A Systematic Integrative Review of Infant Pain Assessment Tools

Lenora J. Duhn, RN, MSc; Jennifer M. Medves, RN, PhD


Adv Neonatal Care. 2004;4(3) 

In This Article

Infant Pain and Pain Assessment

Infants feel pain.[2,3,4] Research confirms that the anatomic structures for pain processing are in place from mid to late gestation. Nociceptive impulses are carried through unmyelinated fibers in the nervous system.[5,6] Although incomplete myelination may affect the speed of pain impulse transmission, this is offset by shorter distances traveled in the infant's central nervous system. Additionally, lack of neurotransmitters in the descending tract suggests that inhibitory mechanisms are lacking in preterm infants, thereby increasing their sensitivity to pain compared to older children and adults.[5,6]

Infant pain assessment is challenging because infants are unable to verbalize the presence and intensity of their pain. Pain is uniquely experienced and expressed by each individual and can be affected by physiological well-being. Further, the younger preterm infant may have diminished responsiveness due to nervous system and musculoskeletal immaturity.[7]

The long-term effect of neonatal pain is not well understood, yet current literature suggests that repeated noxious stimuli can lead to chronic neuropathic states so that normally innocuous stimuli can produce pain.[8] Therefore, minimizing and managing neonatal pain is required to promote normal growth and development and to reduce any potential long-term sequelae. The first step must be assessment.

There is agreement in the literature that a key responsibility for health care practitioners caring for infants is pain assessment.[3,9,10,11] In the 1999 Position Statement on Pain Management in Infants, the National Association of Neonatal Nurses (NANN) endorsed the importance of nurses being diligent in assessing and managing neonatal pain.[12] NANN's Pain Assessment and Management Guideline for Practice underscores the importance of neonatal pain assessment and management.[13] The document is a helpful resource tool for practitioners. Its references to the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) Quick Reference Guide on Acute Pain Management, however, should be viewed with caution given that the AHRQ guidelines "…are no longer viewed as guidance for current medical practice, and are provided for archival purposes only."[14] The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Pain Standards for 2001 echoes the currently expected standard that pain assessment occurs for all patients.[15]

Having identified the reality and complexity of pain, authors have concluded the importance of considering a tool to assess pain that is multidimensional in nature.[2,12,16] One group of researchers examined facial activity, body movements, and physiological measures in 56 preterm and full-term newborns ranging from 25 to 41 weeks gestation.[4] The infant's response to heel lancing, including review of responses to preparation before the lancing and recovery after the procedure, was evaluated. Their results demonstrated physiological response (i.e., altered heart rate) to swabbing and heel lance in neonates as young as age 25 to 27 weeks and an increase in facial activity with the increasing age of the infant. Regardless of gestational age, greater body activity was seen with heel lance than with the other observed events. This suggests that infants have the capacity to differentiate invasive versus noninvasive events. There appeared to be greater specificity to a painful event with the facial activity measure.

Another group of researchers noted that "significant changes occurred in physiologic and behavioral measures in response to procedures indicative of pain responses."[17] This notion has been further supported, suggesting that a combination of both behavioral and physiological indicators is necessary in a measure given the phenomenon of pain.[18] Indeed it has been noted that "a multidimensional assessment is particularly appropriate when the accepted proxy for a "gold standard" of pain—self-report—is not possible."[19]


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