While assessing a newborn, the nurse notes that the infants skin is mottled

• Introduction
• Definition of Pain
• Definition of Terms
• Aim
• The Modified Pain Assessment Tool (PAT)
  • How to complete the mPAT Score
  • Frequency of Pain Assessment
  • Interpreting the mPAT Score
  • Nursing Comfort Measures
  • Documentation
  • Special Considerations when Completing the mPAT Score
• Family Centered Care
• Other Considerations
• Companion Documents
• Links
• Evidence Table 
  

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.

Definition of Pain

 “…an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 1989)

Definition of Terms

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 (between the 60’s to 80’s percent) but then quickly increases again to normal levels. They are usually self-resolving, or self-limiting and require no intervention. Considered normal in premature 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 or energy of systolic myocardial contraction to support the patient’s blood pressure.

Sedated – the neonate is kept calm and 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.

Aim

This guideline aims to provide nursing, medical & allied health 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). 

The Modified Pain Assessment Tool  

The mPAT is an observational scale designed to assess neonatal pain. The mPAT is a modification of the original Pain Assessment Tool (PAT) scale that was first developed and piloted on the Butterfly Ward by Hodgkinson, Bear, Thorn & Blaricum (1994). The mPAT scale was modified by O’Sullivan, Rowley, Ellis, Faasse, & Petrie (2016) and piloted at The National Women’s Newborn Intensive Care Unit at Auckland City Hospital, New Zealand. It is a multidimensional pain assessment tool that was specifically designed for neonates undergoing surgical intervention. The mPAT has been validated for surgical and non-surgical neonates, from 24 weeks gestation to full term, up to 6 months old.

It is recommended that mPAT is used for all patients admitted to Butterfly Ward at RCH and can be utilised for both medical and surgical infants 3-6 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).

Adapted from O’Sullivan et al. (2016)

How to complete the mPAT Score

• Observe neonate and score the following items: behavioural state, colour and facial expression.
  
• Then gently touch the neonate’s limb to assess muscle tone.
  
• Score the neonate for each of the physiological and behavioural parameters, and for the nurse’s perception of pain.
  
• Each item is scored from 0 to 2, and added to generate a total score out of 20 (the higher the score, the higher the level of pain).
  
• 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 not be given for other factors that are contributing to the neonate’s pain (for example, the presence of an ETT, day 1 post-op, the type of surgery, presence of a chest drain etc). This score should be given however, if the neonate is currently perceived to be in pain as a result of those other factors.  

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.   

• Baseline mPAT scores should be completed at least once per shift for all neonates.
  
• Score immediately post-op and continue hourly mPAT scores until stabilised and analgesia optimal. 
  
• 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.
  
• mPAT scores should be completed prior to and following any invasive procedures.
  
• Score ½ hour after any analgesic interventions to establish effectiveness
  
• Neonates who are ventilated or receiving analgesia should have mPAT scores recorded at a minimum of 4 hourly.
  
• 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: 

• mPAT scores should provide a trend for each patient, allowing analgesia to be titrated as required.
  
• Nursing comfort measures should be provided as a first step of management and in addition to any analgesia required.
  
• A stepped approach should be used for pain management:
  
  • Non-opioid analgesia should be considered for mild to moderate pain.
    
  • Opioid analgesia in combination of non-opioid analgesia is reserved for moderate to severe pain.
    
  • 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.

• mPAT scores should be discussed as part of both nursing and medical handovers.
  
• Nurses can also initiate more frequent pain assessment scoring if they believe a neonate is in pain.
  
• 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.
  
• 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.
  
• 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 should be reviewed by medical staff prior to weaning or increasing analgesia. 

Nursing Comfort Measures

Nursing comfort measures are non-pharmacological interventions that are very relevant to neonatal and infant pain management. Both healthcare professionals and parents can implement nursing comfort measures prior to or alongside analgesic interventions.

• Breastfeeding by mother as appropriate
  
• Repositioning - positioning the neonate, appropriate to their gestational maturation, supporting limbs/ trunk and taking care with any attached lines or equipment (i.e. supine or side lying). Rolls or position aids (or nests) can also be used.
  
• Swaddling - neonates can be wrapped in a cloth or blanket, with their arms and legs tucked in, to make them feel secure.
  
• Nesting - a positioning aid or roll that is placed around the neonate to help contain them and make them feel safe and secure by imitating a womb-like environment. It also helps keeps the neonates limbs in alignment when they cannot be wrapped or swaddled.
  
• Facilitated tucking - holding a neonate so that their limbs are in close proximity to the trunk. The neonate is held side lying in a flexed position. This technique involves touch and positioning, and promotes a sense of control and security for the neonate.
  
• Containment holding - the caregiver can use two hands to hold the baby and make them feel secure (i.e. one hand on the baby’s head and one on their feet).
  
• Decreasing environmental sensors (noise/ light)
  
• Tactile soothing - still gentle touch can be provided by caregivers placing their hand on the neonate’s head and abdomen/back.
  
• Talking to neonate
  
• Nappy change
  
• Non-nutritive sucking - refers to the use of a dummy to promote sucking without breast milk or infant formula.
  
• Allowing neonate to grasp a finger
  
• Skin to skin care for the newborn (Kangaroo Care) - nursing of the neonate on the bare skin of their mother or father, upright at a 40-60 degree angle and covered by parent’s shirt/gown, with an additional blanket as required.
  
• Clustering, developmental or cue based care - grouping care to minimise the number of times a neonate is handled. By reducing episodes of handling, periods of sleep can be protected and stress can be minimised. If neonates are displaying signs of stress (such as increased heart rate or facial expression), fewer procedures can be clustered on the next occasion and comfort measures can be provided.
  

Documentation

• After completing the mPAT score, the number should be documented on the EMR (Electronic Medical Records) observation flowsheet.
  
• 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.
  
• Document any special considerations that were taken when completing the mPAT score within EMR.
  
• Hand over these special considerations to the next shift to ensure consistency in pain assessment.
• Document interventions and effectiveness of interventions in the appropriate location within the EMR.

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.
   • A higher baseline heart rate and respiration rate may be normal for premature neonates. 
   • Fluctuating heart rates and oxygen saturations also may be normal for premature neonates.
   • 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 score.
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 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.
4. 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.
5. Intubated and ventilated neonates can still cry, although it will be a silent cry, this should be accounted for in the mPAT score.
6. 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.
7. 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 needs to administered before muscle-relaxing a neonate.
8. 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.

Other Considerations 

• Invasive painful procedures should only be performed when necessary
• 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 http://www.rch.org.au/anaes/   
  
• Skin to Skin Care for the Newborn (Link to Guideline: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Skin_to_Skin_Care_for_the_Newborn/ )
  
• COCOON Resources (Link to Resources: http://www.rch.org.au/neonatal_rch/intranet_resources/COCOON_Resources/ )
• Learning Hero Packages "COCOON" and "Neurodevelopmental Care"
  

Links

• National Newborn Pain Practice Guidelines
  
• IASP http://childpain.org/
  
• ANZCA www.anzca.edu.au
  
• http://www.health.vic.gov.au/neonatalhandbook/procedures/developmental-care.htm 
  
• WHO analgesic ladder: http://www.who.int/cancer/palliative/painladder/en/  
  

Evidence Table

Neonatal Pain Assessment Evidence Table 

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 December 2020.  

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