3. PAIN Assessment Najmeh Ajoodanian, MS, NICU 2014

4. Pain Perception 28 week of gestation pain threshold that is 30% to 50% lower than that of adults lower pain tolerance than older children Premature infants are even more hypersensitive to nociceptive stimuli than full-term infants

5. As the fifth vital sign, pain needs to be monitored routinely in the clinical practice infants cannot speak and advocate Pain...

6. Pain assessment and measurement are the cornerstones of pain management The purpose of this review pain measures in both preterm and full term newborns by introducing a conceptual framework

7. The International Association for the Study of Pain (IASP) “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” “Pain is subjective” defines pain

8. FRAMEWORK FOR MEASUREMENT OF NEONATAL PAIN

9. Neonatal Pain Responses Behavioral Physiologic Autonomic Biochemical

10. Behavioral Pain Responses Facial expression  cleaning the heel or changing diapers Facial expression include: facial grimacing, brows bulged and furrowed eye squeezed, nasolabial furrowing, lips opened and pursed, cupped tongue, quivering chin agitation.

11. Crying is a common response to pain in infants preterm and acutely ill infants may not audibly cry during heel sticks and other painful procedures silent cry

12. Observations of gross motor responses including: body movements of arms, legs and trunks, Whole body, finger splay and fisting, attempts to withdraw from a painful stimulus

13. Observation sleep wake alterations

14. Physiologic Responses increases in heart rate, respiratory rate, blood pressure increases intracranial pressure, and palmar sweating decreases in transcutaneous oxygen saturation, vagal tone, and peripheral blood flow

15. Autonomic Responses changes in skin color, nausea, vomiting, gagging hiccoughing, diaphoresis, palmar sweating dilated pupils

16. Biochemical Responses increased secretion of catecholamines (ie, norepinephrine and epinephrine), glucagon, and corticosteroids or cortisol decreased prolactin, insulin, and immune responses

17. Infant Contextual Parameters in Pain Assessment Age Previous pain experiences Gender Health status especially in preterm infants

18. Health providers’ knowledge, ability, and attitudes toward neonatal pain are significant factors in observation, and using appropriate pain tools to recognize a neonate’s pain.

19. PAIN ASSESSMENT TOOLS 1.Unidimensional Tools 2.Multidimensional Tools

20. Unidimensional Infant Pain Measures Designed for measurement of acute/procedural pain MAX: Maximally Discriminative Facial Coding System NFCS: Neonatal Facial Coding System IBCS: Infant Body Coding System; DAN: Douleur Aiguë du BIIP: Behavioral Indicator of Infant Pain

21. Unidimensional Infant Pain Measures Designed for measurement of postoperative pain CSS: Clinical Scoring System LIDS: Livepool Infant Distress Scale FLACC: Face, legs, activity, cry, consolability UWCH: University of Wisconsin Children’s Hospital Pain Scale CHIPPS: Children’s and Infant’s Postoperative Pain Scale

22. Unidimensional Infant Pain Measures Designed for measurement of prolonged pain BPS: Behavioral Pain Score EDIN: Echelle Douleur Inconfort Nouveau-Ne Neonatal Pain and Discomfort Scale COMFORTneo: modified from the COMFORT

23. Multidimensional Infant Pain Measures Designed for measurement of acute/procedural pain NIPS: Neonatal Infant Pain Scale; NPAT: Neonatal Pain Assessment Tool PIPP: Premature Infant Pain Profile DSVNI: Distress Scales for Ventilated Newborn Infants

24. Multidimensional Infant Pain Measures Designed for measurement of acute/procedural pain SUN: Scale for Use in Newborns PAIN: Pain Assessment in Neonates BPSN: Bernese Pain Scale for Neonates FANS: Faceless Acute Neonatal Pain Scale

25. Multidimensional Infant Pain Measures Designed for measurement of postoperative pain COMFORT Scale (not primarily developed for neonates PAT: Pain Assessment Tool CRIES MIPS: L Modified Infant Pain MAPS: Multidimensional Assessment Pain Scale;

26. Multidimensional Infant Pain Measures Designed for measurement of prolonged/ongoing pain N-PASS: Neonatal Pain, Agitation, and Sedation Scale

27. Premature Infant Pain Profile

28. CRIES scale C-crying R-requires O2 I-increased VS E-expression S-sleepless Simple and easy to use-uses a scale of 1-10, similar to APGAR scoring score of 4 or greater requires intervention objective and behavioral categories

29. FLACC Scale F-face (expression) L-legs (tone) A-activity C-cry C-consolability score is tallied, similar to APGAR (0,1, or 2 for each category) greater than 4 is indicative of pain behaviorally based

30. MeasureAge LevelIndicatorPain Stimulus CRIES Preterm & Full- term Up to 60 Weeks gestation age Crying, requires O2 for saturation, increased vital signs (HR and BP), expression, sleepless Postoperative Pain BPSN Preterm & Full- term neonates Time to calm, skin color, eyebrow bulge with eye squeeze, posture, breathing pattern, heart rate, oxygen saturation Procedural pain in neonates with or without ventilation NIPS Preterm & Full- term neonates Facial expression, cry, breathing pattern, arms, legs, state of arousal Procedural pain PAT Full- term neonates Posture, tone, sleep pattern, expression, color, cry, respiration, heart rate, oxygen saturation, blood pressure, nurses perception of infant pain postoperative pain PIPP Preterm & Full- term neonates Gestational age, behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, nasolabial furrow Procedural and postoperative pain SUN Preterm & Full- term infants Central nervous system state, breathing, movement, tone, face, heart rate, blood pressure Procedural pain

31. New Techniques for Pain Measurement Heart Rate Variability Skin Conductance Brain-Oriented Approach

32. Thank you for your attention

33. 32 If you have any question contact to: ajoodaniyan@yahoo.com

34. References  Cong X. Cusson RM. Pain Assessment and Measurement. Foundations in Newborn Care. 2013;379- 395  Kenner C, Lott JW. Comprehensive Neonatal care an interdisciplinary approach chapter 17: Pain in the Newborn and Infant. 2010  Verklan MT, Walden M. Care curriculum for Neonatal intensive care unit 2010