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Pain Assessment in Preterm Infants

Megan Davis, Tonia Nielsen, Shazlee Aolaolagi, Jennifer Van Meter

Dixie State University

Pain Assessment in Preterm Infants
The purpose of this paper is to summarize an evidence based practice research
project examining pain assessment in preterm infants. Pain is based on the individual and
everyones pain level is specific to them. Patients are able verbalize their pain level to
the nurse so they can receive relief. Preterm infants are unable to verbalize their pain
level. Thus, as nurses, we are unable to determine a preterm infants pain. It is important
for nurses to be able to assess pain in preterm infants so that it can be properly managed,
so we want to find the best method of assessing their pain.
Practice Question
There are a couple of ways nurses can determine the pain level in preterm infants.
One way is to measure a preterm infants behavior and the other is through their physical
movements. This project will determine which measurement is more accurate to
determine a preterm infants pain level.
P Patient Population or Problem
The patient population is preterm infants.
I Intervention
The intervention of interest is behavior measures to assess pain.
C Comparison
The comparison intervention is physical measures to assess pain.
O- Outcomes
Identify the best method to assess pain in preterm infants.

The Following Question was Developed
Are behavioral measures more accurate in assessing pain compared to physical
measures in preterm infants?
The question that was developed is a diagnosis type question and the following
databases and internet sites were searched: ProQuest Nursing, Allied Health Source and
Health Source: Nursing/Academic Edition (EBSCOhost), and CINAHL.
Search Items and Results of Search
Search terms that developed from the PICO question included accurate pain
assessment, infants, and behavior measures vs. physical measures. To narrow down
search results, we had to include preterm so that we had only preterm infant studies and
not all infants. Our group found 5 articles based on our search terms and type of
question. These included 3 Systematic Reviews, 1 Case-Control Study, and 1 Instrument
Development Research Study.
Study One
This systematic review evaluated nursing beliefs compared to their practices on
infant pain assessments. It asked what do nurses self-report regarding their assessment
and understanding of infant pain, what they document in the infants chart regarding pain,
and whether the nurses agreed to the self-reporting and the documentation. The study was
targeted to nurses that worked in the Infant Intensive Care Units and were strictly
Registered Nurses. The study also involved 107 preterm infants. The Registered Nurses
had to work in the IICU at the time of the study and they did not include nurses who were
traveling nurses or were on leave. The majority of nurses involved in the study believed
that infants experience pain. Two thirds agreed that pain in infants goes unrecognized. If
the pain is unrecognized, then the pain is not being relieved or treated. 83.3% of the
involved healthcare providers agreed that infants individually present pain in different
ways. The nurses involved agreed that although they worked with the infants daily, they
needed more education involving the proper way to assess pain in their patients. Only
70.8% of the nurses agreed that the current pain assessment tool being implemented in
their unit was effective at assessing pain.
It was recommended that nurses needed further education. The researchers found
that if an infant was less than 33 weeks gestational age nurses did not assess pain as
frequently as the infants who were closer to full term gestation. RN's stated that the
challenge was that infants cannot verbalize pain as adults can. It also suggested that more
information and research is needed on comparing behavioral and physical measures. The
study did not focus on pre-term infants, but in infants in general that were placed in the
IICU, so this article is of low relevance to our research. It did briefly touch on the pre-
term infant population.
Study Two
This systematic review evaluated different ways to assess pain in preterm infants
in the NICU. The population consisted of preterm infants that were born 29 weeks or
less gestational age. In this article, it was mentioned that there are different tools to use
in assessing pain in preterm infants. The different tools consisted of behavioral and
physical measures; and if they should be used unidimensional (using one variable) or
multidimensional (using more than one variable). The authors looked at several studies
with different ways to measure the pain and concluded that brain-oriented pain
assessments can be very significant. Brain-oriented pain assessments included EEG
and the near-infrared spectroscopy blood flow (NIRS). It also mentioned that brain-
oriented pain assessments will not replace bedside tools to assess pain.
This article didnt answer our question, as to which measurement is best
behavioral or physical. However, it was relevant to support our question even though it
was inconclusive. It gave some background information on what research has been done
to determine ways to assess pain in preterm infants. Thus, the conclusion was that more
research needs to be done to determine the best way to assess pain in preterm infants.
Study Three
This was a systematic review where specific extremity movements in preterm
infants were observed during stressful procedures. Eighteen studies were identified and
eleven studies were dropped from the review. Six of the studies were chosen by
convenience and one by random design. The study included 359 preterm infants that
ranged in gestational age from 23 to 32 weeks of age. The study excluded full term
infants and preterm infants that have been exposed to analgesia or sedation within 72
hours of the observation. The study also used broad categories of extremity movements
rather than specific individual movements.
Premature infants display different behavior towards pain than full term infants
because they are neurologically immature and their responses to pain are dampened. In
order to establish what movements were indicators of pain, they examined what
movements occurred relatively infrequently when the infant was at rest and increased
significantly during or following painful and stressful events. The results of the study
indicated seven specific movements: Sitting on Air (extension of legs fully in the air),
Saluting (extension of arms into mid-air), Airplane (infant extends arms laterally), Finger
spray (backward extension of fingers), hand on face (a defensive response), fisting,
twitching, and startles. With further research, extremity movements may serve as an
additional measurement of pain in preterm infants.
Study Four
This study was a case control study where trained individuals watched videotapes
of 44 pre-term infants during invasive procedures to monitor for behavioral changes that
would indicate that these infants were experiencing pain. The infants were chosen on
their gestational age at birth. In this study the researchers looked at babies born at or
before 32 weeks gestational age.
The trained personnel had a list of behavioral changes that would indicate pain.
These criteria, named NIDCAP behaviors, are specific to term infants. From these
NIDCAP behaviors there were 8 that fit with pre-term infants. They are: flexing and
extending the extremities (especially the extension of the legs), finger spray, fisting, hand
on face, frowning, facial twitching, increased body movements, and sitting on air.
The study had its drawbacks, such as not being blinded to what the infant was
going through while watching their bodies. That is somewhat impractical given the size
of pre-term infants anyway. The study benefits our question. We learned how many
NIDCAP behaviors were valid to preterm infants.
Study Five
This study was instrument development research and the purpose of this study
was to determine the reliability, validity and feasibility of the pain assessment scale for
preterm infants (PASPI). The PASPI was developed by a panel of six neonatal experts. It
includes 6 pain indicators used to assess pain. The six items are transition between states,
facial expression, heart rate, oxygen saturation, limb and body movement, and hand
behavior. After the PASPI was developed, two questions were asked. Is the PAPSI
reliable, valid, and consistent? Is the PASPI a feasible and acceptable tool to use to assess
pain in preterm infants? The target population was preterm infants being cared for in a
level III NICU at a medical center in northern Taiwan. The study involved 60 preterm
infants who were chosen by convenience. The infants were all between gestational ages
of 27 and 37 weeks. The results of the study suggest that the PASPI is a valid, feasible,
and acceptable instrument for assessing pain in preterm infants older than 27 weeks
gestational age. It consistently discriminates different levels of pain and helps nurses
recognize infants pain. It allows nurses to evaluate preterm infant pain at any time. The
results do not completely answer the research question because the study suggests that a
multidimensional approach is the best way to assess pain and it does not discuss whether
physical or behavioral measures are more accurate. However, the results are relevant
because the study suggests a good method for assessing pain in preterm infants.
Summary of Evidence and Practice Recommendation
Evidence shows that there are many different ways to assess pain in preterm
infants, whether it is using behavioral measures (flexing or extending extremities, finger
spraying, fisting, hand on face, frowning, facial twitching, and increased body
movements); physical measures (blood pressure, vital signs, oximetry, respiratory status,
and brain-oriented studies); or multidimensional measures. Most of the studies we
researched determined that practice recommendations right now should include both
behavioral and physical measures.
We asked the question: Are behavioral measures more accurate in assessing pain
compared to physical measures in preterm infants? Our research was inconclusive. We
found that more research is required to determine whether behavioral measures or
physical measures are more accurate. Right now the best way to assess pain in preterm
infants is to use a multidimensional approach, which includes both behavioral and
physical measures.

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