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P. , American Academy of Pediatrics Committee on Pediatric E mergency Medicine, and Section on Anesthesiology and Pain Medicine. ( 2004 a). Relief of pa in and anxiety in pediatric patients in emergency medical systems . Pediatrics , 114 , 1348 \200\2231356. This page intentionally left blank SECTION 5 Measurement of pain This page intentionally left blank CHAPTER 35 Neonatal and infant pain assessment Grace Y. Lee and Bonnie J. Stevens Introduction Pain assessment in neonates and infants is challenging. Although clinicians an d scientists have benefi ted from impressive increases in research on developmental neurobi ology, behavior, and physiol- ogy of infant pain capabilities and responses, there is no \200\230gold stand- ard \200\231 infant pain indicator, measure, or approach. Th erefore, p ain is inferred from the observed responses. Th ese responses are not eas- ily interpretabl e as they are: (1) modifi ed by contextual factors (e.g. previous experience with pain) and individual infant characteristics (e.g. gestational age (GA), postnatal age (PNA), gender, health sta- tus); (2) dependent on the attitudes, beliefs, knowledge, and obser- vational skills of care providers; and (3) reliant on the availability of psychometrically sound ass essment measures. Inferring pain is not unique to infants; in adults, for example, self-rep ort is not a direct unbiased measure of this subjective phenomenon \200\224rather it is inf l uenced by a multiplicity of factors and is thus, an indirect measure. In fact, some would suggest that no direct measure of pain has been validated to date. Conceptualization of pain in neonates and infants Pain and nociception Pain is an elusive p henomenon that poses unique measurement challenges. For adults, pain measurement usually en compasses the verbal response of the individual experiencing it. However, the inability to communicate verbally does not preclude the individual from pain or negate their need for pa in-relieving treatment; thus, behavioral and physiological indicators are commonly used as proxies in assessing pain in infants. However, due to the infant \200\231s developmental st age and associated vulnerability, they are com- pletely dependent on their caregivers to ob serve and interpret these indicators. Th eir expression of pain and experience are intrinsi cally intertwined with the caregiver and the sociocultural context in which pain is experie nced. Pain is oft en conceptualized within the biomedical model of care where the focus is on the sensory processes of nociception and the transmission of signals originating from peripher al nociceptors to receptors in the brain. Th is model is limited in understanding pain in i nfants and is an incomplete representation of pain in humans (Sullivan, 2008 ). Given the i mportance attributed to the psycho- social context and the processes of development and int eraction with the infant \200\231s environment, theories such as the systems-based synactiv e theory of development (Als, 1982 ) and the social commu- nication model (SCM) of infant p ain (Craig, 2009 ) are extremely relevant. Pain assessment is an essential foundation for instituting pain relieving interventions to mitigate pain and its consequences in the developing child. Eff ective pain management is f requently con- sidered an indicator of quality health care practice (Sidani, 2003 ). Th ere fore, accurate, timely and feasible pain assessment needs to be featured in policies, guide lines, and procedures at the institutional and policy implementation levels. However, the m easurement of pain in neonates and infants may be imprecise and inadequate. Th is dilemma b egs the question as to whether it is possible to develop the perfect measure for this popul ation. In the meantime, we advo- cate using the best measures available while addressing th e existing measurement issues. Th e synactive theory of development Th e synactive theory of development (Als, 1982 ) focu ses on the evolving, continuous, and dynamic relationship between key sub- systems within t he developing infant organizational structure (e.g. autonomic, motor, state organizational, attentional-interactive, and self-regulatory) and salient aspects of the environment. Als asserts that the infant alternates between stabilizing (e.g. smooth well-regulated function ing) and integrating responses to facilitate functional competence. Th e caregiver \200\231 s role is to protect the infant (especially preterm newborns) against external sources of s tress and mitigating its eff ects. Th e Neonatal Individualized Developmental Th is chapter encompasses: (1) the conceptualization of infant pain within a particular bio psychosocial and developmental con- text; (2) a comprehensive evaluation of existing neonat al/infant pain assessment measures and indicators (e.g. biomarkers and cortical indicators) ; (3) integration of recommendations on pain assessment measures and practices within clini cal practice guide- lines, policies, and procedures; and (4) challenges associated with neo natal and infant pain assessment in terms of research, clinical and knowledge translation ( KT) issues. SECTION 5 measurement of pain 354 Care and Assessment (NIDCAP) program with a central focus on the social processes involved in protecting and maintaining the stability of the infant within a particular external envi ron- ment has evolved from this theory. Th e Assessment of Preterm Infants \200\231 Behavio r (APIB) instrument (Als et al., 1982 ) provides a systematic profi le for assessing the in dividual infant \200\231s behavioral cues as a measure of their system capacity and regulat ory abilities. Preventing and/or minimizing stressful procedures, assisting the infant to m aintain and regulate organized behavioral state and instituting developmentally specifi c s trategies to mitigate the eff ects of stressful events are hallmark interventions. Th ese p hysical (e.g. positioning, bundling), tactile (e.g. kangaroo care, non-nutritive sucking), and behavioral (e.g. distraction) strategies are also used as pain-relieving interventions. determining behavioral and physiological responses; multidimen- sional and composite measur es are almost exclusively comprised of indicators from acute pain studies. A typical behavi oral response depicting the behavioral facial action acute pain response in infants is show n in Figure 35.1 . Chronic pain is frequently defi ned as pain that has persisted beyond th e normal tissue healing time. However, the temporal delineation of \200\230healing time \200\231 is debated as somewhere between 3 and 6 months. Th e temporal delineation presents additional dilemmas when consider- ing prolonged pain in infants. In addition to the issue of total life span, which may be less than 3 or 6 months, infants have limited time com- p rehension abilities and cannot fully appreciate past, present, and future or process inform ation in a moment by moment fashion. Researchers have largely ignored chronic pain assessme nt and its complexities in infants focusing almost exclusively on acute pain, with only a f ew meas- ures addressing this more prolonged phenomenon (see Table 35.1 ). Th e social communication model of pain Th e SCM (Craig, 2009 ) promotes understanding of t he complex interactions between biological, psychological, and social features of pain. Cra ig asserts that pain is a sequence of complex interde- pendent stages, characterized by fee dback loops among sequential stages. Assessing infant pain is construed as a dynamic, inter active process between child and caregiver (e.g. health professional, fam- ily or others) w ho are uniquely infl uenced by family, community, and culture. Infants almost invariably re act to acute tissue stress and damage in a manner that distinguishes \200\230pain \200\231 from \200\230non-pain \200\231 states. Th ese reactions provide a means for caregivers to decode the pain expression and infer the infant \200\231s subjective state from biologi- c al and behavioral correlates. Unidimensional versus multidimensional Infant pain measures can also be classifi ed as eith er unidimensional (one global item or a multiple items within a single domain) or multidime nsional (multiple items with multiple domains/compos- ite measures) where dimension refers to an aspect of a phenomenon and domain is the set of possible dimensions within the phenom e- non. Applying these defi nitions to pain, unidimensional single item measures capture on e dimension of the experience (e.g. visual ana- logue scale capturing pain intensity) where as unidimensional sin- gle domain measures include: (1) multiple items (e.g. brow bulge, ey e squeeze) from a single domain (e.g. facial expression) within a single dimension (e.g. be havioral), for example, the Neonatal Facial Coding System (Grunau and Craig 1987 ); or (2) multiple items (e.g. brow bulge, hand movement, high pitch cry) from mul- tiple domains (e. g. facial expression, movement, cry) within a sin- gle dimension (e.g. behavioral), for exa mple, Douleur Aigue du Nouveau-ne (Carbajal et al., 1997 ). Th is model is unique in its focus on interaction with the caregiver encompassing their cog nitive and aff ective capabilities that support complex social interactions and processes. Once pain is expressed by the infant, caregivers interpret that the infant is in pain. Th i s attribution of pain is infl uenced by the caregiver \200\231s (1) sensitivities, (2) know ledge level (e.g. of the specifi c child or alternatives to dis- tress), (3) attitudes and beliefs, and (4) prior relationship to the child. Th e stage is then set for implementing a nd evaluating pain- relieving interventions. Multidimensional (composite) measures include multiple items (e.g. brow bulge, heart rate, gestational age) from multiple domains (e.g. facial expression, biomarker,) within multiple dimensions (e.g. behavioral, physiological,), such as the Premature Infant Pain Profi le ( Stevens et al., 1996 ). Th e issue of combining dimensions in multi- dimensional measures i s frequently raised by measurement critics, who suggest mixing poorly correlated dimensions in total scores is unjustifi ed and may lead to ineff ective or incomplete management. Con versely, proponents suggest dissociation between indicators is common in a complex entity a nd therefore taking all dimensions into account is necessary to capture the full scope of t he phenomenon for well-informed decision-making (McDowell, 2006 ). While the SCM of infant pain addresses the broader context of pain, our current knowledge i s primarily centered on acute tissue- damaging or nociceptive pain, with little clarity on the infant \200\231s experience and expression of more prolonged acute (e.g. postoper- ativ e), persistent (e.g. recurrent), or chronic pain. Th is understand- ing is important as the basis for the development and validation of pain assessment indicators and measures in the se domains. A more detailed exploration of the SCM is provided by Pillai Riddell et al. ( C hapter 9 , this volume). Existing neonatal and infant pain measures Approximately four dozen measures have been deve loped to assess pain in neonates and infants over the past three decades. Several have been extensively validated, although their feasibility and clinical utility are infrequently ad dressed. Th e most well-validated measures are multidimensional behavioral indicators or co mpos- ite measures. Only a few measures incorporate individual infant characteristics or co ntextual factors. Furthermore, the current body of neonatal pain measures is comprised of a narrow and fi nite cadre of behavioral and physiological items. Recommendations to expand this repertoire and to explore potential new indicators Pain assessment measures and indicators Acute versus chronic Neonatal and infant pain asses sment measures have been devel- oped for both acute and chronic pain. Acute pain signals a specifi c nociceptive event, injury, or illness, is usually of sudden onset, and is limited to a short period of time. Acute pain typically subsides with eff ective management aft er the painful event (e.g. heel lance) or when the illness or injury resolves; it can be pers istent and re- occur in multiple episodes over time. Most research on infant pain assessmen t has used tissue damaging stimuli as the paradigm for CHAPTER 35 neonatal and infant pain assessment 355 (a) (b) (c) (d) Figure 35.1 Example of a typical behavioral response depicting the behavioral facial action acute pain response in infants. (e.g. cortical indices) or biomarkers (e.g. cortisol) and their rela- tionship to observed behavioral indicators have only recently been considered. A critical appraisal of unidimens ional and multi- dimensional neonatal and infant pain measures with demonstrated reliabilit y and validity is summarized in Table 35.1 .