Intensive care of the newborn. IMPLEMENTATION OF A PAIN ASSESSMENT TOOL IN THE NEONATAL INTENSIVE CARE UNIT

University Degree Subjects allied to Medicine

Registration NO: 100252125

Module NO : SNM2137/3114

Unit Leader : Angela Thurlby

Word Count : 2058

According to the international association for the study of pain, it is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (American Academy of paediatrics 2000). In addition, Boxwell (2010) identifies that if newborn pain is not recognised, treated or managed, it can have several short term and long term consequences. Slater et al (2008) suggests that because babies are unable to express the intensity of pain verbally, the assessment of their pain is a complex issue, as it is difficult to measure their pain accurately. As a result, this shortcoming is a major hindrance in providing effective analgesia for babies undergoing neonatal intensive care. It is recommended that nursing and medical staff need to acquire the observational skills necessary to assess the physiological and behavioural cues of the babies to enable them give effective neonatal pain management (Walden M,Gibbins S 2008). They also suggest that the implementation of a pain assessment using a recognised pain assessment tool is necessary.

In the past it was believed that neonates have an immature central nervous system with non myelinated pain fibres and was incapable of perceiving pain (Merenstein & Gardner 2011). However, according to more recent studies babies are capable of feeling pain neurologically from 20 weeks gestation and probably before (D Crawford and Whickson 2002). A study by Ahn (2006) observed a link between behavioural states and pain responses in premature infants, finding that relatively healthy premature infants in a state of quiet or active sleep could express pain related responses to NICU procedures. The study also suggests that a pain assessment tool, using the correct responses to measure pain can be effective.

I have recently cared for a baby, born at 26 weeks gestation weighing 960 grams born by emergency caesarean section. She had a venous thrombus in her liver, hypoglycaemia, hyponatremia, low set posteriorly rotated ears, a furrowed tongue and neurological sequelae following resuscitation. The baby was delivered in another hospital by emergency caesarean section because of maternal APH. She was intubated at birth and ventilated and was gradually weaned on to biphasic CPAP. However, because of her respiratory deterioration which needed prolonged resuscitation including CPR, she was transferred to the unit where I work, for ventilation. She was fed using TPN and had a continuous infusion of morphine at 20 micro grams per kg. It was very difficult to assess her pain with the Pain Assessment Tool (PAT) (Spence et al. 2005), which is used in our unit. The PAT measures physiological, behavioural, nurse’s, and perception variables, for post operative and ventilated term and preterm babies. Though it is the most appropriate tool in this situation (as the baby was on ventilator), I felt it did not give accurately quantify the baby’s pain, as upon handling, she had frequent desaturations and bradycardia.

Boxwell (2010) suggests that in the past neonatal pain was not seen as a priority and was often unrecognised and untreated. However more recently there have been great changes in recognising and managing pain in neonates. In practice it has been observed that nursing staff usually depend on facial expressions and other clinical features of distress as means of communication, but it has been a challenge for nurses to choose a suitable pain assessment tool. According to Crawford (2002) a physiological basis for the assessment of neonatal pain and stress could be provided by the use of a neonatal pain assessment tool and thus leading to well devised care by health care providers. It also increases the awareness that neonates experience pain. Reflecting on the baby discussed, she had so many problems and had undergone a lot of invasive procedures such as re intubations (three times) insertion of UVC, UAC, long lines, peripheral lines and heel pricks all of which must have caused her pain and discomfort. Much research has been carried out over the years to try and discover best ways to manage pain and to understand the short term and long term consequences of pain in babies in the Neonatal intensive care. Therefore I will analyse research in to some of the pain assessment tool which are now available as a result of this research also how these can be used to help manage the pain of babies more effectively.

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For the assessment of acute neonatal pain there are over 40 tools which have been reviewed by several authors (Duhn and Medves 2004; Crellin et al 2007; Burton and Mackinnon 2007). Some of the pain assessment tools that are frequently used include: Behavioural Indicators of Infant Pain (BIIP) (Holsti et al. 2008), The COMFORT scale (Van Dijk et al. 2005), Neonatal Infant Pain Score (NIPS) (Lawrence et al. 1993) which is an adaptation of the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS). Neonatal Facial Coding system (NFCS) Peters et al. (2003), Neonatal Pain Agitation and Sedation scale (N-PASS), Pain assessment tool (PAT) (Spence et al. 2005), and finally Premature Infant pain Profile (PIPP) Stevens et al. (1996). Even though there are many pain assessment tools available, there is no single tool to recognise the pain exactly for varied painful condition (Ranger et al 2007). Several researchers agreed that the measurement of pain in the neonates is possible using physiological, hormonal, metabolic and behavioural parameters (Anand K.J.2001; Prince.w, Horns.K, Latta.T, et al 2004). Boxwell (2010) describes how the PIPP score uses the heart rate, oxygen saturation and facial actions, whilst taking the state and gestational age into account. She also suggests that the physiological symptoms are the result of sympathetic nervous system activation indicated by increased heart rate, elevated blood pressure, desaturation, apnoea and palmar sweating, stating also that physiological and behavioural response to noxious stimulation such as limb withdrawal and increased heart rate may occur early in development.

According to Stevenson et al (2007), the most important behaviour which babies use as a signal of emotional and painful distress is to cry. The baby in the case discussed had behavioural changes each time she was exposed to invasive procedures which was a very reliable indicator of pain. Therefore a tool such as CRIES (Crying, Requiring Oxygen, Increased Vital Signs, Expression, and Sleeplessness), Hogan et al. (1996) would be quite appropriate. However because the technique also involves recording the crying of the baby in order to give a score, this would be difficult to score because the baby in this case was intubated and receiving ventilation. Further, in a different situation, for example, where the baby was not able move, different variables would need to be measured. Therefore there is a need to observe the baby in order to determine which assessment tool would be more effective depending on variables that can be measured.

Buttner and Finkew (2001) found that hormonal and metabolic alterations occur when pain is repetitive or persists for hours or days, which compensate the physiological parameters thus making the assessment of pain more difficult. Biochemical measurement of pain includes measuring blood levels of steroids, catecholamine, glucagon, growth hormone, insulin and rennin (Anand et al 2007). These tests may require invasive and complex procedures therefore are not readily available in clinical practice. Metabolic response to pain can be measured by skin conductance (Harrison et al 2006; Eriksson et al 2008). Cortical response to noxious stimulation began to be measured using near infrared spectroscopy (NIRS) Slater et al. (2007). This is a technique by which the change in intensity between the emitted and absorbed light is used to measure the concentration changes in the tissue oxygenation. It helps to assess the functional activation of brain based on the assumption that increased tissue oxygenation represents an increased cerebral blood flow which is associated with increase in underlying neural activity. Therefore each of the tools mentioned has different set of criteria, and would be more accurate in different situations. This must be taken to account.

According to The American Academy of Paediatrics (2000), pain assessment tools should be multidimensional, including measurements for both physiological and behavioural indicators of pain, because neonates cannot self-report pain. Hennessy (2006) carried out a study using babies in the NICU to compare the pain response using CRIES, FLACC (Face, Leg, Activity, Cry, Consolability), and PIPP for a total of ninety four stimulants including angiocatheter insertions, trunk rubbings and loud noises. Pain responses were observed using sixty four infants demonstrating a significant difference among the mean scores between the different tests. All of these tests used similar variables in order to assess pain. The study shows that the pain assessment tools that are available now are not accurate, and as such a more accurate pain assessment tool needs to be developed. It gives rise to the suggestion that the tools used need to be constantly updated. This may also be due to inaccuracy in the use of the above tools, that is, gaps in knowledge on how to use them. According to Warnock and Lander (2004) these gaps in knowledge can be attributed to; the lack of basic knowledge about pain behaviour, overreliance on an invasive short-term pain model, pain measurement issues and a lack of knowledge about contributing factors to the painful experience. Even when a successful tool is used the results must be used to enable a good management strategy. Pillai Ridell and Craig (2007) suggests that if similar ratings on a pain scale have different meaning for different health care workers, it will result in different strategies used to alleviate pain. In the case discussed, even if the baby was identified to have considerable pain, the correct dose of morphine and TPN must still be given. Therefore, training staff in the use of pain assessment tools would also be necessary in their implementation.

A fifteen year follow up survey in Sweden into the pain assessment of all neonatal units was performed during 1993, 1998, 2003 and 2008 concerning the use and need for pain assessment tools (Maria Gardin and Mats Eriksson). They found that the usage of the tools increased from 64% in 1993 to 83%, in 2008. In this study, the most common indication of pain was facial expressions. They also found a correlation between increased usage and better care of the babies. Thus in the NICU, tools can be effective in management; which also illustrates that, using a tool which involves observable pain would prove to be more effective. Furthermore, a study by Miki Yamamoto (2007) found that the tools when used together had greater effectiveness when comparing with the findings of the medical staff, nurses and midwives. They also found that NIPS had the best agreement rate, with 63% accuracy. Using different tools together may aid identification of pain. The baby in the case discussed had to be given a very high dose of morphine, which could have been avoided if her pain had been identified and dealt with earlier which may have been easier with multiple tools.

In practice, alternatives are also considered such as the effects of the environment when preventing the long term consequences of pain. Cignacco et al. (2007) demonstrated that using non pharmacological alleviation proved successful in the alleviation of pain. This includes improving the baby’s sense of security and providing a favourable environment such as the use of non-nutritive sucking, swaddling, facilitated tucking, breastfeeding and oral sucrose for procedural pain. However all of these must be used in conjunction with pain assessment tools to provide effective strategies for pain management.

According to Boxwell (2010), although pain tools have their limitations, their use is essential because they can provide as a guide for practice decisions by allowing nursing and medical staff to make visual and written observations to support claim for pain relief for a baby. This could also promote continuity of care among care givers. The baby discussed in this case had experienced severe pain and distress which resulted in a number of physiological changes associated with pain such as a change in heart rate, desaturations, and limb withdrawals. These variables were clearly observed and a tool that takes into consideration such variables could be implemented in practice to give accurate assessment of pain. Anand (2006) recommends that more research is needed in to the assessment of pain in the neonatal period. It has also been identified that there is an evidence-practice gap for the assessment and management of pain in neonates even though there is a vast amount of evidence (Gharavi et al 2007; Heaton et al 2007).

Therefore in conclusion, training staff to use different tools that measure different variables along with using them more frequently in the NICU will mean that pain assessment tools are both successfully, and accurately implemented, leading to greater effectiveness in identification of pain; which, in the neonatal unit is the most crucial part in providing effective care. If such a tool and techniques had been used for the baby discussed, her pain could have been discovered earlier and managed more effectively. When choosing a pain assessment tool, the clinical value or viability relative to that particular setting should be taken into consideration. This would guarantee compliance among health workers and success in the implementation of a standard pain assessment tool. At the same time further research into more accurate and reliable tools must also be undertaken.

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