HRV in both bands decreased during pain (P<0.001), followed by a recovery to near-baseline levels (P = 0.166). Venepuncture and mechanical ventilation attenuated the HRV response to pain (P= 0.024 and P=0.001 respectively). HRV at the baseline increased with GA but the gro wth rate of high-frequency power was reduced in mechanically ventilated infants Physiological Behavioral Stevens et al., 2007 Prospective observational cohort study comparing pain responses to heel lance from infants at high (Cohort A, n = 54), moderate (Cohort B, n = 45) and low (Cohort C, n = 50) risk for NI (n = 149) A signi \201 cant cohort by phase interaction for total facial action (F(6, 409) = 3.50, p = 0.0022) and 4 individual facial actions existed; with Cohort C demonstrating the most fa cial action. A signi \201 cant Phase e \200 ect existed for increased maximum HR (F(3, 43 1) = 58.1, p = 0.001), minimum HR (F(3, 431) = 78.7, p = 0.001), maximum O 2 saturation (F( 3, 425) = 47.6, p = 0.001), and minimum O 2 saturation (F(3, 425) = 12.2, p = 0.001) with n o cohort di \200 erences Cohort B had signi \201 cantly higher minimum (F(2, 79) = 3.71, p = 0.029), and mean (F(2, 79) = 4.04, p = 0.021) fundamental cry frequencies A signi \201 cant phase e \200 ect for low/high-frequency HRV ratio (F(2, 216) = 4.97, p = 0.008) was found with the greatest decrease in Cohort A. Signi \201 cant cohort by phase interactions existed for low- and high-frequency HRV measures in appropriate designs are needed. For example, for rand- omized controlled trials , a measure of methodological quality such as the CONsolidated Standards of Reporting Trial s (CONSORT, 2010) statement that includes whether a validated measure, appro- priate random ization, and follow-up of outcomes are used should be incorporated as a guideline for repor ting the methodological quality of published studies and responsible external generalizatio n of the results. imaging \200\224MRI), and near-infrared spectroscopy (NIRS), have been explored to try and better understand structural, biochemical, or functional neuronal activity in the brain \200\231s response to noxious stimulation. A summary of the most recent studies are include d in Table 35.3 . Recently, Brummelte et al. ( 2012 ), using MRI, three-dimensional magnetic resonance spectr oscopic imaging, and diff usion ten- sor imaging demonstrated that greater numbers of skin- break- ing procedural pain indicators may contribute to impaired brain development in prete rm infants. Fabrizi and colleagues ( 2011 ) systematically mapped the maturation of tactile and nociceptive activity in the developing human brain using EEG signals. Specifi c neural circuits for discrimination between touch and nociception emerged from 35 to 37 weeks GA i n the human brain. Current clinical practice guidelines, policies, and procedures An important aspect of impro ving clinical outcomes is to ensure that the most recent evidence is eff ectively translate d into clinical practice. Th is translation needs to be supported by inclusion of rec- omme ndations for pain assessment within wider pain management guidelines. To date, several publ ished guidelines from professional organizations have included recommendations on pain asse ss- ment and management (see Table 35.4 ). Th e majority do not focus on children, although there are a few that are specifi c to children Although, biomarkers, cortical indicators and cognitive mapping provide novel and objective means to exploring the infant \200\231s response to pain, decoding their complex and varia ble patterns and compar- ing them to behavioral pain indicators and composite measures has not been suffi ciently explored. Carefully designed measure- ment studies comparing cogniti ve indicators with established CHAPTER 35 neonatal and infant pain assessment 363 Table 35.3 Cognitive indicators of neonatal/infant pain Indicator Reference Study design/methods Main results Magnetic resonance imaging (MRI) Brummelte et al., 2012 Prospective cohort study (n = 86 preterm infants 24 \200\22332 weeks GA) to examine relatio nship between procedural pain and early brain development Greater numbers of painful procedures were associated with reduced white matter (p = 0.028) and reduced subcortical gray matter (p = 0.004) after adjusting for multiple clinical fact ors Electro- encephalography (EEG) Fabrizi et al., 2011 Prospective cohort study (N = 18 infants 37 \200\22345 weeks GA; and N = 41 infants 28 \200 \22345 weeks GA (born at 24 \200\22341 weeks GA)) comparing touch or heel lance Occurrence in the preterm infants was signi \201 cantly less than in the full-term infants (p = 0.01tactile potential; p = 0.01 nociceptive-speci \201 c potential). Latencies of ta ctile and nociceptive-speci \201 c potentials were shorter in full-term infants than in pr emature infants. Neuronal bursts were signi \201 cantly greater in preterm infants than te rm infants whether evoked by touch (p = 0.048) or noxious lance (p <0.001) Neural circuits for discrimination between touch and nociception emerge from 35 \200\22337 weeks GA in the human brain Slater et al., 2010 Pilot prospective cohort study to determine whether cortical neurons are speci \201 cally activated by noxious stimuli in newborns (N = 10 infants 35 \200\22339 weeks PMA) using EEG recording following a routine heel lance Th e potential was observed in the central electrodes and characterized by a positivity tha t occurs at approximately 560 msec post-stimulus Th e magnitude of the nociceptive-speci \201 c potential was not dependent on sleep state, whereas an earlier potential, which was sleep-state dependent, was evoked by both noxious and non-noxious stimulation Researchers r eport that results provide the \201 rst direct evidence of speci \201 c noxious-evoked n eural activity in the infant brain Electro- myography (EMG) Schasfoort et al., 2008 Prospective cohort study to determine the feasibility of long-term, objective, and continuo us measurement of peripheral motor parameters to discriminate between pain and no pain in h ospitalized pre-verbal infants during (a) acute painful procedure: n = 9 (5 \200\223175 day s of age): and (b) postoperative pain: n = 14 infants (age range 45 \200\223400 days for ag e) measured for prolonged periods (mean 7 h) using acceleration sensors on one arm and both legs, and two muscle activity parameters derived from EMG sensors Acute painful procedure: the accelerometry-based parameters legs activity and overall extre mity activity (i.e. mean of arm and legs) was signi \201 cantly higher during heel lance t han before or after lance (p \211 0.001) Post-operative pain: relationships existed betwe en accelerometry-based overall extremity activity and COMFORT scale (r = 0.76, p <0.001), a nd between EMG-based wrist \202 exor activity and COMFORT (r = 0.55, p <0.001, for a subg roup of 7 infants) Researchers conclude that long-term, objective, and continuous measureme nt of peripheral motor parameters is feasible, has high potential, and is promising to asse ss pain in preverbal hospitalized infants Tactile stimulation produced no changes in HR or SaO 2 HR increased in the \201 rst 20 se c (p < 0.001), while SaO 2 decreased during the 40 sec after venepuncture (p <0.0001). Foll owing tactile or painful stimulation, [HbO 2 ] increased bilaterally (p <0.0001) Pain-induc ed [HbO 2 ] increases in the contralateral somatosensory cortex (p <0.05) were not mirrored in the occipital cortex (p >0.1) Pain-related [HbO 2 ] increases were signi \201 cantly m ore pronounced in male neonates, inversely correlated with GA and directly correlated with PNA. Researchers concluded that painful and tactile stimuli elicit speci \201 c haemodynam ic responses in the somatosensory cortex, implying conscious sensory perception in preterm neonates Near-infrared spectroscopy (NIRS) Bartocci et al., 2006 Prospective cohort study to study patterns of supraspinal pain processing in neonates (N = 40 preterm neonates at 28 \200\22336 weeks GA) and at 25 \200\22342 h following standardize d tactile (skin disinfection) and painful (venepuncture) stimuli. Changes were monitored by NIRS over both somatosensory cortices in 29 newborns, and over the contralateral somatosen sory and occipital areas in 11 newborns. HR and peripheral O 2 saturation (SaO 2 ) were rec orded simultaneously with NIRS parameters: oxygenated (HbO 2 ), deoxygenated, and total hem oglobin were also measured Slater et al., 2006 Prospective cohort study to determine whether premature infants process pain at a cortical level (N = 18 infants 25 and 45 weeks PMA) assessed by changes in cerebral oxygenation over the somatosensory cortex in response to noxious stimulation using real-time NIRS Noxious stimulation produced a clear cortical response, measured as an increase in total he moglobin concentration [HbT] in the contralateral somatosensory cortex, from 25 weeks. Cort ical responses were signi \201 cantly greater in awake versus sleeping infants. In awake i nfants, the response in the contralateral somatosensory cortex increased with age while lat ency decreased with age. Researchers concluded that noxious information is transmitted to t he preterm infant cortex from 25 weeks, highlighting the potential for both higher-level pa in processing and pain-induced plasticity in the human brain (Continued) SECTION 5 measurement of pain 364 Table 35.4 Pain assessment guidelines and recommendations for neonates and infants Guideline source/association Content Pain assessment measures recommended Feasibility/clinical utility Assessment and management of acute pain in the newborn \200\224Web continuing education res ource (Association of Women \200\231s Health, Obstetric and Neonatal Nurses (AWHONN), Canad a, 2002) Acute pain and consequences Validity and reliability of pain assessment measures Selection of newborn pain assessment tools Practice exercises PIPP CRIES NIPS FLACC CDSVN RIPS POPS BPS EDIN NFCS PAIN 27 pages No speci \201 c recommendations for timing or documentation of pain assessment Assessment of acute pain in children: development of evidence-based guidelines United Kingd om (Stapelkamp et al., 2011) Appraisal of tools for (a) children with or without cognitive impairment and (b) neonates, infants and verbal children, and non-verbal children with cognitive impairment Practice rec ommendations Practice points NFCS NNICUPAT NIPS OPS PAT PIPP 12 pages Recommendation of timing and documentation: (a) assess, record and re-evaluate pai n at regular intervals; (b) frequency of assessment determined according to the individual needs of the child and setting; (c) language, ethnicity and cultural factors may in \202 u ence expression and assessment of pain Clear tables outlining recommendations. E \200 ecti ve use of symbols to illustrate features of pain assessment measures Best Practice Clinical Guideline Assessment and Management of Neonatal Pain (Australian and New Zealand Neonatal Network, 2007) Key recommendations listed Audit tool Algorithms for procedural pain and pain assessment No speci \201 c pain measures recommended. 14 pages Overall strategies for timing and frequency of assessment: (a) at beginning of the shift, (b) prior to/end of a painful procedure, (c) at least once/shift (every 4 \200\2236 h) and when analgesia is being used, and (d) during weaning and 48 h following weaning Spe ci \201 c actions based on assessment score Consensus Statement for the Prevention and Management of Pain in the Newborn (Anand and the International Evidence-Based Group for Neonatal Pain, 2001) General principles for the prevention and management of pain in newborns Painful procedures in the NICU Methods for pain assessment pain in newborns Recommended analgesic doses for n eonates, adverse e \200 ects PIPP NFCS NIPS CRIES 8 pages Recommended timing: concomitantly with the vital signs, undertaken and documented e very 4 \200\2236 h or as indicated by the pain scores or clinical condition of the neonate Other recommendations: (a) pain assessment instruments should be sensitive and speci \201 c for infants of di \200 erent GA and/or pain types; (b) Pain assessment should be compreh ensive and multidimensional, including contextual, behavioral, and physiological indicators Recommended timing: (a) baseline pain assessment on admission and with a substantial change in health status; (b) during routine care, at least once per shift or when infant seems un comfortable Table with guide for use of an assessment tool Evidenced-based clinical practice guideline for management of newborn pain Australia (Spenc e et al., 2010) Key recommendations Audit tool Algorithms for procedural pain and pain assessment General recommendation for using validated measures but no speci \201 c measures recommend ed. PIPP NFCS NIPS CRIES 9 pages No speci \201 c recommendations for timing or documentation of pain assessment Mor e emphasis with management of pain Guideline statement: management of procedure-related pain in neonates Australia (Pediatrics & Child Health Division, Th e Royal Australasian College of Physicians, 2006) Pain and its consequences, responses of infants to pain, general principles for the prevent ion and management of pain in neonates Summary of current evidence in prevention and manage ment of pain with speci \201 c procedures (e.g. venepuncture, ROP exam) (Continued) CHAPTER 35 neonatal and infant pain assessment 365 Table 35.4 (Continued) Guideline source/association Content Pain assessment measures recommended Feasibility/clinical utility Nursing Best Practice Guideline \200\224 Assessment & Management of Pain Canada (Registered Nurses Association of Ontario 2002; revised 2007) Guideline development Process and responsibilities Interpretation of evidence De \201 niti on of terms Practice, education, organization and policy Recommendations Evaluation and mon itoring PIPP NIPS 174 pages Guideline for all populations across the lifespan Recommended timing: (a) at leas t once a day, (b) on a regular basis according to the type and intensity of pain and the tr eatment plan. Recommended documentation: (a) on a standardized form speci \201 c to the po pulation and setting; (b) include initial, comprehensive and re-assessment; (c) document re gularly and routinely on forms that are accessible to all clinicians; (d) teach individuals and families (as proxy recorders) to document pain assessment on the appropriate tools Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recomme ndations United States (American Society for Pain Management Nursing, 2006) Discusses pain assessment in all non-verbal patients Background information on pain assessm ent in neonates CHEOPS CHIPPS COMFORT CRIES DSVNI PIPP RIPS UWCH 9 pages Recommended timing and documentation; (a) Pain should be routinely monitored, asses sed, reassessed, and documented clearly to facilitate treatment and communication; (b) afte r intervention and regularly over time, and (c) documented in a readily visible and consist ent manner that is accessible to all health care providers Prevention and Management of Pain in the Neonate: An Update (American Academy of Pediatrics , Committee on Fetus and Newborn and Section on Surgery, Section on Anesthesiology and Pain Medicine, Canadian Pediatric Society and Fetus and Newborn Committee, 2006) Pain and stress in the neonate Pain assessment Recommendations CRIES COMFORT PIPP NIPS N-PASS NFCS PAT SUN EDIN BPSN Speci \201 c to neonates Focused and easy to read Age appropriateness of measures indicate d Recommended timing: neonates should be assessed for pain routinely and before and after p rocedures No speci \201 c recommendations for documentation of pain assessment and even fewer for neonates and infants. Th e major content areas covered in these guidelin es include background material on pain and its consequences, summaries of current evidence in preven- tion and management of pain with specifi c procedures (e.g. heel lance) and reco mmendations for implementation. From a system- atic review of pain assessment guidelines us ing Medical Subject Headings (MeSH) terms Pain Measurement , Pain Management , exp Pain/cl , di [Classifi cation , Diagnosis] , Guideline or practice guideline , Intensive Care Units , Neonatal and limited to newborn, English lan- guage from 1946 to present, only seven gui delines included specifi c recommendations of neonatal or infant pain assessment meas- ures ; the PIPP and NFCS were most commonly recommended. Six guidelines recommended specifi ed t iming and frequency of pain assessment. Th e recommendations were generally consistent acro ss timing of assessments and documentation every 4 to 6 h or as indicated by the pain score s or clinical condition of the neonate. Overall, although great eff orts have been made by researchers to consolidate evidence into practice guidelines, several gaps remain. Also, al though some guidelines are clear with user-friendly tables and fl ow diagrams, many require more concrete recommendations. For example, more specifi c directives (e.g. care paths or care plans) that include clear, succinct statements on pain assessment with vis- ual decision-making aids and specifi c rec ommendation for timing, documentation of assessment measures utilized and scores, and actio n plans to follow with assessment results targeted specifi cally for the neonatal and infan t populations are needed. Challenges and controversies associated with neonatal and infant pain assessment Th ere has been a long history of neglect of pain during infancy. Although many improvements have bee n achieved in the wake of ever-increasing knowledge expansion in the past few decades, futu re advancement will depend on adequately addressing and resolving current theoretical, clin ical, research, and KT challenges and controversies. Th eoretical challenges and controversies Science, as a social institution, has not stimula ted adequate sup- port for a comprehensive understanding of the interpersonal and SECTION 5 measurement of pain 366 social aspects of pain within the infant. Th e current focus has been more on the biology o f pain with diminished importance placed on the psychological aspects (Craig, 2009 ). Clear ly defi ning pain in infants in accurate terms that are broadly applicable to the neonatal and infant population is essential. Without this defi nition, terms such as nociception, pa in, stress, distress, as well as analgesia, calm- ing, and comfort are oft en used intercha ngeably or incorrectly and may result in inadequate measurement and erroneous conclusions r egarding pain management. infl uences during infancy suggests that steps taken to manage pain need to be varied and t ailored to the individual infant \200\231s needs. Clinical challenges and controversies Clinical challenges in pain assessment relate to the integration of knowledge into practice or KT. From the measurement perspective, diffi culty in identifying a criterion ( \200\230gold standard \200\231) for determin- ing the validit y of the phenomenon, lacking the subjective, unique and private nature of the symptom is pa ramount (Sidani, 2003 ). Behavioral and physiological variables oft en correlate inconsist- ently and poorly with each other and with other indicators (e.g. correlation is oft en aro und 0.3). Th is incongruence and the lack of the patient \200\231s self-report, oft en brin gs into question the validity of the measure or indicator, creates controversies on the ben efi ts and disadvantages of unidimensional verses multidimensional meas- urement approaches , and may aff ect judgment about pain intensity and decision-making about the eff ectivenes s of interventions. Th e multidimensionality of the pain phenomenon in measurement is oft e n vigorously debated; whereas some lobby for the simplicity of a single indicator of pain, many feel a multidimensional approach is essential for a comprehensive understanding of the experience that informs individualized and eff ective interventions. Supporters of a more unidimensional approach, fail to articulate how scores on individual indicators or groups o f indicators can be viewed to comprehensively provide accurate information to the clinician making decisions at the bedside. Pain intensity is most oft en the only dimension reported , when occurrence, frequency, duration, impact, meaning, and response are other important i nformation required. Th e absence of a behavioral pain response to stimulation which would normally be painful ( e.g. heel lance) is particularly in need of exploration in relation to pain in infants. Abs ence of pain response as measured by behavioral or a composite of behav- ioural and physiol ogical indicators, has been reported to occur in approximately 20% of infants (Johnston et al 1999 ). Th is may be because: (1) the response is so weak that it escapes observer detec - tion, (2) the infant may be incapable of mounting any response due to extenuating circums tances (e.g. severity of illness, extreme prematurity), or (3) the infant does not perceive the stimulus as painful. Regardless of the reason, this is a serious situation because pai n behavior in response to tissue damage is such a universal response in other populations a nd makes evolutional sense. It is also diffi cult to dispute the importance of behavioral i ndicators in particular given their consistency across populations, situations, and context s. Furthermore, it places infants in a vulnerable situ- ation where they are completely dep endent on the judgment of caregivers to make accurate conclusions surrounding their care an d pain management. Similarly, absence of a physiological (e.g. heart rate (HR)) or corti- cal response (e.g. E EG) to nociceptive stimulation also does not nec- essarily indicate absence of pain (or ana lgesia, if an intervention is being evaluated). It may indicate that an inappropriate respo nse was measured or that the sensitivity of the measure or the analyzes was questionable. T h ese issues illustrate the need for sensitive and valid indicators of pain and clarity sur rounding the terms \200\230pain \200\231, \200\230nocic- eption \200\231, and \200\230an algesia \200\231 in infants amongst clinicians and researchers in relation to pain assessme nt. Future investigation needs to focus on whether a relationship exists between behavioral observational indicators of pain (e.g. facial action) and biomarkers or cortical indicator s associated with noxious stimulation, and under what conditions. With the development of a broad array of measures for assessing acute pain, selection of th e \200\230best \200\231 pain measure becomes a challenge. Developing clearly articulated s election criteria for choosing a meas- ure for clinical and/or research purposes is essenti al. Th ese criteria could include: (1) validity (measuring accurately the phenomenon of int erest; being responsive to changes in the phenomenon), (2) reliability (measuring with the least amount of measurement error so that the score is reliable and reproducible across rat ers and time), (3) feasibility (ease of scoring, time, cost, clarity of instructions), and (4) clinical utility (ability to use pain scores for a particular infant, in a particular s etting, in a meaningful way to make deci- sions on future pain management strategies). Progress has been primarily made in the conceptualization and assessment of acute pain in n eonates and infants. Further consideration of unique developmental and communication proces ses requires further attention. Key unanswered questions relate to (1) how repeated pain at certain stages of the infant \200\231s development influences pain expression and (2) what are the crucial elements from the infant \200\231s interaction with the environ- ment and caregivers that influence pain expression and assess- ment by caregivers? Despite the plethora of existing pain measures, there is still a pau- city of validated mea sures for the most vulnerable groups of infants who are most critically ill, paralyzed, and preterm, at the end of life or with severe neurological impairments. For example, few meas - ures have been validated with the most preterm or extremely low gestational age (ELGA) in fants. Because of their immature pain processing, stress-response systems, and development, these infants \200\231 responses may be diff erent or at least more subtle and diffi cult to detect than those of more mature neonates. In addition, non-pain- ful touch and pain res ponses are oft en similar. Th is phenomenon is thought to be due to the wide receptive fi e lds that do not allow for diff erentiation between these two types of stimuli, thus making it diffi cult for the care provider to discern whether the infant is expe- riencing pain or not or whether a targeted intervention is eff ective. Yet these infants have large numbers of painful events for diagnosis and treatment. Th us, there is an urgent need to develop n ew meas- ures or validate existing measures for this population. Progress towards the optimal management of pain during infancy also demands an exploration of pain beyond the acute-procedural (e.g. immunization pain), acute-repetitive (e.g. multip le heel lances), or acute-prolonged (e.g. postoperative pain) domains. Examination of the e xistence of a pathological pain state, whereby pain contin- ues beyond expectation or persi sts for a signifi cant portion of the infant \200\231s existence is crucial. Knowing that t he human nervous sys- tem is extremely malleable in response to noxious environmental CHAPTER 35 neonatal and infant pain assessment 367 Routine pain assessment using validated measures is generally purported to be the basis of timely and eff ective pain management and quality care. Th ese pain practices represent a k ey component in pain guidelines, policies, and professional standards; yet, pain assessment in infants is not universal or even well integrated into clinical care. Franck and Bruce ( 2009 ) suggest that there is insuf- fi cient evidence to evaluate the eff ectiveness of st andardized pain assessment in terms of process or clinical outcomes. More research on the e ffi cacy, eff ectiveness, and cost benefi t of standardized pain assessment in relation to clinical and process outcomes needs to be considered as existing research on the use of sta ndardized pain assessment tools has limited evidence for improved process or patient outcom es. Furthermore, a misalignment may exist between the necessity of engaging care providers in accurate assessment of pain in the non-verbal individual and their ability and motiva- t ion to do so: \200\230Poor compliance with pain assessment guidelines may not simply be an issue of the \200\234research-to-practice gap \200\235, but it may indicate unspoken resi stance to use of methods that are overly simplistic, burdensome to patients, oft en inaccur ate and perhaps even disrespectful of clinical expertise and experience \200\231 (Franck an d Bruce, 2009 , p. 19). pain and concentrate on accurately assessing pain that is prolonged, persistent, or palliat ive is crucial. Integrating the science of meas- urement with clinical excellence remains a challenge for clinicians and researchers alike. Case example Baby C was born at 27 weeks, is now 15 days old and presented with necrotizing enterocoliti s (NEC) and bowel perforation. Her condition is unstable with poor perfusion. She is intuba ted, ventilated, and is being stabilized for the operation room (OR). A peripheral arterial line insertion was attempted but unsuccessful. She is lethargic with minimal spontaneous m ovement. Th e vital signs are: heart rate (HR) 179, respiratory rate (RR) 60, blood pressur e (BP) 50/32 (25), oxygen saturation 92, ventilation rate 40/min, pressures 18/7 O 2 55%O 2 . Th e nurse suspects the baby is in pain, because when she checks the abdominal girth she notices that the baby is wincing. She does not have time to complete a formal assessment u sing a validated pain measure. Th e surgery was completed. Upon return from the OR, the baby was not reversed from anesthe tic and displayed minimal movement. Th e vital signs were HR 180, BP 56/26 (30), O 2 sat 95 in 70% O 2 . Th e baby \200\231s color is pale. Th e PIPP score is 9. A morphine infusion of 10 mcg/kg/min is started. Th e vital signs 1 h later are: HR 165, BP 60/32 (40), O 2 sat 92 in 40% O 2 . Research and KT challenges and controversies Several areas for future research have been in dicated to improve and expand pain assessment in neonates and infants. Unanswered questions continue to be posed on the most optimal measurement approach as well as the feasibility a nd clinical utility of existing measures and indicators. Without seeing clinical benefi t o f pain assessment for the infants, there is little hope for engaging clini- cians in this m ost important aspect of quality patient care. Th ere is clear debate on the value and limit ations of unidimensional and multidimensional approaches to measurement and potential ways to resolve these issues. Pain is well entrenched within the biomedi- cal model of providing health care and future research needs to explore the infl uence of the context of pain ass essment in relation to individual (e.g. their capacity and sensitivity to detect pain in ot hers) and system (e.g. culture of unit, priority of pain manage- ment, leadership, timeline ss, busyness, expectations) factors that may infl uence assessing and management of pain. S trategies to facilitate the translation of what we \200\230know \200\231 into what we \200\230do \200\231 for infants and their families in relation to assessment and manage- me nt of pain is also lacking. KT strategies that include reminders, education and educational outreach, and audit and feedback need to be better incorporated into changing behaviors or health care professionals to enable pain practice changes and ultimately clinical outcomes . During rounds the next day, pain assessment of the baby was reviewed with the following discussion: 1. A pain assessment score should be completed on admission as per hospital pain guidelines . Clinicians need to think about pain as the \201 fth vital sign. Although the nurse was extremely busy, it was important to complete a pain score and inform the doctor that she su spected the baby was in pain with a validated pain score. 2. A morphine infusion could have been started prior to the OR to reduce the baby \200\231s pain. 3. Postoperative guidelines were reviewed and a plan for fre- quent monitoring of pain was posted at the bedside as per the guidelines. References Als , H. ( 1982 ). Towards a synactive theory of development: promise for the as sessment and support of infant individuality . Infant Ment Health J , 3 , 229 \200\223243. Als , H. , Lester , B. M. , Tronick , E. C. , and Brazelton , T. B. ( 1982 ). Manual for th e assessment of preterm infants \200\231 behavior (APIB) . Appendix to Als, H., Lester, B. M., Tronick, E. C., and Brazelton, T. B. Towards a research instrument for the assessment o f preterm infants \200\231 behavior. In H. E. Fitzgerald , B. M. Lester , and M. W. Yogman (eds) Th eory and research in behavioral pediatrics , Vol 1 , pp. 65 \200\223132. New York : Plenum Publishers . Ambuel , B. , Hamlett , K. W. , Marx , C. M. , and Blumer , J. L. ( 1992 ). Assessing distress in pediatric intensive care environments: the COMFORT scale . J Pediatr Psychol , 17 (1), 95 \200\223109. Summary Pain assessment in neonates and infants is complex and challeng- ing. Although a br oad variety of pain measures have been devel- oped and validated, many fall short of meetin g the needs of this population; especially those who are most vulnerable, preterm, ill, or cognitively or developmentally challenged. Lack of a gold stand- ard continues to plague pa in assessment in infants; yet clinically there is a need to use the best measures available to attempt opti- mal pain management. Biomarkers and cortical indicators are cur- rently b eing investigated to expand our understanding of pain and its eff ects in infants. Th e nee d to move beyond acute procedural American Academy of Pediatrics Committee on Fetus and Newborn, American Academy of Pediatri cs Section on Surgery, Canadian Pediatric Society Fetus and Newborn Committee , Batton , D. G. , Barrington , K. J. , and Wallman , C. ( 2006 ). Prevention and management of pain in the neonate: an update . [Erratum appears in Pediatrics , 2007; 119(2), 425]. Pediatrics , 118 (5), 2231 \200\2232241. SECTION 5 measurement of pain 368 American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Healt h. Task Force on Pain in Infants, Children and Adolescents. ( 2001 ). Th e assessment and m anagement of acute pain in infants, children, and adolescents . Pediatrics , 108 (3), 793 \200\223797. Faye , P. M. , De Jonckheere , J. , Logier , R. , Kuissi , E. , Jeanne , M. , Rakza , T. , et al . ( 2010 ). Newborn infant pain assessment using heart rate variability analysis . Cl in J Pain , 26 (9), 777 \200\223782. Franck , L. S. , and Bruce , E. ( 2009 ). Putting pain assessment into practice: why Anand , K. J. and International Evidence-Based Group for Neonatal Pain. ( 2001 ). Consensus statement for the prevention and management of pain in the newborn . Arch Pediatr Adolesc Med , 155 (2), 173 \200\223180. is it so painful? Pain Res Manag , 14 (1), 13 \200\22320. Franck , L. S. , Ridout , D. , Howard , R. , Peters , J. , and Honor , J. W. ( 2011 ). A co mparison of pain measures in newborn infants aft er cardiac surgery . Pain , 152 (8), 1758 \200\2231765. Association of Women \200\231s Health, Obstetric and Neonatal Nurses (AWHONN). ( 2002 ). As sessment and management of acute pain in the newborn \200\224 Web continuing education reso urce. Available at: < http://motherbaby. weebly.com/uploads/4/9/7/6/4976511/neonatal_pain.p df >. Gibbins , S. , Stevens , B. , Beyene , J. , Chan , P. C. , Bagg , M. , and Asztalos , E. ( 2008 a). Pain behaviors in extremely low gestational age infants . Early Hum Dev , 84 (7), 451 \200\223458. Australian and New Zealand Neonatal Network (ANZNN). ( 2007 ). Best practice clinical guide line assessment and management of neonatal pain . Sydney : ANZNN . Gibbins , S. , Stevens , B. , McGrath , P. , Dupuis , A. , Yamada , J. , Beyene , J. , et a l . ( 2008 b). Changes in physiological and behavioral pain indicators over time in preterm and term infants at risk for neurologic impairment . Early Hum Dev , 84 (11), 731 \200 \223738. Barrier , G. , Attia , J. , Mayer , M. N. , Amiel-Tison , C. , and Shnider , S. M. ( 1989 ) . Measurement of post-operative pain and narcotic administration in infants using a new cli nical scoring system . Intens Care Med , 15 (Suppl 1), S37 \200\22339. Grunau , R. E. , and Craig , K. D. ( 1987 ). Pain expression in neonates: facial action and cry . Pain , 28 (3), 395 \200\223410. Bartocci , M. , Bergqvist , L. L. , Lagercrantz , H. , and Anand , K. J. ( 2006 ). Pain act ivates cortical areas in the preterm newborn brain . Pain , 122 (1 \200\2232), 109 \200 \223117. Grunau , R. E. , Tu , M. T. , Whitfi eld , M. F. , Oberlander , T. F. , Weinberg , J. , Yu , W. , et al . ( 2010 ). Cortisol, behavior, and heart rate reactivity to immunization pain at 4 months corrected age in infants born very preterm . Clin J Pain , 26 (8), 698 \200 \223704. Bellieni , C. , Maff ei , M. , Ancora , G. , Cordelli , D. , Mastrocola , M. , Faldella , G . , et al . ( 2007 ). Is the ABC pain scale reliable for premature babies? Acta Paediatr , 96 (7), 1008 \200\2231010. Guinsburg , R. , Kopelman , B.I. , Anand , K.J. , De Almeida , M.F. , Peres Cde , A. and Mi yoshi , M.H. ( 1998 ). Physiological, hormonal, and behavioral responses to a single fentan yl dose in intubated and ventilated preterm neonates . J Pediatr , 132 (6), 954 \200\22395 9. Bellieni , C. V. , Bagnoli , F. , Sisto , R. , Neri , L. , Cordelli , D. , and Buonocore , G. ( 2005 ). Development and validation of the ABC pain scale for healthy full-term babies . Acta Paediatr , 94 (10), 1432 \200\2231436. Hartwig , S. , Roth , B. , and Th eisohn , M. ( 1991 ). Clinical experience with continuous intravenous sedation using midazolam and fentanyl in the pediatric intensive care unit . E ur J Pediatr , 150 , 784 \200\223788. Blauer , T. and Gerstmann , D. ( 1998 ). A simultanous comparison of three neonatal pain sc ales during common NICU procedures . Clin J Pain , 14 (1), 39 \200\22347. Herr , K. , Coyne , P. J. , Key , T. , Manworren , R. , McCaff ery , M. , Merkel , S. , et al . ( 2006 ). Pain assessment in the nonverbal patient: position statement with clinical p ractice recommendations . Pain Manage Nurs , 7 (2), 44 \200\22352. Brummelte , S. , Grunau , R. E. , Chau , V. , Poskitt , K. J. , Brant , R. , Vinall , J. , et al . ( 2012 ). Procedural pain and brain development in premature newborns . Ann Neurol , 71 , 385 \200\223396. Buchholz , M. , Karl , H. W. , Pomietto , M. , and Lynn , A. ( 1998 ). Pain scores in infan ts: a modifi ed infant pain scale versus visual analog . J Pain Symptom Manage , 15 (2), 11 7 \200\223124. Hodgkinson , K. , Bear , M. , Th orn , J. , and Van Blaricum , S. ( 1994 ). Measuring pain in neonates: evaluating an instrument and developing a common language . Aust J Adv Nurs , 12 (1), 17 \200\22322. Buttner , W. and Finke , W. ( 2000 ). Analysis of behavioral and physiological parameters f or the assessment of postoperative analgesic demand in newborns, infants and young children : a comprehensive report on seven consecutive studies . Paediatr Anaesth , 10 (3), 303 \200\223318. Holsti , L. and Grunau , R. E. ( 2010 ). Considerations for using sucrose to reduce procedu ral pain in preterm infants . Pediatrics , 125 (5), 1042 \200\2231047. Holsti , L. and Gru nau , R. E. ( 2007 a). Initial validation of the Behavioral Indicators of Infant Pain (BIIP) . Pain , 132 (3), 264 \200\223272. Carbajal , R. , Lenclen , R. , Jugie , M. , Paupe , A. , Barton , B. A. , and Anand , K. J. S. ( 2005 ). Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates . Pediatrics , 115 (6), 1494 \200\2231500. Holsti , L. , Weinberg , J. , Whitfi eld , M. F. , and Grunau , R. E. ( 2007 b). Relationsh ips between adrenocorticotropic hormone and cortisol are altered during clustered nursing c are in preterm infants born at extremely low gestational age . Early Hum Dev , 83 (5), 341 \200\223348. Carbajal , R. , Paupe , A. , Hoenn , E. , Lenclen , R. , and Olivier-Martin , M. ( 1997 ). [APN: evaluation behavioral scale of acute pain in newborn infants] . Arch Pediatrie , 4 (7 ), 623 \200\223628. Horgan , M. and Choonara , I. ( 1996 ). Measuring pain in neonates: an objective score . Paediatr Nurs , 8 (10), 24 \200\22327. Horgan , M. F. , Glenn , S. , and Choonara , I. ( 2002 ). Further development of the Liverp ool Infant Distress Scale . J Child Health Care , 6 (2), 96 \200\223106. Cignacco , E. , Denhaerynck , K. , Nelle , M. , Buhrer , C. , and Engberg , S. ( 2009 ). Va riability in pain response to a non-pharmacological intervention across repeated routine pa in exposure in preterm infants: a feasibility study . Acta Paediatr , 98 (5), 842 \200\223 846. Hudson-Barr , D. , Capper-Michel , B. , Lambert , S. , Palermo , T. M. , Morbeto , K. , and Lombardo , S. ( 2002 ). Validation of the Pain Assessment in Neonates (PAIN) scale with th e Neonatal Infant Pain Scale (NIPS) . Neonatal Netw , 21 (6), 15 \200\22321.