Indicators of pain in neonates at risk for neurological impairment

Authors

  • Bonnie Stevens,

    1. Bonnie Stevens PhD RN Signy Hildur Eaton Chair in Paediatric Nursing Research Associate Chief Nursing Research The Hospital for Sick Children, Toronto, Ontario, Canada
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  • Patrick McGrath,

    1. Patrick McGrath PhD OC FRSC Vice President, Research IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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  • Annie Dupuis,

    1. Annie Dupuis PhD Biostatistician Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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  • Sharyn Gibbins,

    1. Sharyn Gibbins PhD RN Director of Interdisciplinary Research Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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  • Joseph Beyene,

    1. Joseph Beyene PhD Scientist Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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  • Lynn Breau,

    1. Lynn Breau PhD Registered Psychologist School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
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  • Carol Camfield,

    1. Carol Camfield MD FRCPC Professor of Pediatrics Department of Pediatric Neurology, IWK Health Centre Halifax, Nova Scotia, Canada
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  • Gordon Allen Finley,

    1. Gordon Allen Finley MD FRCPC FAAP Medical Director Pediatric Pain Management, Centre for Pediatric Pain Research, IWK Health Centre Halifax, Nova Scotia, Canada
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  • Linda S. Franck,

    1. Linda S. Franck PhD RN RSCN Professor of Children’s Nursing Research Institute of Child Health, Centre for Nursing and Allied Health Professions Research, Great Ormond Street Hospital for Children, London, UK
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  • Alexandra Howlett,

    1. Alexandra Howlett MD FRCPC Neonatologist Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
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  • Celeste Johnston,

    1. Celeste Johnston DEd RN James McGill Professor School of Nursing, McGill University, Montreal, Quebec, Canada
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  • Patricia McKeever,

    1. Patricia McKeever PhD RN Senior Scientist Bloorview Kids Foundation Chair in Childhood Disability Studies, and Professor Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
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  • Karel O’Brien,

    1. Karel O’Brien MD FRCPC Interim Pediatrican-in Chief Department of Pediatrics, Mount Sinai Hospital Toronto, Ontario, Canada
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  • Arne Ohlsson,

    1. Arne Ohlsson MD FRCPC Professor Departments of Paediatrics, Obstetrics and Gynaecology, and Health Policy, Management and Evaluation, University of Toronto, and Director Evidence Based Neonatal Care and Outcomes Research, Department of Pediatrics, Mount Sinai Hospital, Ontario, Canada
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  • Janet Yamada

    1. Janet Yamada MSc, RN Research Associate Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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B. Stevens: e-mail: b.stevens@utoronto.ca

Abstract

Title. Indicators of pain in neonates at risk for neurological impairment.

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.

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