Introduction

Neonates frequently experience pain during their hospital admission as a result of diagnostic or therapeutic interventions or as a result of a disease process. They cannot verbalise their pain experience and depend on others to recognise, assess and manage their pain. Neonates may suffer immediate or long-term consequences of unrelieved pain. Accurate assessment of pain is essential to provide adequate management. Observation scales, which include physiological and behavioural responses to pain, are available to aid consistent pain management. Pain assessment is considered a 5th vital sign.

Aim

This guideline aims to provide clinical staff an outline for pain assessment in neonates and infants up to 6 months of age, admitted to the Royal Children’s Hospital (RCH) to ensure effective and consistent pain assessment. This guideline focuses on the use of the modified Pain Assessment Tool (mPAT) that is currently used to assess pain for all patients admitted to the RCH Butterfly Ward, Neonatal Intensive Care (NICU). 

Definition of Terms

• Pain – “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (IASP, 2020)
• mPAT – modified Pain Assessment Tool; an updated and modified multidimensional observational scale used to assess or measure pain
  
• PAT – Pain Assessment Tool; a multidimensional observational scale used to assess or measure pain
  
• Fleeting desaturation – occurs when oxygen saturations drop to low levels (60-80%) but then quickly resolve to baseline normal levels. They are usually self-limiting and require no intervention. Considered normal in premature neonates and unwell term neonates and occurs due to their immaturity.
  
• Muscle Relaxant – a medication given to neonates to paralyse and stop all muscle movement. It is usually used in the NICU to reduce metabolic demand or to stop neonatal movement to protect an airway.
  
• Inotropic support – a medication given as a continuous infusion, which alters the force of systolic myocardial contraction to support the patient’s blood pressure.
  
• Sedated – the neonate is kept calm and/or put to sleep using a sedative drug, such as midazolam.
  
• Heavily Sedated – the neonate is very sedated, and not easily rousable or unrousable. 
  
• COCOON – ‘Circle Of Care Optimising Outcomes for Newborns’ is a model of care on Butterfly Ward to improve the experience of families whose babies are cared for on Butterfly Ward, and subsequently improve neonatal health outcomes. 

The Modified Pain Assessment Tool  

It is recommended that the mPAT is used for all patients admitted to Butterfly Ward at RCH and can be utilised for both medical and surgical infants up to 6 months of age in other ward areas.

The mPAT scale focuses on behavioural and physiological responses to painful stimuli, and includes a nurse’s perception indicator (Table 1).

Table 1: The modified Pain Assessment Tool (mPAT)

How to complete the mPAT Score

a)        Observe neonate and score the following items: behavioural state, colour and facial expression.

b)       Then gently touch the neonate’s limb to assess muscle tone.

c)       Score the neonate for each of the physiological and behavioural parameters, and for the nurse’s perception of pain.

d)       Each item is scored from 0 to 2, then added to generate a total score out of 20 (the higher the score, the higher the level of pain).

e)       If a baby is muscle-relaxed the total score is out of 10, since a muscle-relaxed neonate can only be scored on the physiological indicators of pain, not the behavioural indicators of pain.

A score of 2 for the ‘nurse’s perception of pain’ should be given if the neonate is perceived to be in pain at the time of assessment. It should not be given for other factors that are anticipated to contribute to the neonate’s pain.

A pain score completed by both medical and nursing staff together may be useful if there are any score discrepancies or concerns.

Frequency of Pain Assessment 

Frequency of pain assessment will depend on the clinical situation.  If pain is a concern, then frequency of scoring can be increased. 

a) Baseline mPAT scores should be completed at least 8-12 hourly (once per shift) for all neonates

b) Score immediately post-op and continue hourly mPAT scores until stabilised and analgesia optimal 

c) Minimum 4 hourly mPAT scores should then be recorded for a minimum of 48 hours post-op or until analgesia is ceased for 48 hours

d) mPAT scores should be completed prior to and following any invasive procedures

e) Score ½ hour after any analgesic interventions to establish effectiveness

f) Neonates who are ventilated or receiving analgesia should have mPAT scores recorded at a minimum of 4 hourly

g) Long-term ventilated patients should have at least one mPAT score at commencement of each shift

Interpreting the mPAT Score

Pain management must be individual to each patient and situation; however, RCH recommends: 

a) mPAT scores should provide a trend for each patient, allowing analgesia to be titrated as required

b) Nursing comfort measures should be provided as a first step of management and in addition to any analgesia required. 

c) A stepped approach should be used for pain management:

          i) Non-opioid analgesia should be considered for mild to moderate pain.

          ii) Opioid analgesia in combination of non-opioid analgesia is reserved for moderate to severe pain.

          iii) The following is to be used as a guide only, clinical judgment and collaboration with the multidisciplinary team is advised (Table 2).

Table 2:

The mPAT score for muscle-relaxed neonates is out of 10, so the threshold to intervene is lower. The threshold to intervene is also lower for heavily sedated neonates.

a) mPAT scores should be discussed as part of both nursing and medical handovers

b) Nurses can also initiate more frequent pain assessment scoring if they believe a neonate is in pai

c) If mPAT scores are consistently low then weaning analgesia should be considered. However, a low mPAT score does not mean that a neonate is ready for their analgesia to be weaned, it indicates that the neonate has adequate analgesia for their current condition

d) Likewise, a high mPAT score does not ‘justify’ the requirement for analgesia. It indicates that the current analgesia being provided is inadequate for the neonate’s current condition

e) Clinical judgment and collaboration with the multidisciplinary team may also be used in conjunction with the mPAT scores to ensure adequate pain management

mPAT scores and trending should be reviewed by medical staff prior to weaning or increasing analgesia. For more information on neonatal pain management please visit the Neonatal Pain Management in the NICU guideline.

Documentation

a) After completing the mPAT score, the number should be documented on the observation flowsheet

b) Document the correct time the mPAT score was taken, and the context of the score during this time, for example, awake or asleep or heavily sedated

c) Document any special considerations that were taken when completing the mPAT score 

d) Hand over these special considerations to the next shift to ensure consistency in pain assessment

e) Document interventions and effectiveness of interventions 

Special Considerations 

The following considerations present challenges in pain assessment. Continue to use the mPAT score and be mindful of these contextual matters when making changes to analgesia provided.

1. Preterm infants have a hypersensitivity to sensory stimuli. This may be demonstrated by an exaggerated response to painful stimuli, such as during adhesive tape removal or during moving/handling.
        i) A higher baseline heart rate and respiration rate is normal for premature neonates 
        ii) Fluctuating heart rates and oxygen saturations also may be normal for premature neonates
        iii) This needs to be taken into consideration for the premature neonate, however, if there are variations from what is normal for the individual premature neonate, then this needs to be accounted for in the mPAT scor
2. Neonates with neurological impairment may exhibit altered processing and modulation of pain. These patients may not display the usual behavioural and physiological responses to pain. E.g. during a heel lance procedure, a neonate with neurological impairment may not exhibit facial grimace and change in heart rate. 
   
3. Neonates who may be withdrawing from opioids or maternal substance use, may exhibit behaviours that are similar to pain, but are not pain. The WAT1 and NAS assessment tools may be more appropriate for assessing these neonates
4. Neonates who may be experiencing delirium may also exhibit behaviours that are similar to pain but are not pain. The Butterfly ward is currently trialling the CAPD score for these neonates as a more appropriate assessment.
   
5. Neonates who are receiving inotropic support may have an altered heart rate and blood pressure, which will affect the outcome of the mPAT score. These altered baseline heart rate and blood pressures need to be accounted for in the mPAT score, and any changes from this new baseline needs to be documented in the mPAT score accordingly.
   
6. Neonates may appear pale/blue/grey/mottled/dusky for a variety of reasons including; low haemoglobin levels, congenital heart disease, or other disease processes. This abnormal colour may be normal for the neonate. This should be accounted for in the mPAT score, however, variations from the neonate’s normal should also be accounted for in the mPAT score.
7. Intubated and ventilated neonates can still cry, although it will be a silent cry, this should be accounted for in the mPAT score.
   
8. Vulnerable neonates may learn to become helpless in order to restore energy, especially when constant attempts to communicate pain are unrecognised.  E.g. a neonate, who has frequently been exposed to painful stimuli, does not respond to a nasogastric tube insertion or heel lance procedure or nappy change.  This does not mean that they are not experiencing pain, but they have learnt this behaviour in order to conserve their energy.
   
9. Patients who are receiving muscle-relaxants can only have a score based on physiological changes; hence the mPAT score becomes a maximum of 10. Adequate analgesia and sedation MUST be administered before muscle-relaxing a neonate
10. Sedation may mask the neonate’s response to painful stimuli. Sedation does not provide pain relief. Sedation should be combined with analgesia.

Family Centred Care

When completing a pain assessment, healthcare professionals can gain information from the parents about any particular behavioural cues that their baby may be displaying. Healthcare professionals can provide explanations to parents regarding rationales for pain observations and interventions. Parents can be involved and given the opportunity to comfort their child appropriately. This can be achieved by teaching them about cues of distress for their baby and how they can provide developmental care. More information is available on the COCOON website and via the MyRCH app. This will help improve their confidence as a parent and enable them to be more involved in the care and comfort of their baby.

Also Consider

• Invasive painful procedures should only be performed when necessary and clustered with other procedures and cares if appropriate
• Time painful procedures with parents present (as desired), so they can provide comfort and soothing to their child
• Ensure hands are not cold when handling neonates
• Oral sucrose can also be used to support procedural pain management in neonates (Refer to  Sucrose (oral) for Procedural Pain Management in Infants)

Companion Documents

• Sucrose (oral) for Procedural Pain Management in Infants
• Pain assessment and measurement 
• Anaesthesia and Pain Management CPGs and learning packages
• Skin to Skin Care for the Newborn
• COCOON Resources
• Neonatal Pain Management in the NICU
• Neonatal Pain Assessment Learning Hero Package
• Neonatal Pain Management Learning Hero Package
• Weaning Guideline for Sedation/Analgesia in PICU
• Delirium Prevention and Management in the PICU
• Revised CAPD for younger patients

Links

• National Newborn Pain Practice Guidelines
• IASP
• ANZCA
• http://www.health.vic.gov.au/neonatalhandbook/procedures/developmental-care.htm 
• WHO analgesic ladder
  

Please remember to read the disclaimer. 

The development of this nursing guideline was coordinated by Bianca Devsam, Clinical Nurse Specialist, Butterfly Ward, Neonatal Intensive Care Unit, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2024.