Modern approaches and practices for assessing neonatal pain (literature review)

Authors

DOI:

https://doi.org/10.15574/SP.2025.3(147).7886

Keywords:

newborns, neonatal pain, pain assessment, treatment, pharmacological and non-pharmacological methods, multidisciplinary approach

Abstract

Pain experienced during the neonatal period may have long-term consequences for a child’s physical, mental, and emotional development, justifying the need for accurate pain assessment and effective management of pain syndromes. The study explores various approaches to identifying pain in newborns, particularly in preterm infants, who exhibit heightened sensitivity to painful stimuli due to the immaturity of their nervous system.

The aim - to analyze scientific data on the causes of development, clinical manifestations and current practices of pain assessment in newborns.

The article analyzes pain assessment methods, including subjective and objective scales such as N-PASS, NIPS, CRIES, COMFORTneo, and PIPP-R. Challenges in standardizing these tools, driven by individual variations in neonatal responses, are discussed. The impact of pain on physiological parameters, such as heart rate, blood pressure, and oxygen saturation, as well as on behavioral manifestations, including crying and facial expressions, and neurodevelopment, is examined, supported by findings from recent studies.

Advanced technologies for pain assessment, including biobehavioral methods such as heart rate variability analysis, electroencephalography, and near-infrared spectroscopy, are reviewed. Non-pharmacological pain management strategies, such as breastfeeding, the Kangaroo Mother Care method, and sucrose administration, are described, alongside pharmacological approaches, including the use of opioids and local anesthetics. The article also addresses ethical considerations and the importance of a multidisciplinary approach to caring for newborns undergoing painful procedures. The need for ongoing training of healthcare professionals and updates to clinical protocols to enhance the quality of care is outlined.

Conclusion.Effective pain management is impossible without timely and accurate pain assessment. To implement modern methods and approaches, it is necessary to constantly improve the qualifications of medical professionals, update clinical protocols, and ensure access to the latest diagnostic tools.

The authors declare no conflict of interest.

References

Ahola Kohut S, Pillai Riddell R. (2009). Does the Neonatal Facial Coding System differentiate between infants experiencing pain-related and non-pain-related distress? The journal of pain. 10(2): 214-220. https://doi.org/10.1016/j.jpain.2008.08.010; PMid:19081306

Anand KJS. (2017). Defining pain in newborns: need for a uniform taxonomy?. Acta paediatrica (Oslo, Norway : 1992). 106(9): 1438-1444. https://doi.org/10.1111/apa.13936; PMid:28556311 PMCid:PMC5601230

Bellieni CV. (2012). Pain assessment in human fetus and infants. The AAPS journal. 14(3): 456-461. https://doi.org/10.1208/s12248-012-9354-5; PMid:22528505 PMCid:PMC3385812

Boundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E et al. (2016). Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis. Pediatrics. 137(1): e20152238. https://doi.org/10.1542/peds.2015-2238; PMid:26702029 PMCid:PMC4702019

Boyle EM, Bradshaw J, Blake KI. (2018). Persistent pain in neonates: challenges in assessment without the aid of a clinical tool. Acta paediatrica (Oslo, Norway : 1992). 107(1): 63-67. https://doi.org/10.1111/apa.14081; PMid:28925559

Campbell-Yeo M, Eriksson M, Benoit B. (2022). Assessment and Management of Pain in Preterm Infants: A Practice Update. Children (Basel, Switzerland). 9(2), 244. https://doi.org/10.3390/children9020244; PMid:35204964 PMCid:PMC8869922

Christoffel MM, Castral TC, Daré MF, Montanholi LL, Gomes ALM, Scochi CGS. (2017). Attitudes of healthcare professionals regarding the assessment and treatment of neonatal pain. Esc Anna Nery. 21(1). https://doi.org/10.5935/1414-8145.20170018

Collados-Gómez L, Ferrera-Camacho P, Fernandez-Serrano E, Camacho-Vicente V, Flores-Herrero C et al. (2018). Randomised crossover trial showed that using breast milk or sucrose provided the same analgesic effect in preterm infants of at least 28 weeks. Acta paediatrica (Oslo, Norway : 1992). 107(3): 436-441. https://doi.org/10.1111/apa.14151; PMid:29150862

Committee on fetus and newborn and Section on anesthesiology and pain medicine. (2016). Prevention and Management of Procedural Pain in the Neonate: An Update. Pediatrics. 137(2): e20154271. https://doi.org/10.1542/peds.2015-4271; PMid:26810788

Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. (2016). Profilaktyka boliu pry provedenni protsedur u novonarodzhenykh i likuvalna taktyka, spriamovana na yoho zmenshennia. Rekomendatsii Komitetu z problem plodiv i novonarodzhenykh ta Sektsii z anesteziolohii i medytsyny boliu Amerykanskoi akademii pediatriv. Dytiachyi likar. 5(50). URL: https://d-l.com.ua/ua/archive/2016/5%2850%29/pages-50-58/profilaktika-bolyu-pri-provedenni-procedur-u-novonarodzhenih-i-likuvalna-taktika-spryamovana-na-yogo-zmenshennya.

Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. (2003). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. The Cochrane database of systematic reviews. (2): CD002771. https://doi.org/10.1002/14651858.CD002771

Cong X, Wu J, Vittner D, Xu W, Hussain N, Galvin S et al. (2017). The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU. Early human development. 108: 9-16. https://doi.org/10.1016/j.earlhumdev.2017.03.003; PMid:28343092 PMCid:PMC5444300

Crellin D, Harrison D, Santamaria N, Babl FE. (2021). Comparison of the Psychometric Properties of the FLACC Scale, the MBPS and the Observer Applied Visual Analogue Scale Used to Assess Procedural Pain. Journal of pain research. 14: 881-892. https://doi.org/10.2147/JPR.S267839; PMid:33833566 PMCid:PMC8020135

Crellin DJ, Harrison D, Santamaria N, Babl FE. (2015). Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use? Pain. 156(11): 2132-2151. https://doi.org/10.1097/j.pain.0000000000000305; PMid:26207651

Desai A, Aucott S, Frank K, Silbert-Flagg J. (2018). Comparing N-PASS and NIPS: improving pain measurement in the neonate. Advances in Neonatal Care. 18(4): 260-266. https://doi.org/10.1097/ANC.0000000000000521; PMid:29889729

Doğan İE, Balcı NÇ, Gündüz AG. (2022). Physiotherapy and Rehabilitation Approaches to Premature Infants in Neonatal Intensive Care Units. Journal of Physical Medicine Rehabilitation Studies & Reports. 150: 2-5. doi: 10.47363/JPMRS/2021(4).

Gao H, Gao H, Xu G, Li M, Du S, Li F et al. (2016). Efficacy and safety of repeated oral sucrose for repeated procedural pain in neonates: A systematic review. International journal of nursing studies. 62: 118-125. https://doi.org/10.1016/j.ijnurstu.2016.07.015; PMid:27474944

Gibbins S, Stevens BJ, Yamada J, Dionne K, Campbell-Yeo M, Lee G et al. (2014). Validation of the Premature Infant Pain Profile-Revised (PIPP-R). Early human development. 90(4): 189-193. https://doi.org/10.1016/j.earlhumdev.2014.01.005; PMid:24491511

Goksan S, Hartley C, Emery F, Cockrill N, Poorun R, Moultrie F et al. (2015). fMRI reveals neural activity overlap between adult and infant pain. eLife. 4: e06356. https://doi.org/10.7554/eLife.06356; PMid:25895592 PMCid:PMC4402596

Grunau RE. (2013). Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. Rambam Maimonides medical journal. 4(4): e0025. https://doi.org/10.5041/RMMJ.10132; PMid:24228168 PMCid:PMC3820298

Grunau RE, Holsti L, Whitfield MF, Ling E. (2000). Are twitches, startles, and body movements pain indicators in extremely low birth weight infants?. The Clinical journal of pain. 16(1): 37-45. https://doi.org/10.1097/00002508-200003000-00007; PMid:10741817

Guo W, Liu X, Zhou X, Wu T, Sun J. (2020). Efficacy and safety of combined nonpharmacological interventions for repeated procedural pain in preterm neonates: A systematic review of randomized controlled trials. International journal of nursing studies. 102: 103471. https://doi.org/10.1016/j.ijnurstu.2019.103471; PMid:31783193

Halian AI. (2019). Psychophysiology of pain and features of its control by children and teenagers. Theory and practice of modern psychology. 1; 1: 119-123. URL: http://tpsp-journal.kpu.zp.ua/archive/1_2019/part_1/26.pdf.

Hall RW, Shbarou RM. (2009). Drugs of choice for sedation and analgesia in the neonatal ICU. Clinics in perinatology. 36(1): 15-26. https://doi.org/10.1016/j.clp.2008.09.007; PMid:19161862 PMCid:PMC2662993

Harrison D, Reszel J, Bueno M, Sampson M, Shah VS, Taddio A et al. (2016). Breastfeeding for procedural pain in infants beyond the neonatal period. The Cochrane database of systematic reviews. 10(10): CD011248. https://doi.org/10.1002/14651858.CD011248.pub2; PMid:27792244 PMCid:PMC6461192

Hartley C, Goksan S, Poorun R, Brotherhood K, Mellado GS, Moultrie F et al. (2015). The relationship between nociceptive brain activity, spinal reflex withdrawal and behaviour in newborn infants. Scientific reports. 5: 12519. https://doi.org/10.1038/srep12519; PMid:26228435 PMCid:PMC4521152

Hartley KA, Miller CS, Gephart SM. (2015). Facilitated tucking to reduce pain in neonates: evidence for best practice. Advances in neonatal care : official journal of the National Association of Neonatal Nurses. 15(3): 201-208. https://doi.org/10.1097/ANC.0000000000000193; PMid:26002861

Ho LP, Ho SS, Leung DY, So WK, Chan CW. (2016). A feasibility and efficacy randomised controlled trial of swaddling for controlling procedural pain in preterm infants. Journal of clinical nursing. 25(3-4): 472-482. https://doi.org/10.1111/jocn.13075; PMid:26818372

Ivanova TP, Shunko YeIe, Bakaieva OM, Barinov YuV, Brukhanska TL, Vodianytskyi SL et al. (2014). Protokol nadannia medychnoi dopomohy novonarodzhenym Neonatolohichnoho tsentru z profilaktyky ta likuvannia boliu. Natsionalna dytiacha spetsializovana likarnia «OKhMATDYT». m. Kyiv, Ukraina. URL: https://anest.vn.ua/file/pain.pdf.

Johnston CC, Filion F, Snider L, Majnemer A, Limperopoulos C, Walker CD et al. (2002). Routine sucrose analgesia during the first week of life in neonates younger than 31 weeks' postconceptional age. Pediatrics. 110(3): 523-528. https://doi.org/10.1542/peds.110.3.523; PMid:12205254

Katilov OV, Bandurka NM, Dmitriev DV, Layko LI. (2015). Mechanisms of infants'pain and pain syndromes diagnostic features. Reports of Vinnytsia National Medical University. 1; 19: 224-229.

Kharchuvannia khvorykh novonarodzhenykh. Ukrainian-Swiss Mother and Child Health Programme. URL: https://babykrok.com.ua/upload/intext/Anestesia/ane7.pdf.

Li Q, Tan X, Li X, Tang W, Mei L et al. (2022). Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis. PloS one. 17(5): e0268033. https://doi.org/10.1371/journal.pone.0268033; PMid:35522649 PMCid:PMC9075656

Mazumder S, Taneja S, Dube B, Bhatia K, Ghosh R, Shekhar M et al. (2019). Effect of community-initiated kangaroo mother care on survival of infants with low birthweight: a randomised controlled trial. Lancet (London, England). 394(10210): 1724-1736. https://doi.org/10.1016/S0140-6736(19)32223-8; PMid:31590989

Melzack R. (2001). Pain and the neuromatrix in the brain. Journal of dental education. 65(12): 1378-1382. https://doi.org/10.1002/j.0022-0337.2001.65.12.tb03497.x; PMid:11780656

Nist MD, Harrison TM, Steward DK. (2019). The biological embedding of neonatal stress exposure: A conceptual model describing the mechanisms of stress-induced neurodevelopmental impairment in preterm infants. Research in nursing & health. 42(1): 61-71. https://doi.org/10.1002/nur.21923; PMid:30499161 PMCid:PMC6749822

Pereira FL, Gaspardo CM. (2024). Neonatal pain and developmental outcomes in children born preterm: An updated systematic review. Psychology & Neuroscience. 17(1): 1-15. https://doi.org/10.1037/pne0000332

Perry M, Tan Z, Chen J, Weidig T, Xu W, Cong XS. (2018). Neonatal Pain: Perceptions and Current Practice. Critical care nursing clinics of North America. 30(4): 549-561. https://doi.org/10.1016/j.cnc.2018.07.013; PMid:30447813 PMCid:PMC6570422

Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S et al. (2023). Non-pharmacological management of infant and young child procedural pain. The Cochrane database of systematic reviews. 6(6): CD006275. https://doi.org/10.1002/14651858.CD006275.pub4; PMid:37314064 PMCid:PMC10265939

Posternak G, Tkachova M, Soboleva T. (2013). Assessment of Pain in Newborns and Infants. Emergency medicine. (4.51): 31-36. https://doi.org/10.22141/2224-0586.4.51.2013.89288

Ravikiran SR, Kumar PM, Meundi AD. (2011). Pain response in newborns to the order of injecting BCG and Hepatitis-B vaccines: a randomized trial. Indian journal of pediatrics. 78(6): 693-697. https://doi.org/10.1007/s12098-010-0327-3; PMid:21193975

Schattenburg L, Kulchynskyi Ya. (2019). Psykhodynamika boliu. NeuroNews: psykhonevrolohiia ta neiropsykhiatriia». 4(105): 34-37.

Selvanathan T, Miller SP. (2024). Effects of pain, sedation and analgesia on neonatal brain injury and brain development. Seminars in perinatology. 48(5): 151928. https://doi.org/10.1016/j.semperi.2024.151928; PMid:38937163

Selvanathan T, Ufkes S, Guo T, Chau V, Branson HM, Ibrahim GM et al. (2024). Pain Exposure and Brain Connectivity in Preterm Infants. JAMA network open. 7(3): e242551. https://doi.org/10.1001/jamanetworkopen.2024.2551; PMid:38488791 PMCid:PMC10943417

Snisar V. (2022). Features of Infusion Therapy in Critically Ill Children. Child's health. 3(63): 86-90. https://doi.org/10.22141/2224-0551.3.63.2015.75222

Stenkjaer RL, Pedersen PU, Hundrup YA, Weis J. (2019). Evaluation of NICU nurses' competence in pain assessment 5 Years after implementation of the COMFORTneo scale. Advances in Neonatal Care. 19(5): 409-415. https://doi.org/10.1097/ANC.0000000000000636; PMid:31517644

Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. (2016). Sucrose for analgesia in newborn infants undergoing painful procedures. The Cochrane database of systematic reviews. 7(7): CD001069. https://doi.org/10.1002/14651858.CD001069.pub5; PMid:27420164 PMCid:PMC6457867

Useinovic N, Jevtovic-Todorovic V. (2022). Novel anesthetics in pediatric practice: is it time? Current opinion in anaesthesiology. 35(4): 425-435. https://doi.org/10.1097/ACO.0000000000001156; PMid:35787582 PMCid:PMC10104442

Van Dijk M, Peters JWB, Van Deventer P, Tibboel D. (2005). The COMFORT behavior scale: a tool for assessing pain and sedation in infants. AJN, American Journal of Nursing. 105(1): 33-36. https://doi.org/10.1097/00000446-200501000-00019; PMid:15659992

Vittner D, McGrath J, Robinson J, Lawhon G, Cusson R, Eisenfeld L et al. (2018). Increase in Oxytocin From Skin-to-Skin Contact Enhances Development of Parent-Infant Relationship. Biological research for nursing. 20(1): 54-62. https://doi.org/10.1177/1099800417735633; PMid:29017336

Waxman JA, Pillai Riddell RR, Tablon P, Schmidt LA, Pinhasov A. (2016). Development of Cardiovascular Indices of Acute Pain Responding in Infants: A Systematic Review. Pain research & management. 2016: 8458696. https://doi.org/10.1155/2016/8458696; PMid:27445630 PMCid:PMC4904608

Williams MD, Lascelles BDX. (2020). Early Neonatal Pain-A Review of Clinical and Experimental Implications on Painful Conditions Later in Life. Frontiers in pediatrics. 8: 30. https://doi.org/10.3389/fped.2020.00030; PMid:32117835 PMCid:PMC7020755

Witt N, Coynor S, Edwards C, Bradshaw H. (2016). A Guide to Pain Assessment and Management in the Neonate. Current emergency and hospital medicine reports. 4: 1-10. https://doi.org/10.1007/s40138-016-0089-y; PMid:27073748 PMCid:PMC4819510

Xu W, Walsh S, Cong XS. (2016). Development of Accumulated Pain/Stressor Scale (APSS) in NICUs: A National Survey. Pain management nursing : official journal of the American Society of Pain Management Nurses. 17(6): 354-362. https://doi.org/10.1016/j.pmn.2016.08.004; PMid:27756592 PMCid:PMC5609453

Published

2025-04-28