Assessing pain in babies

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Read about the assessment of pain in babies. From birth, babies are capable of feeling pain very acutely. Learn about tests that are run, such as the PIPP.

Key points

  • Pain assessment tools take into account behavioural, physiological and contextual measures.
  • The Premature Infant Pain Profile (PIPP) is a comprehensive assessment tool used for newborn babies born either at full-term or preterm.
  • The PIPP measures facial expressions, heart rate, oxygen level in the blood, gestational age at birth and sleep/wake state.

From the day they are born, babies can feel and express pain. Over the years, heath care experts have learned to assess pain in babies. An assessment of pain in babies relies mostly on observing behaviours. For example, newborn babies can respond to painful events such as a heel prick within the first minutes of life.

In addition to noting behavioural changes that might indicate pain, there are physiological measures that can be used to assess pain in babies. These include temperature, blood pressure, heart rate, and oxygen consumption, among others.

The situational context is also taken into account when assessing pain. In the case of babies, gestational age and the baby’s sleep and waking states are important in this regard.

Although there are established and proven methods to assess pain in babies, pain assessment is not an exact science. To lessen the guesswork, pain assessment tools, which are generally checklists of possible pain indicators, take into account behavioural, physiological, and contextual measures. However, it should be noted that changes in behaviour and physiology can be due to other factors.

Behaviour in response to pain

Babies in pain tend to display pain in their facial expressions, arm and leg movements, and cries. They may try to guard or protect a sore part of their body or even pull on it. Changes in eating, moving, and sleeping can also be indicators of pain.

Facial expressions are generally regarded as the best single behavioural indicator of pain in all age groups. A grimace, eyes squeezed shut and mouth stretched open with a tensed and curled tongue, are common expressions of pain.

Babies cry for reasons such as hunger, anger, or fear, but the cries of pain are distinctive. The typical pain cry is high-pitched, tense, harsh, non-melodious, sharp, short, and loud. However, the absence of crying does not mean a baby is not in pain. A baby in severe pain may not cry at all. They may simply not have the energy to cry.

Very young babies may not move and may become still in response to pain. This absence of movement has also been noted in older children recovering from surgery. They recognize that moving hurts and so remain still to minimize the amount of pain.

Assessing a baby’s pain by observing takes skill and requires an understanding of infant development. This is why no single measure is used exclusively. Several measures are used to make a determination of pain.

Physical reactions to pain

Physiological indicators, including heart rate, breathing rate, blood pressure, skin colour, vomiting, sweating, and dilated or widened pupils, are also used to determine if a baby is in pain. Because changes in these indicators can result from other causes, including physical stress, fear, or anxiety, they can be difficult to interpret. Despite these limitations, when used with behavioural and contextual indicators, these signs can be useful as part of an overall assessment for a baby in pain.

Contextual indicators

In addition to behavioural and physical reactions to pain, the context of the situation will also be taken into account when assessing pain. For example, when multiple procedures are going on, sometimes a baby will respond with an exaggerated response to pain or may painfully respond to non-painful procedures. Other babies may become limp and cease responding to repeated painful procedures. Studies are underway to determine why babies tend to respond one way or the other.

Time and experience can also be contextual factors that influence pain. For example, if a baby has had to endure multiple painful procedures, over time their response to the next painful procedure is often reduced.

How well and how much a baby sleeps can also be an indication of pain. This is another area that is currently being studied.

Common events and conditions that cause pain

Pain can be experienced through procedures or because of conditions and injuries.

Common painful procedures that babies go through include heel prick blood tests or needles. Babies who are more ill may undergo other painful procedures such as intravenous insertions, suctioning of mouth and nose, lumbar punctures, intramuscular injections, or surgery.

Some painful conditions that can occur in babies include burns, skin conditions, gastrointestinal problems, and fractures.

Pain assessment tools for babies

Premature Infant Pain Profile

The Premature Infant Pain Profile (PIPP) is a comprehensive assessment tool used for newborn babies born either at full-term or preterm. A newborn baby's pain intensity is determined by measuring behavioural indicators such as facial expressions, physiological indicators such as heart rate and oxygen level in the blood, and considering contextual indicators such as the baby's gestational age at birth as well as their sleep/wake state. These indicators are scored together to provide an indication of acute pain.

Other assessment tools

In addition to PIPP, other pain assessment tools can be used to help determine how much pain a baby is experiencing. These include:

  • the Neonatal Facial Coding Scale (NFCS)
  • the Faces, Legs, Activity, Cry, and Consolability Scale (FLACC)
  • the Neonatal Infant Pain Scale (NIPS)
  • the CRIES Score

In general, all of these tools use similar behavioural, physiological, and contextual markers to assess pain in babies.

Last updated: October 18th 2010