Related Experiment Video
Updated: Jun 27, 2026
Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
Indicators of pain in neonates at risk for neurological impairment
Bonnie Stevens1, Patrick McGrath, Annie Dupuis
1The Hospital for Sick Children, Toronto, Ontario, Canada. b.stevens@utoronto.ca
Insights
Pain indicators in neurologically impaired neonates differ between nurses and researchers. Facial expressions are key, but risk level impacts perceived importance of physiological signs.
Area of Science:
- Neonatal care
- Pain assessment
- Neurology
Background:
- Neonates at risk for neurological impairment are underrepresented in pain measure development.
- Understanding of pain indicator perception by clinicians and researchers in this population is lacking.
Purpose of the Study:
- To compare the perceived importance and usefulness of physiological and behavioral pain indicators in neonates at risk for neurological impairment.
- To evaluate ratings provided by nurse clinicians and pain researchers.
Main Methods:
- A data triangulation approach was used in three Canadian Neonatal Intensive Care Units.
- Data included 149 neonates (varying neurological impairment risk), 95 nurse clinicians, and 14 international pain researchers.
- Thirteen neonatal pain indicators and 39 clinician/researcher-generated indicators were assessed for importance and accuracy.
Main Results:
- Facial indicators like brow bulge, eye squeeze, and nasolabial furrow showed high accuracy in identifying pain.
- Nurse clinician ratings of pain indicators correlated moderately to poorly with neonatal accuracy scores, especially in higher-risk infants.
- Pain researchers demonstrated a significantly better understanding of pain indicator importance compared to nurse clinicians.
Conclusions:
- Facial actions are crucial indicators of neonatal pain.
- As neurological impairment risk increased, both nurse clinicians and pain researchers prioritized physiological indicators, diverging from the neonates' actual pain expressions.
Aim:
This paper is a report of a study to compare the importance and usefulness ratings of physiological and behavioural indicators of pain in neonates at risk for neurological impairment by nurse clinicians and pain researchers.
Background:
Neonates at risk for neurological impairment have not been systematically included in neonatal pain measure development and how clinicians and researchers view pain indicators in these infants is unknown.
Methods:
Data triangulation was undertaken in three Canadian Neonatal Intensive Care Units using data from: (a) 149 neonates at high, moderate and low risk for neurological impairment, (b) 95 nurse clinicians from the three units where infant data were collected and (c) 14 international pain researchers. Thirteen indicators were assessed following heel lance in neonates and 39 indicators generated from nurse clinicians and pain researchers were assessed for importance and accuracy. Data were collected between 2004 and 2005.
Results:
Across risk groups, indicators with the highest accuracy for discriminating 'pain' among neonates were: brow bulge (77-83%), eye squeeze (75-84%), nasolabial furrow (79-81%), and total facial expression (78-83%). Correlations between nurse ratings and neonatal accuracy scores ranged from moderate to none (mild risk r = 0.52, P = 0.07; moderate r = 0.43, P = 0.15; high r = -0.12, P = 0.69). Researchers demonstrated a better understanding of the importance of pain indicators (mild risk, r = 0.91, P < 0.001; moderate 0.85, P < 0.001; 0.0002; high r = 0.64, P = 0.019) than nurse clinicians.
Conclusion/Discussion:
Facial actions were rated as the most important indicators of neonatal pain. However, as neurological impairment risk increased, physiological indicators were rated more important by nurse clinicians and pain researchers, opposite to pain indicators demonstrated by neonates.
