subcutaneous
Continuous infusion
Oral/parenteral ratio
0.050.2 mg/kg
Give over at least 5 minutes.

Repeat as required (usually every 4 hours).
0.010.02 mg/kg/h
Give loading dose of 0.10.15 mg/kg over 1 hour. Oral dose

is 35 times IV dose.
Intermittent IV
14 mcg/kg
Repeat as required (usually every 24 hours).
Continuous infusion
15 mcg/kg/h
Tolerance may develop rapidly after constant infusion. Adjust

weaning schedule based on withdrawal symptoms.
By mouth (PO)
0.050.2 mg/kg
Long-acting narcotic analgesic. Most commonly used for

weaning.
Give oral dose every 1224 hours.
Adjust weaning schedule based on withdrawal symptoms.
Nonsteroidal Antiinflammatory Drugs

Acetaminophen
PO
Rectal
1215 mg/kg
1218 mg/kg
Give loading dose of 2025 mg/kg.

Give loading dose of 30 mg/kg.
Maintenance intervals:
Term infants: Give every 6 hours.
Preterm infants 32 weeks postconceptional age: Give
every 8 hours.
Preterm infants <32 weeks postconceptional age: Give every
12 hours.
Note. From NeoFax (19th ed., pp.150, 152153, 161, 166167), by T. E. Young and B. Mangum, 2006, Raleigh, NC: Acorn
Publishing. Copyright 2006 by author. Adapted with permission.
28
Table 2.
Suggested Management of Painful Procedures Commonly Performed in

the Neonatal Intensive Care Unit
Pacifier
with
Procedures
Sucrose
Diagnostic Procedures
Swaddling,
Containment,
or Facilitated EMLA
Tucking
Cream
Subcutaneous
Infiltration of
Lidocaine
Opioids Other
Arterial puncture
Heel lancing
Lumbar puncture
Venipuncture
Eye examination
Consider venipuncture, skinto-skin contact with mother;

mechanical spring-loaded lance
Use careful physical handling
Consider topical anesthetic
Therapeutic Procedures
Central venous
line placement
Chest tube
insertion
Gavage tube
insertion
Intramuscular
injection
Peripherally
inserted central
catheter
placement
Consider general anesthesia
Anticipate need for intubation

and ventilation in neonates
spontaneously breathing,
consider short-acting anesthetic agents, avoid midazolam
Gentle technique and appropriate lubrication
Give drugs intravenously,
whenever it is possible
Endotracheal
intubation
Endotracheal
suction
Sucrose
optional
Various combinations of
atropine, ketamine, thiopental
sodium, succinylcholine chloride, morphine, fentanyl, nondepolarizing muscle relaxant;
consider topical lidocaine spray
Surgical Procedures
Circumcision
Mogen clamp preferred over

Gomco clamp; dorsal penile
nerve block, ring block, or caudal block using plain or buffered
lidocaine; consider acetaminophen for postoperative pain
Note. From Identification, Management, and Prevention of Newborn/Infant Pain, by M. Walden and L. S. Franck in Comprehensive
Neonatal Nursing: A Physiologic Perspective (3rd ed., p. 853), C. Kenner and J. W. Lott (Eds.), 2002, Philadelphia: W.B. Saunders.
Copyright 2002 by W.B. Saunders. Reprinted with permission. This table was originally adapted from Consensus Statement for the
Prevention and Management of Pain in the Newborn, by K. J. Anand and International Evidence-Based Group for Neonatal Pain,
2001, Archives of Pediatric Adolescent Medicine, 155, pp. 173180. Copyright 2001 by the American Medical Association. Adapted
with permission.
29
4700 W. Lake Avenue

Glenview, IL 60025-1485
800/451-3795
Fax 888/477-6266
www.NANN.org

Pain Final

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pain Final

Uploaded by

Copyright:

Available Formats

Pain Assessment

Marlene Walden, PhD RNC NNP CCNS

Pain Assessment and Management

Development and Acknowledgments

4700 W. Lake Avenue

Pain Assessment and Management: Guideline for Practice

Pain Assessment and Management

5. Performance and findings from continuous

Pain Assessment and Management

Pain Assessment and Management

2. The most frequently studied behavioral responses

f. Cognitively impaired infants show similar

2001; Duhn & Medves, 2004; IASP, 2005; NANN,

those who require mechanical ventilation

and acute pain and sedation in preterm and

Pain Assessment and Management

Wolf, & Miller, 1998). Every attempt should

a. The most effective dose of sucrose remains

infants, has not been established and further

plasma concentrations of opioids for longer

Kelly, 2003). Data are insufficient to determine

the lancing procedure in combination with

Another study by Ogawa and colleagues (2005)

b. Data are inconsistent on whether nonsteroidal antiinflammatory drugs and

Goldbach, Ipp, Stevens, and Koren (1995) examined

Pain Assessment and Management

4. Healthcare providers are obligated to ensure

Pain Assessment and Management

Pain Assessment and Management

4. List pain instruments approved for use with

Pain Assessment and Management

1. Intervals of pain assessment

Pain Assessment and Management

Bellu, R., de Waal, K. A., & Zanini, R. (2005). Opioids for

Pain Assessment and Management

Craig, K., Whitfield, M., Grunau, R., Linton, J., &

Franck, L. (1986). A new method to quantitatively describe

Pain Assessment and Management

Grunau, R., Linhares, M. B., Holsti, L., Oberlander, T. F., &

International Association for the Study of Pain. (2004). IASP Pain

Pain Assessment and Management

Lynn, A. M., Opheim, K. E., & Tyler, D. C. (1984). Morphine

Reynolds, M., Alvares, D., Middleton, J., & Fitzgerald, M.

Pain Assessment and Management

Stevens, B., Taddio, A., Ohlsson, A., & Einarson, T. (1997).

Pain Assessment and Management

Premature Infant Pain Profile (PIPP)

PIPP Scoring Guidelines

1. Score the correct gestational age before beginning.

National Association of Neonatal Nurses

CRIES: Neonatal Postoperative Pain Assessment Score

Heart rate and blood pressure

Heart rate and blood pressure

Heart rate and blood pressure

CRIES Scoring Guidelines

Pain Assessment and Management

Neonatal Infant Pain Scale (NIPS)

National Association of Neonatal Nurses

Incorporating Pain Assessment into the Vital-Sign Record

Pain Incident Description

Pain Incident Description Codes

Pain Assessment and Management

Analgesic Medications, Routes of Administration, and Recommended

Give over at least 5 minutes.

Heart rate and blood pressure

Heart rate and blood pressure

Heart rate and blood pressure