Neonatal Pain Assessment Research Articles

Event-related potentials evoked by skin puncture reflect activation of Aβ fibers: comparison with intraepidermal and transcutaneous electrical stimulations.

BackgroundRecently, event-related potentials (ERPs) evoked by skin puncture, commonly used for blood sampling, have received attention as a pain assessment tool in neonates. However, their latency appears to be far shorter than the latency of ERPs evoked by intraepidermal electrical stimulation (IES), which selectively activates nociceptive Aδ and C fibers. To clarify this important issue, we examined whether ERPs evoked by skin puncture appropriately reflect central nociceptive processing, as is the case with IES.MethodsIn Experiment 1, we recorded evoked potentials to the click sound produced by a lance device (click-only), lance stimulation with the click sound (click+lance), or lance stimulation with white noise (WN+lance) in eight healthy adults to investigate the effect of the click sound on the ERP evoked by skin puncture. In Experiment 2, we tested 18 heathy adults and recorded evoked potentials to shallow lance stimulation (SL) with a blade that did not reach the dermis (0.1 mm insertion depth); normal lance stimulation (CL) (1 mm depth); transcutaneous electrical stimulation (ES), which mainly activates Aβ fibers; and IES, which selectively activates Aδ fibers when low stimulation current intensities are applied. White noise was continuously presented during the experiments. The stimulations were applied to the hand dorsum. In the SL, the lance device did not touch the skin and the blade was inserted to a depth of 0.1 mm into the epidermis, where the free nerve endings of Aδ fibers are located, which minimized the tactile sensation caused by the device touching the skin and the activation of Aβ fibers by the blade reaching the dermis. In the CL, as in clinical use, the lance device touched the skin and the blade reached a depth of 1 mm from the skin surface, i.e., the depth of the dermis at which the Aβ fibers are located.ResultsThe ERP N2 latencies for click-only (122 ± 2.9 ms) and click+lance (121 ± 6.5 ms) were significantly shorter than that for WN+lance (154 ± 7.1 ms). The ERP P2 latency for click-only (191 ± 11.3 ms) was significantly shorter than those for click+lance (249 ± 18.6 ms) and WN+lance (253 ± 11.2 ms). This suggests that the click sound shortens the N2 latency of the ERP evoked by skin puncture. The ERP N2 latencies for SL, CL, ES, and IES were 146 ± 8.3, 149 ± 9.9, 148 ± 13.1, and 197 ± 21.2 ms, respectively. The ERP P2 latencies were 250 ± 18.2, 251 ± 14.1, 237 ± 26.3, and 294 ± 30.0 ms, respectively. The ERP latency for SL was significantly shorter than that for IES and was similar to that for ES. This suggests that the penetration force generated by the blade of the lance device activates the Aβ fibers, consequently shortening the ERP latency.ConclusionsLance ERP may reflect the activation of Aβ fibers rather than Aδ fibers. A pain index that correctly and reliably reflects nociceptive processing must be developed to improve pain assessment and management in neonates.

A Comparison of Pain Scale on Neonates in a Top Refferal Hospital in Indonesia

Background: Pain assessment scale in neonates is the cornerstones of pain management so that the impact of pain can be prevented to maximize neonatal growth and development.Purpose: This study aimed to identify the most appropriate pain assessment scale used for neonates in Indonesia.Methods: A cross sectional study design was used in 30 neonates hospitalized using Neonatal Infant Pain Scale (NIPS), Neonatal infant Acute Pain Assessment Scale (NIAPAS) and Pain Assessment Tool (PAT). Pain assessment was performed by nurses (n=30) and expert nurses (n=5) participated in the validation of scales. Statistical analysis using validity (content, construct and concurrent validity) and reliability (inter-rater reliability and internal consistency) test.Results: NIPS instrument have excellent validity, reliability, and feasibility value compared with NIAPAS and PAT.Conclusion: NIPS was shown a valid, reliable, and practical scale for assessing pain in neonates. It allows nurses to identifying pain and help to provide of appropriate pain management

Validity and reliability of the Neonatal Infant Acute Pain Assessment Scale (NIAPAS) in Turkish: prospective study.

Using pain scales helps nurses in making early diagnoses and in assessing and managing pain symptoms and findings when developing a nursing care plan. To determine the validity and reliability of the Turkish form of the Neonatal Infant Acute Pain Assessment Scale (NIAPAS). Prospective study conducted in Istanbul Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey. 145 newborns in the 26th to 42nd gestational weeks that were receiving treatment and care in the neonatal intensive care unit were included in this study. A total of 1740 pain assessments were made by two independent observers on these 145 newborns. The research data was collected using a newborn description form, NIAPAS and the Neonatal Infant Pain Scale (NIPS). The scope validity index of NIAPAS was found to be between 0.90 and 1.00 and its Cronbach's alpha coefficient was 0.914. Correlations between characteristics and total scores (r = 0.20-0.82) were found to be sufficiently high. In an assessment on concurrency validity, there was a strong positive relationship between NIAPAS and NIPS scores (r = 0.73-0.82; P < 0.000). From kappa analysis (0.73-0.99) and intraclass correlation (r = 0.75-0.96), it was determined that there was concordance between the observers. NIAPAS was found to be a valid and reliable scale for evaluating acute pain in newborns.

What Facial Features Does the Pediatrician Look to Decide That a Newborn Is Feeling Pain?

The study aimed to analyze the gaze fixation of pediatricians during the decision process regarding the presence/absence of pain in pictures of newborn infants. Experimental study, involving 38 pediatricians (92% females, 34.6 ± 9.0 years, 22 neonatologists) who evaluated 20 pictures (two pictures of each newborn: one at rest and one during a painful procedure), presented in random order for each participant. The Tobii-TX300 equipment tracked eye movements in four areas of interest of each picture (AOI): mouth, eyes, forehead, and nasolabial furrow. Pediatricians evaluated the intensity of pain with a verbal analogue score from 0 to 10 (0 = no pain; 10 = maximum pain). The number of pictures in which pediatricians fixed their gaze, the number of gaze fixations, and the total and average time of gaze fixations were compared among the AOI by analysis of variance (ANOVA). The visual-tracking parameters of the pictures' evaluations were also compared by ANOVA according to the pediatricians' perception of pain presence: moderate/severe (score = 6-10), mild (score = 3-5), and absent (score = 0-2). The association between the total time of gaze fixations in the AOI and pain perception was assessed by logistic regression. In the 20 newborn pictures, the mean number of gaze fixations was greater in the mouth, eyes, and forehead than in the nasolabial furrow. Also, the average total time of gaze fixations was greater in the mouth and forehead than in the nasolabial furrow. Controlling for the time of gaze fixation in the AOI, each additional second in the time of gaze fixation in the mouth (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.08-1.46) and forehead (OR: 1.16; 95% CI: 1.02-1.33) was associated with an increase in the chance of moderate/severe pain presence in the neonatal facial picture. When challenged to say whether pain is present in pictures of newborn infants' faces, pediatricians fix their gaze preferably in the mouth. The longer duration of gaze fixation in the mouth and forehead is associated with an increase perception that moderate/severe pain is present. · Neonatal pain assessment is intrinsically subjective.. · Visual tracking identifies the focus of attention of individuals.. · Adults' gaze in neonates' mouth and forehead is associated with pain perception..

Psychometric Properties of the Turkish Version of the Neonatal Infant Acute Pain Assessment Scale

PurposeEven the healthiest neonates experience pain during painful interventions (e.g. administration of Vitamin K, heel lance) in their first moments of life. This study aimed to examine the validity and reliability of the Turkish version of the Neonatal Infant Acute Pain Assessment Scale. Design and methodsThis methodological study was conducted with 100 newborns receiving treatment and care in a tertiary neonatal intensive care unit. The data were collected using the Neonate Demographic Form, the Neonatal Infant Acute Pain Assessment Scale, and the Premature Infant Pain Profile. The scale was analyzed in terms of validity, internal consistency, and interobserver reliability. ResultsThe content validity index of the scale was found to be between 0.87 and 1.00, while Cronbach's alpha coefficient was between 0.708 and 0.833. According to the item analysis results, item-total correlation values were high. A strong positive correlation was found between the scores of the two scales that were analyzed for concurrent validity. Conclusions/practice implicationsThe Turkish version of the Neonatal Infant Acute Pain Assessment Scale was determined to be valid and reliable. More studies should be done to accurately measure and effectively manage neonatal pain.

Nurses' perception, knowledge, and use of neonatal pain assessment.

Preterm and sick newborn infants undergo several painful procedures during their hospital stay, potentially leading to short‐ and long‐term negative consequences. Pain assessment should be performed regularly to provide optimal pain management. Nurses' knowledge of and attitude toward neonatal pain assessment affect how pain is assessed and managed in the clinical situation. The aim of this study was to explore Swedish nurses' perception, knowledge, and use of neonatal pain assessment. This descriptive, cross‐sectional questionnaire study was conducted across all Swedish neonatal units (n = 38). Respondents were chosen through convenience sampling by the head nurses at each unit. Ten nurses from each unit were asked to complete the survey, which contained both closed and open questions. A majority of the units (30/38; 79%) participated and 232 surveys were returned, a response rate of 61%. Of the nurses, 91% thought that neonatal pain assessment was important. Many nurses mentioned various difficulties with pain assessment and concerns that the scales used might not assess pain correctly. About half of the nurses considered themselves to have enough knowledge of neonatal pain assessment. Those who reported having enough knowledge of pain assessment viewed the pain scales used at their units more positively. Of the nurses, 74% reported using a pain assessment scale several times per work shift. Pain management guidelines were available according to 75% of nurses, but only 53% reported that the guidelines were followed. Although nurses in general expressed a positive attitude toward pain assessment scales, this was not necessarily evident in their clinical practice. Lack of knowledge, available or accessible guidelines, or concerns regarding the validity of available pain scales seemed to limit their use.

The Effect of Maternal Voice on Venipuncture Induced Pain in Neonates: A Randomized Study

BackgroundVenipuncture is a common procedure in the neonatal intensive care unit (NICU) and causes significant pain for neonates. AimTo evaluate the effect of maternal voice on pain caused by venipuncture (including peripheral venipuncture and femoral venipuncture) in neonates hospitalized in the NICU. DesignExperimental, randomized controlled study. SettingThe study was conducted in the NICU of two hospitals in China from November 2017 to January 2019. MethodsOne hundred and sixteen neonates were randomly assigned to the maternal voice or routine care groups. The maternal voice group received recorded maternal voice intervention before, during, and after venipuncture. Three phases of procedures were videotaped. Neonatal Infant Acute Pain Assessment Scale (NIAPAS) was assessed by the same evaluator at different phases. ResultsThe study showed that NIAPAS scores, behavioral indicator scores, and physiological indicator scores in the maternal voice group were significantly lower compared with those in the routine care group. ConclusionRecorded maternal voice can improve pain caused by venipuncture in neonates. These are simple, rapid, and cost-effective methods that nurses can implement during venipuncture in neonates.

Can Event-Related Potentials Evoked by Heel Lance Assess Pain Processing in Neonates? A Systematic Review.

To clarify the possibility of event-related potential (ERP) evoked by heel lance in neonates as an index of pain assessment, knowledge acquired by and problems of the methods used in studies on ERP evoked by heel lance in neonates were systematically reviewed, including knowledge about Aδ and C fibers responding to noxious stimuli and Aβ fibers responding to non-noxious stimuli. Of the 863 reports searched, 19 were selected for the final analysis. The following points were identified as problems for ERP evoked by heel lance in neonates to serve as a pain assessment index: (1) It is possible that the ERP evoked by heel lance reflected the activation of Aβ fibers responding to non-noxious stimuli and not the activation of Aδ or C fibers responding to noxious stimulation; (2) Sample size calculation was presented in few studies, and the number of stimulation trials to obtain an averaged ERP was small. Accordingly, to establish ERP evoked by heel lance as a pain assessment in neonates, it is necessary to perform a study to clarify ERP evoked by Aδ- and C-fiber stimulations accompanied by heel lance in neonates.

Nurses' knowledge and practice in assessment and management of neonatal pain at Governmental Hospitals in Gaza Strip: A cross sectional study

Objective: The study aimed to investigate neonatal nurses' knowledge and practices related to pain assessment and management that may contribute to improve the quality of pain management by nurses at Neonatal Intensive Care Units (NICUs) of governmental hospitals in Gaza Strip. Design: The study design was quantitative, descriptive cross sectional, conducted at the NICUs affiliated to the governmental hospitals "Al Shifa Hospital - Al Nasser Pediatric Hospital - European Gaza Hospital". Materials and Methods: The sample consisted of all nurses working in NICUs. The total number of nurses was 102. The data were collected from study participants by using a self-administered questionnaire. The response rate was 100%. The data collected were analyzed by using descriptive and inferential statistical tests with level of statistical significance at p &lt; 0.5. Results: The results showed that nurses had very low of knowledge level with mean percentages (59.42%) and very low of practice level with mean percentages (58.33%). Conclusion: Therefore, the study recommended to developing course or educational program related to assessment and management of neonatal pain to promote their integrated pain management care for neonates.

Ouch that was sore: Advanced Midwifery and Neonatal Nursing Science students’ knowledge and perceptions of neonate pain assessment

Introduction: A neonate is subjected to pain in a variety of invasive and non-invasive activities. It is significant that the midwife assesses for pain in the neonate due to their inability to give verbal expression to their pain. The study aimed to gain an in-depth understanding of Advanced Midwifery students’ attitudes, knowledge and perceptions on pain assessment in neonates. Method: A qualitative content analysis using Elo and Knynas’ (2008) approach, explored the participants’ experiences of neonatal pain assessment. Purposive sampling allowed for the selection of Advanced Midwifery and Neonatal Nursing Science students from a select university. Data were collected through a focus group discussion for an extended period to ensure data saturation and that no new information emerged. Results: The following three categories emerged: elimination process, restricted assessment and non-standardised approach. Conclusion: Pain was not given primacy as an indicator of neonatal discomfort. There was a paucity of knowledge on the assessment tools, with haphazard assessment, which lacked a scientific approach.

Indian association of paediatric anaesthesia advisory for pain management in neonates and preverbal children

In the past, management of pain in neonates was regarded as unnecessary, with the belief that neonates have an immature nervous system and do not perceive pain. Later studies confirmed that neonates certainly do feel pain, though they lack the inhibitory mechanisms that modulate excruciating stimuli, unlike in older children. Repeated painful encounters experienced in the newborn period are associated with poor cognitive and motor development by 1 year of age. Pain in preverbal infants and children is also poorly recognized and often undertreated. Neonates and preverbal children cannot verbally communicate their pain and discomfort but express them through specific behavioral, physiological, and biochemical responses. Several pain measurement tools have been developed for young children as surrogate measures of pain. To achieve optimum postoperative or procedural pain relief, easily understandable tools and a multimodal treatment module should be tailor-made for each health-care facility that cares for neonates and young infants. The aim of this advisory is to outline key concepts of pain assessment in neonates and preverbal children and suggest a rational approach to its management by all anesthesiologists, pediatricians, nursing staff, and other medical personnel caring for these children. The Indian Association of Paediatric Anaesthesia (IAPA) convened an online meeting in April 2020 to formulate the advisory on pain management in neonates and preverbal children under the chairmanship of Dr. Elsa Varghese, President IAPA, and members of the guideline committee. After several such meetings and revisions using feedback from IAPA members, the final guidelines were released in October 2020 on the IAPA website. Recommendations: Pain relief should generally be accomplished with a combination of nonpharmacologic approaches and pharmacologic techniques in a stepwise tiered manner by escalating type and dose of analgesia with anticipated increases in procedural pain. Nonpharmacological distraction measures may be sufficient for minor needle procedures like vaccination and venipuncture and may be offered as a first step and to complement other pain management remedies. An interdisciplinary approach involving pharmacologic, cognitive-behavioral, psychologic, and physical treatments should be employed whenever feasible.

Scales for assessment of pain in infants, neonates and children

Scales for assessment of pain in infants, neonates and children

Practical approaches to sedation and analgesia in the newborn.

The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.

The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates

BackgroundThe neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. ObjectiveThe objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. MethodsNeonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score. ResultsNurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the ‘variation in the timing of the pain score’ and the ‘integration of critical thinking and judgement’ used when assessing pain in neonates. ConclusionsThe clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.

Implementierung eines neonatalen Schmerzassessmentinstruments auf einer neonatologischen Intensivstation - Ein Qualitätsentwicklungsprojekt.

Implementation of a Neonatal Pain Assessment Instrument at a Neonatal Intensive Care Unit - A Quality Improvement Project Abstract. Background: Optimal pain management is necessary in order to not jeopardize the development of preterm neonates. Aim: Implementation and evaluation of systematic and best possible pain assessment with the Bernese Pain Scale for Neonates for all preterm and sick neonates of a neonatal intensive care unit by nursing staff. Methods: The educational concept is based on three key strategies: knowledge translation (group- and one-on-one training), reflection (case conferences) and clinical training. The frequency of the use of the Pain Score was recorded before (T0) and after implementation (T1) and six months after completion of the project (T2). Results: Before the implementation (T0) the use of the Bernese Pain Scale was regulated by an internal guideline but its application could not be verified during the baseline period (fulfillment rate of 0 %). After implementation (T1) at least one assessment per shift per neonate could be achieved in 99.1 % of the cases. Nurses conducted 210 assessments on 38 neonates in T1. In follow-up (T2) six months after implementation fulfillment rate of 100 % in 34 neonates was achieved with 188 pain assessments. Conclusions: This implementation strategy was successful in establishing the assessment instrument in clinical practice.

A survey of procedural pain assessment and non-pharmacologic analgesic interventions in neonates in Spanish public maternity units.

To qualify and quantify clinical practices related to pain assessment and non-pharmacologic analgesia (NPA) in newborns in Spanish public maternity hospitals STUDY DESIGN: We surveyed providers online regarding their use of pain assessment scales, NPA interventions in neonates undergoing procedures, as well parents' presence or absence during interventions. The number of painful procedures and the subjective grading of pain from the responding physicians were similar in all hospitals. Only 12.5% of hospitals used pain scales. No NPA was employed in 37.7% of procedures, with less NPA used in the lower complexity hospitals for venous extraction (p < 0.001) and gastric lavage (p = 0.001). Respondents reported parents' absence during 56.1% of procedures. Available pain assessment scales and NPA interventions to mitigate pain are being underused. The presence of the parents during painful interventions is low despite the evidence that this may help to reduce newborns' perception of pain.

Acute pain measured with the modified Bernese Pain Scale for Neonates is influenced by individual contextual factors.

Individual contextual factors like gestational age (GA) or previous painful experiences have an influence on neonates' pain responses and may lead to inaccurate pain assessment when not appropriately considered. We set out to determine the influence of individual contextual factors on variability in pain response in neonates, measured with the modified Bernese Pain Scale for Neonates (BPSN), and, if necessary, to incorporate relevant individual factors into a revised version of the BPSN. We videotaped 154 full-term and preterm neonates of different GAs during 1-5 capillary heel sticks in their first 14days of life. For each heel stick, we produced three video sequences: baseline, heel stick, and recovery. The randomized sequences were rated on the BPSN by five blinded nurses. Individual contextual factors were retrospectively extracted from patient charts and from the video recordings. We analysed the data in single and multiple linear mixed models. Premature birth (b=-0.721), caffeine (b=-0.302), and the behavioural states quiet and awake (b=-0.283), active and asleep (b=-0.158), and quiet and asleep (b=-0.498) were associated with changes in behavioural pain scores. Premature birth (b=-0.232), mechanical ventilation (b=-0.196), and duration of the heel stick procedure (b=0.0004) were associated with changes in physiological pain scores. Premature birth (b=-0.907), Caffeine (b=-0.402), the behavioural states quiet and awake (b=-0.274), and quiet and asleep (b=-0.459), and duration of the heel stick procedure (b=0.001) were associated with changes in the modified BPSN total scores. Postmenstrual age, behavioural state, caffeine, and ventilation status have an influence on neonates' pain response and should be incorporated in the revised BPSN to enhance clinical pain assessment in neonates with different GAs. We identified individual contextual factors associated with dampened pain response in neonates and will incorporate them into a revised version of the Bernese Pain Scale for Neonates to provide clinicians with a tool they can use to more accurately assess and manage pain in this vulnerable population.

AB012. Neonatal pain: beliefs, skepticism, and scientific knowledge

: During the last decades, a considerable improvement has been made in understanding the pathophysiology of neonatal pain and the long-term consequences of untreated pain in this age group, overcoming, thus, myths and beliefs of the past that have greatly influenced everyday clinical practice for years. Nevertheless, evidence show that, still, there is a large variation in the management of neonatal pain across centers and countries. Fear of acute adverse effects and poor neurodevelopment in the long-term following the administration of analgesics-sedatives in neonates, difficulties in pain assessment, relative paucity of relevant pharmacological studies, and personal preferences are important contributors to the existing differences among neonatologist, worldwide. On the other hand, clinical data regarding neurological outcomes after exposure to drugs such as opioids are conflicting, so that the question of whether the specific drugs may promote the damage of preterm brain largely remains unanswered. Inadequate pain assessment in neonates most probably reflects difficulties and reliability of the existing scales in assessing pain and its types (acute procedural, postoperative and chronic pain) as well as “culture on neonatal pain” and organizational issues (e.g., understaffing, increased number of admissions, etc.). To eliminate drug exposure and significant side effects, several non-pharmacological modalities—environmental (measures to minimize bright light, loud noises or frequent handling) and behavioural (skin-to-skin care, sweet solutions)—are increasingly being used so that to reduce total amount of noxious stimuli. Overall, prevention and minimization of pain must be a high-priority goal during neonatal care, as early events like neonatal pain and stress may lead to epigenetic alternations affecting the infants’ developmental trajectory. Given, however, the aforementioned concerns, a tiered approach to sedation/analgesia seems most appropriate. Drugs should be used wisely when needed, while neonatal units should promote continuous education and protocol development on pain assessment and management.

A Systematic Review of Clinical Practice Guidelines for Acute Procedural Pain on Neonates.

During hospitalization in neonatal intensive care units, neonates are exposed to many painful procedures within a stressful environment. To date, many evidence-based guidelines are available. However, the quality of these guidelines and their clinical application remain unclear. This systematic review aimed to determinie the quality of existing guidelines on the management of procedural pain in neonates and to summarize the recommendations provided by these guidelines. A structured search was conducted in Embase, PubMed, CINAHL, JBI database, and gray literature resources in November 2018 to identify relevant guidelines published from 2007 onward. Published guidelines and guidelines from complementary searches were included in the treating assessment or management of procedural pain in neonates. The methodological quality was analyzed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument. A total of 1154 records were identified. After screening for eligibility, 17 guidelines were included in this review. Among these, 11 were identified to be high-quality guidelines. Besides the usual recommendations for pharmacological and nonpharmacological treatments, the inclusion of parents, improving interprofessional collaboration, and considering the setting were identified as important elements. The results of this review show that there is a need to improve the methodological quality of guidelines for procedural pain in newborns. The set of recommendations for procedural pain prevention needs to involve not only pharmacological and nonpharmacological pain treatment but also parents and interprofessional collaboration. It is also essential to take into account facilitators, barriers, and the context to improve pain management.

Temporal assessment of neonatal pain after airway aspiration.

ObjectiveTo temporally assess a painful stimulus in premature infants using 3 neonatal pain scales.MethodsA total of 83 premature infants were observed during airway aspiration by 3 evaluators (E1, E2 and E3) using 3 pain assessment scales (Neonatal Facial Coding System - NFCS; Neonatal Infant Pain Scale - NIPS; and Premature Infant Pain Profile - PIPP) at 5 time points: T1 (before airway aspiration), T2 (during airway aspiration), T3 (1 minute after airway aspiration), T4 (3 minutes after airway aspiration), and T5 (5 minutes after airway aspiration). Light’s Kappa (agreement among examiners and among scales at each time point) and the McNemar test (comparison among time points) were used considering p < 0.05.ResultsThere was a significant difference between the 3 examiners for T1 and T2 using the 3 scales. In T3, pain was observed in 22.9%/E1, 28.9%/E2, and 24.1%/E3 according to the NFCS; 22.9%/E1, 21.7%/E2, and 16.9%/E3 according to the NIPS; and 49.4%/E1, 53.9%/E2, and 47%/E3 according to the PIPP. There was a difference between T1 and T3 using the 3 scales, except for 2 examiners for the PIPP (E2: p = 0.15/E3: p = 0.17). Comparing T4 and T5 to T1, there was no difference in the 3 scales.ConclusionPremature infants required at least 3 minutes to return to their initial state of rest (no pain).