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CHAPTER 12 Pain and Pain Relief
Agitation
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289
Calming occurs
Agitation continues
Provide sedation
FIGURE 12.4 Decision tree for assessing and managing pain and/or agitation. (From Gordin P. Assessing and managing agitation in the
critically ill infant. Matern Child Nurs. 1990;15:26.)
Rule out respiratory
cause, increase support
Agitation continues
Assess environment,
reduce stimulation
behavioral symptom of many problems, including environmental overstimulation, respiratory
insufficiency, neurologic irritability, and pain.
Factors influencing chronic irritability and agitation in neonates in the NICU are shown in
Fig. 12.5. Causes of agitation other than pain
should be eliminated before pain management
and/or sedation is initiated. Assessment of envi-
ronmental stimuli should be a routine part of the
neonate’s care. The neonate may associate certain
stimuli with unpleasant events over time, and
repeated exposure (e.g., ventilator alarms, placement of heel warmer, the odor of an alcohol wipe)
may trigger agitation. Although these stimuli are
inevitable, identifying, avoiding, or limiting them
will help prevent anticipatory decompensation in
these fragile infants.
411
Strategies to prevent and intervene with irri-
table or agitated infants include the following:
• Minimize caregivers, and provide consistency in
care by staff and family.
• Determine whether there is a “locus of pain”
(e.g., pain-related irritability).
• Determine whether physiologic instability (e.g.,
needs suction/position change; hypoxemia) is the
cause or the result of irritable behaviors.
• Use developmental care (see Chapter 13).
• Use sedatives judiciously.
411
Agitation continues
Look for pain source,
provide analgesia
Calming occurs
Calming occurs
• Use individualized, developmental care to significantly reduce the need for sedatives in VLBW
411
infants.
Pain-related irritability must be treated by
alleviating pain with the use of opioids and
comfort measures. Use of sedatives alone for
pain-related irritability suppresses behavioral
expression of pain, has no analgesic effects, and
may increase pain. Sedatives should be used only
when pain has been ruled out as the source of
the irritability or agitation. Although no research
documents the safety or efficacy of combining sedatives and analgesics for the treatment of neonatal
pain, sedatives are used with opioids to wean infants
who have developed tolerance from prolonged opioid therapy.
411
Assessment Tools
To quantify and objectify a neonate’s pain expe-
rience and to facilitate health care professionals’
recognition of the presence and severity of pain in
neonates, research has resulted in the development
of over 40 infant pain assessment tools.98 Both
the AAP13 and the International Evidence-Based
Group for Neonatal Pain strongly recommend use
of neonatal pain assessment tools.
Commission requires the selection and use of
12,23
The Joint
UNIT TWO Support of the Neonate290
People
Numerous caregiv
Ph
Consultants
Kno
Le
Lac
Noncontingent interactions
Staffing/wor
P
Dr
Dr
Lines
Immobility/confinement/
Nasal prongs or cannula
Repeated minor painful
Major procedures/surger
Dr
Procedures, Treatments
Infant
Environmental
R
R
T
A
B
L
T
Y
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ysicians, RNs, RTs, etc.
ers
wledge, skills, attitudes
vel of collaboration
k of consistency/familiarity
kload
arent involvement
ug side effects
ug-drug interactions
, tubes, catheters
restraint
procedures
ugs, Equipment,
Lighting/windows
Noise
Temperature changes
Sleep disruption
Inconsistent, unpredictable
routine
Lack of diurnal rhythmicity
Inappropriate stimulation
Unpredictable/chaotic
Unit layout
Ventilator/oscillators
Monitors/alarms
Radiology
Ventilation/air systems
Paging systems, beepers,
phones
ECMO/nitric oxide
ies
Technology
Postconceptual/postnatal age
History/diagnosis/surgeries
Regulation/consolability
(internal and external)
Drug exposure
Severity of illness
Temperament
Thresholds, sensitivities,
capabilities
Length of stay
Chronic condition
Pain, sedation, and/or
agitation scoring systems for
identification/planning
Pagers, phones, overhead
paging, or intercoms
Adequate documentation/
communications process
Care plans/access and
accountability
Administrative support
Systems, Process, and
Communication
FIGURE 12.5 Fishbone diagram of factors influencing irritability. ECMO, Extracorporeal membrane oxygenation; RNs, registered nurses;
RT, respiratory therapist. (From Walden M, Carrier C. Sleeping beauties: the impact of sedation on neonatal development, J Obstet Gynecol
Neonatal Nurs. 2003;32:393.)
I
I
I
I
a valid, reliable pain assessment tool; however,
there is no “gold standard” neonatal pain assessment tool.
23,98,221
Of the myriad neonatal pain assessment tools,
the Premature Infant Pain Profile (PIPP); and
Neonatal Pain, Agitation, and Sedation Scale
(N-PASS), Neonatal Facial Coding System, the
Behavioral Infant Pain Profile, and the Echelle
Douleur Inconfort Nouveau-Ne (EDIN) scale
have been extensively tested and their validity
and reliability established.
The PIPP (Table 12.3) is a multidimensional
(physiologic and behavioral) assessment tool
intended for use within clinical practice.
PIPP is a seven-item, four-point scale; its maximum
score depends on the infant’s GA and behavioral
state of the premature infant at baseline. The PIPP
has been validated with both full-term and preterm
neonates and can distinguish between procedural
and postoperative pain and nonpain (e.g., noxious)
events. The revised PIPP (PIPP-R) has recently
been validated in full-term neonates and preterm
infants greater than 26 weeks’ GA, it is easy to use,
and higher pain scores require effective interven-
156
tions.
that pain intervention strategy is efficacious.
PIPP has not been validated for assessment of the
efficacy of analgesia nor for its usefulness in the
13
assessment of continuous pain.
Lower pain scores in the PIPP-R indicate
156
The N-PASS (Table 12.4) is an easily used clin-
The
ical scale to assess, document, and manage pain
377
The
and sedation.
117,119,204,207–205
mechanically ventilated or in the immediate postoperative period were assessed with the N-PASS before
and after pharmacologic intervention. N-PASS
measures acute, prolonged, and chronic pain,
as well as the level of sedation.
NICU infants being
98,117,119,208
The
N-PASS is a reliable and valid assessment tool for
CHAPTER 12 Pain and Pain Relief
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TABLE
12.3
Infant Study Number: ______________________________
Date/Time: ______________________________________
Event: __________________________________________
PROCESS INDICATOR 0 1 2 3 SCORE
Chart
Observe infant
15 seconds
Observe
baseline heart
rate oxygen
saturation
Observe infant
30 seconds
PREMATURE INFANT PAIN PROFILE (PIPP)
Gestational age
Behavioral state Active/awake;
Heart rate (max) 0–4 beats/min
Oxygen saturation
(min)
Brow bulge None
Eye squeeze None
Nasolabial None
36 wk and more 32–35 wk,
eyes open; facial
movements
increase
0%–2.4%
decrease
0%–9% of time
0%–9% of time
0%–9% of time
6 days
Quiet/awake;
eyes closed; no
facial movement
5–14 beats/
min increase
2.5%–4.9%
decrease
Minimum
10%–39% of
time
Minimum
10%–39% of
time
Minimum
10%–39% of
time
28–31 wk,
6 days
Active/asleep;
eyes closed;
facial movement
5–24 beats/
min increase
5.0%–7.4%
decrease
Moderate
40%–69% of
time
Moderate
40%–69% of
time
Moderate
40%–69% of
time
Less than 28 wk
Quiet/asleep; eyes
closed; no facial
movements
25 beats/min or
more increase
7.5% or more
decrease
Maximum
70% of time or
more
Maximum
70% of time or
more
Maximum
70% of time or
more
291
Scoring method for the PIPP:
1 Familiarize yourself with each indicator and how it is to be scored by looking at the measure.
2 Score gestational age (from the chart) before you begin.
3 Score behavioral state by observing the infant for 15 seconds immediately before the event.
4 Record baseline heart rate and oxygen saturation.
5 Observe the infant for 30 seconds immediately after the event. You will have to look back and forth from the monitor to the infant’s face. Score physiologic and
facial action changes seen during that time, and record immediately after the observation period.
6 Calculate the final score.
min, Minimum; max, maximum; wk, weeks.
From Stevens B, Johnston C, Petroshen P, et al. Premature Infant Pain Profile: development and initial validation. Clin J Pain. 1996;12:13.
pain/agitation and sedation in postoperative and/or
ventilated neonates (0 to 100 days of age) at 23 or
more weeks of gestation.
The Neonatal Facial Coding System (Table
12.5) is an assessment tool based on nine facial
119,204,207,209
expressions of term newborns in four sleepwake states while experiencing the discomfort
of heel rub and the pain of heel lance. Quiet,
awake neonates demonstrate the most facial activity, whereas those in quiet sleep demonstrate the
TABLE
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12.4
UNIT TWO Support of the Neonate292
NEONATAL PAIN, AGITATION, AND SEDATION SCALE (N-PASS)
ASSESSMENT
CRITERIA
Crying Irritability No cry with
Behavior state No arousal to
Facial expression Mouth is lax
Extremities
Tone
Vital signs: HR,
RR, BP, Sao
ASSESSMENT OF SEDATION ASSESSMENT OF PAIN/AGITATION
• Sedation is scored in addition to pain for each behavioral and physiologic
• Sedation does not need to be assessed/scored with every pain
• Sedation is scored 0 → –2 for each behavioral and physiologic criterion,
• A score of 0 is given if the infant has no signs of sedation, does not
• Desired levels of sedation vary according to the situation:
• “Deep sedation” → goal score of –10 to –5
• “Light sedation” → goal score of –5 to –2
• Deep sedation is not recommended unless an infant is receiving
• A negative score without the administration of opioids/sedatives may
• The premature infant’s response to prolonged or persistent pain/stress
• Neurologic depression, sepsis, or other pathology
2
criterion to assess the infant’s response to stimuli.
assessment/score.
then summed and noted as a negative score (0 → –10).
underreact.
ventilatory support, related to the high potential for hypoventilation
and apnea.
indicate the following:
–2 –1 0/0 +1 +2
painful stimuli
any stimuli
No spontaneous
movement
No expression
No grasp reflex
Flaccid tone
No variability
with stimuli
Hypoventilation
or apnea
SEDATION SEDATION/PAIN PAIN/AGITATION
Moans or cries minimally
with painful stimuli
Arouses minimally to
stimuli
Little spontaneous
movement
Minimal expression with
stimuli
Weak grasp reflex
↓ muscle tone
<10% variability from
baseline with stimuli
No sedation/No
pain signs
No sedation/No
pain signs
No sedation/No
pain signs
No sedation/No
pain signs
No sedation/No
pain signs
• Pain assessment is the fifth vital sign. Assessment for pain should be
included in every vital sign assessment.
• Pain is scored from 0 → +2 for each behavioral and physiologic criterion
and then summed:
• Points are added to the premature infant’s pain score based on his
or her gestational age to compensate for his or her limited ability to
behaviorally communicate pain.
• Total pain score is documented as a positive number (0 → +11).
• Treatment/interventions are indicated for scores >3.
• Interventions for known pain/painful stimuli are indicated before the
score reaches 3.
• The goal of pain treatment/intervention is a score ≤3.
• More frequent pain assessment indications:
• Indwelling tubes or lines that may cause pain, especially with move-
ment (e.g., chest tubes) → at least every 2–4 hours
• Receiving analgesics and/or sedatives → at least every 2–4 hours
• 30–60 minutes after an analgesic is given for pain behaviors to
assess response to medication
• Postoperative → at least every 2 hours for 24–48 hours and then
every 4 hours until off medications
Irritable or crying at
intervals Consolable
Restless, squirming
Awakens frequently
Any pain expression
intermittent
Intermittent clenching
toes, fists, or finger
splay
Body is not tense
↑↓ 10%–20% from
baseline Sao
76%–85% with
stimulation, quick
recovery
High-pitched or silent,
continuous cry
Inconsolable
Arching, kicking
Constantly awake or
Arouses minimally/
no movement (not
sedated)
Any pain expression
continual
Continual clenched toes,
fists, or finger splay
Body is tense
↑↓ >20% from baseline
2
Sao2 ≤75% with stimulation, slow recovery
Out of sync with vent
CHAPTER 12 Pain and Pain Relief
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TABLE
12.4
PARALYSIS/NEUROMUSCULAR BLOCKADE
• It is impossible to behaviorally evaluate a paralyzed infant for pain.
• Increases in heart rate and blood pressure at rest or with stimulation may be the only indicator of a need for more analgesia.
• Analgesics should be administered continuously by drip or around-the-clock dosing.
• Higher, more frequent doses may be required if the infant is postoperative, has a chest tube, or has other pathology (e.g., NEC) that would normally
SCORING CRITERIA
CRYING/IRRITABILITY
–2 → No response to painful stimuli:
• No cry with needle sticks
• No reaction to ETT or nares suctioning
• No response to caregiving
–1 → Moans, sighs, or cries (audible or silent) minimally to painful stimuli (e.g., needle sticks, ETT, or nares suctioning, caregiving)
0 → No sedation signs or No pain/agitation signs
+1 → Infant is irritable/crying at intervals but can be consoled
• If intubated, intermittent silent cry
+2 → Any of the following:
• Cry is high pitched
• Infant cries inconsolably
• If intubated, silent continuous cry
NEONATAL PAIN, AGITATION, AND SEDATION SCALE (N-PASS)—CONT’D
cause pain.
293
BEHAVIOR/STATE
–2 → Does not arouse or react to any stimuli:
• Eyes continually shut or open
• No spontaneous movement
–1 → Little spontaneous movement; arouses briefly and/or minimally to any stimuli:
• Opens eyes briefly
• Reacts to suctioning
• Withdraws to pain
0 → No sedation signs or No pain/agitation signs
+1 → Any of the following:
• Restless, squirming
• Awakens frequently/easily with minimal or no stimuli
+2 → Any of the following:
• Kicking
• Arching
• Constantly awake
• No movement or minimal arousal with stimulation (not sedated, inappropriate for gestational age or clinical situation)
Continued
UNIT TWO Support of the Neonate294
Brows:
,
F
pain in the infant
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TABLE
12.4
NEONATAL PAIN, AGITATION, AND SEDATION SCALE (N-PASS)—CONT’D
FACIAL EXPRESSION
acial expression of physical distress and
–2 → Any of the following:
• Mouth is lax
• Drooling
• No facial expression at rest or with stimuli
–1 → Minimal facial expression with stimuli
0 → No sedation signs or No pain/agitation signs
+1 → Any pain face expression observed intermittently
+2 → Any pain face expression is continual
Lowered, drawn together
Forehead:
Bulge between brows
vertical furrows
Eyes:
Tightly closed
Cheeks:
Raised
Nose:
Broadened, bulging
Nasolabial fold:
Mouth:
Open, squarish
Deepened
EXTREMITIES/TONE
–2 → Any of the following:
• No palmar or plantar grasp can be elicited
• Flaccid tone
–1 → Any of the following:
• Weak palmar or planter grasp can be elicited
• Decreased tone
0 → No sedation signs or No pain/agitation signs
+1 → Intermittent (<30 seconds’ duration) observation of toes and/or hands as clenched or fingers splayed
• Body is not tense
+2 → Any of the following:
• Frequent (≥30 seconds’ duration) observation of toes and/or hands as clenched or fingers splayed
• Body is tense and stiff
CHAPTER 12 Pain and Pain Relief
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TABLE
12.4
VITAL SIGNS: HR, BP, RR, AND O2 SATURATIONS
–2 → Any of the following:
• No variability in vital signs with stimuli
• Hypoventilation
• Apnea
• Ventilated infant—no spontaneous respiratory effort
–1 → Vital signs show little variability with stimuli—less than 10% from baseline
0 → No sedation signs or No pain/agitation signs
+1 → Any of the following:
• HR, RR, and/or BP are 10%–20% above baseline
• With care/stimuli, infant desaturates minimally to moderately (Sao2 76%–85%) and recovers quickly (within 2 minutes)
+2 → Any of the following:
• HR, RR, and/or BP are >20% above baseline
• With care/stimuli, infant desaturates severely (Sao2 <75%) and recovers slowly (>2 minutes)
• Out of sync/fighting ventilator
© Pat Hummel, MA, APN, NNP, PNP. Loyola University Health System, Loyola University Chicago, 2009 (rev. 2/10/09). All rights reserved. No part of this document may be reproduced
in any form or by any means electronic or mechanical without written permission of the author. This tool is currently undergoing testing for validity and reliability and the author cannot
accept responsibility for errors or omission or for any consequences resulting from the application or interpretation of this material.
BP, Blood pressure, ETT, endotracheal tube; HR, heart rate; NEC, necrotizing enterocolitis; RR, respiratory rate; Sao2, oxygen saturation.
NEONATAL PAIN, AGITATION, AND SEDATION SCALE (N-PASS)—CONT’D
295
TABLE
12.5
ACTION DESCRIPTION
Brow bulge Bulging, creasing, and vertical furrows above and between brows occurring as a result of the lowering and drawing
Eye squeeze Identified by the squeezing or bulging of the eyelids; bulging of the fatty pads about the infant’s eyes is pronounced
Nasolabial furrow Primarily manifested by the pulling upward and deepening of the nasolabial furrow (a line or wrinkle that begins adjacent
Open lips Any separation of the lips
Stretch mouth (vertical) Characterized by a tautness of the lip corners coupled with a pronounced downward pull on the jaw; seen when an
Stretch mouth (horizontal) Appears as a distinct horizontal pull at the corners of the mouth
Lip purse Lips appear as if an “oo” sound is being pronounced
Taut tongue Characterized by a raised, cupped tongue with sharp tense edges; the first occurrence of taut tongue usually is easy to
Chin quiver An obvious high-frequency up-down motion of the lower jaw
Data from Grunau RVE, Craig KD. Pain expression in neonates: facial action and cry. Pain. 1987;28:399; Grunau R, Craig K. Facial activity as a measure of neonatal pain expression. In
Tyler DC, Krane EJ, eds. Advances in Pain, Research and Therapy. Vol 15. New York, NY: Raven; 1990.
NEONATAL FACIAL CODING SYSTEM
together of the eyebrows
to the nostril wings and runs downward and outward beyond the lip corners)
already wide-open mouth is opened a fraction further by an extra pull at the jaw
see, often occurring with a wide-open mouth; after this first occurrence, the mouth may close slightly; taut tongue is still
scorable on the basis of the still visible tongue edges
UNIT TWO Support of the Neonate296
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176,180
least.
Facial activity also increases with GA,
so both infant state and GA must be considered
when using this scale. Despite the fact that the
Behavioral Infant Pain Profile (discussed next) is a
one-dimensional pain assessment tool, both tools
have been found to be more sensitive in detecting
behavioral pain cues in term newborns than the
PIPP tool.37 This tool is sensitive to changes in pain
intensity and useful for evaluating the effectiveness
of interventions. There is evidence of reliable clinical use of this tool in term and preterm infants for
acute and prolonged pain as well as postoperative
177
pain.
The Behavioral Infant Pain Profile (BIIP)
196
(Table 12.6) is a behavioral assessment tool that
combines sleep/wake states, facial responses,
and two-hand movements by term and preterm
infants responding to procedural (any skin-breaking procedure) pain. Through psychometric test-
ing, the BIIP is a valid and reliable tool with high
internal consistency for assessing acute procedural
pain in preterm infants. Additionally, the BIIP is a
practical clinical tool because it is easily scored by
both experienced and inexperienced observers with
very high inter-rater reliability.
The Neonatal Infant Pain Scale (NIPS) (Table
12.7) is a behavioral assessment tool for preterm
and term neonates responding to a needle
puncture. The NIPS provides a measurement of
intensity of infant responses to a painful procedure during and after the event (Fig. 12.6).
250
NIPS scores have been correlated with GA and
Apgar scores. The NIPS provides an objective
measure of pain-relieving interventions and their
effectiveness.
250
The NIPS is objective and nonintrusive and assesses only behavioral response to pain;
compared with other pain scales, it has been found
to be easy and quick to use.
250
Flow sheets have also
been designed to facilitate the documentation of
pain scores and behaviors.
250
The EDIN scale consists of five items
(facial activity, body movements, quality of
sleep, quality of contact with nurses, and consolability) and is meant to assess prolonged,
chronic pain. However, because there is no
accounting for the developmental immaturity of
preterm infants, a modified EDIN score (adding
a sixth item, postmenstrual age) has been created and tested. The EDIN6 scale (Table 12.8)
was tested against the EDIN scale and found
to be more sensitive in assessing (and thus
TABLE
12.6
BEHAVIORAL INDICATORS OF INFANT
PAIN (BIPP) SCORING SHEET: PRETERM
AND FULL TERM
TIME
SITUATION
(E.G., POST-OP; PROCEDURE (E.G.,
SUCTION, BLOOD WORK, IV START)
SCORE
0
0
0
1
2
1
1
1
1
1
1
1
NOTES
Hear rate (no change;
increase; decrease)
Oxygen saturation
(no change; increase;
decrease)
Environmental
Support
Analgesia
Sedation Given
From Holsti L, Grunau RE. Initial validation of the Behavioral Indicators of Infant Pain
(BIIP). Pain 2007;132:264. Used with permission.
intervening in) prolonged pain in preterm
infants of various gestational ages in one
NICU.
332
Cumulative scores on the EDIN6
of greater than 6 are considered pain expressions that require intervention. This study also
STATE
Deep Sleep
Active Sleep
Quiet Awake
Active Awake
Agitated/Crying
FACE
Brow bulge
Eye squeeze
Naso-labial furrow
Horizontal mouth stretch
Taut tongue
HAND
Finger splay
Fisting
TOTAL SCORE
CHAPTER 12 Pain and Pain Relief
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TABLE
12.7
0—Relaxed muscles Restful face, neutral expression
1—Grimace Tight facial muscles; furrowed brow, chin, jaw (negative facial expression—nose, mouth, and brow)
CRY
0—No cry Quiet, not crying
1—Whimper Mild moaning, intermittent
2—Vigorous cry Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidenced by obvious
0—Relaxed Usual pattern for this infant
1—Change in breathing Indrawing, irregular, faster than usual; gagging; breath holding
0—Relaxed/restrained No muscular rigidity; occasional random movements of arms
1—Flexed/extended Tense, straight arms; rigid and/or rapid extension, flexion
NEONATAL INFANT PAIN SCALE (NIPS) OPERATIONAL DEFINITIONS
FACIAL EXPRESSION
mouth and facial movement)
BREATHING PATTERNS
ARMS
297
LEGS
0—Relaxed/restrained No muscular rigidity; occasional random leg movement
1—Flexed/extended Tense, straight legs; rigid and/or rapid extension, flexion
STATE OF AROUSAL
0—Sleeping/awake Quiet, peaceful sleeping or alert and settled
1—Fussy Alert, restless, and thrashing
From Lawrence J, Alcock D, McGrath P, et al. Children’s Hospital of Eastern Ontario; 1993.
surveyed 70 NICU nurses who were educated
about neonatal pain, but of varying clinical experience, about their evaluation of the EDIN6 tool.
In addition to the objective evaluation, the NICU
nursing staff also perceived the EDIN6 to be
better suited for the assessment of pain in more
immature preterm infants.
332
The National Practice Guidelines provide a
list of assessment questions to ask when assessing pain management in the neonate (Box 12.5).
Lack of validated assessment tools may leave
health care providers wondering if behaviors
are indicators or responses to pain. The Acute
Pain Management Guideline suggests that “if
care providers are unsure whether a behavior
indicates pain, and if there is reason to suspect
pain, an analgesic trial can be diagnostic, as well
as therapeutic.”
Assessment of pain and delivery of effective
pain-relieving interventions in daily clinical
practice must not be delayed while adequate,
objective assessment tools are developed.
2
98,375
UNIT TWO Support of the Neonate298
Time relative to needle puncture
Mean NIPS score
6
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FIGURE 12.6 Mean Neonatal Infant Pain Scale (NIPS) scores over time in
22 infants. (From Lawrence J, Alcock D, McGrath P, et al. The development of
a tool to assess neonatal pain. Neonat Netw. 1993;12:62.)
TABLE
The usefulness of pain scores was recently assessed
in 196 ventilated premature infant patient-days.
5
Although only 2% of pain scores suggested the
presence of pain and only 0.1% of the pain scores
4
resulted in analgesic use, these ventilated infants
were obviously exposed to multiple pain-related
3
2
1
0
Before
During
After
procedures. In this study, regular reassessment and
assignment of a pain score was poorly correlated
with exposure to painful procedures.
340
All health
care providers must use their highly developed
assessment skills, along with input from the parents,
to gather information about infant behavioral, physiologic, and hormonal or catabolic stress responses
before, during, and after painful stimuli.98 These
same assessment skills enable care providers and parents to evaluate the effectiveness of pharmacologic
and comfort interventions and institute more and/
or different interventions as necessary to relieve pain
and suffering.
12.8
ITEM DESCRIPTION SCORE
Facial activity Relaxed facial activity
Body movements Relaxed body movements
Quality of sleep Falls asleep easily
Quality of contact with
nurses
Consolability Quiet, total relaxation
Postmenstrual age Gestational age >37 weeks
EDIN6 SCALE* INTEGRATED BY GESTATIONAL AGE AS A SIXTH ITEM
Transient grimaces with frowning, lip purse, and chin quiver
Frequent grimaces, lasting grimaces
Permanent grimaces resembling crying or blank face
Transient agitation, often quiet
Frequent agitation but can be calmed down
Permanent agitation with contraction of fingers and toes and hypertonia of
limbs or infrequent, slow movements and prostration
Falls asleep with difficulty
Frequent spontaneous arousals, independent of nursing, restless sleep
Sleepless
Smiles, attentive to voice
Transient apprehension during interactions with nurses
Difficulty communicating with nurses. Cries in response to minor stimulation
Refuses to communicate with nurses. No interpersonal rapport. Moans without stimulation
Calms down quickly in response to stroking or voice or with sucking
Calms down with difficulty
Disconsolate. Sucks desperately
Gestational age 33–37 weeks
Gestational age <33 weeks
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
340
*Modified by Debillion 2001: Echelle Douler Inconfort Nouveau-Ne. From: Raffaeli G, Cristofori G, Befani B, et al. EDN scale implemented by gestational age for pain assessment in preterms:
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