Pain Assessment and Management (Neonatal)

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    Pain Assessment and Management (Neonatal) - CE/NCPD

    The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.


    Pain assessment instruments do not replace clinical judgment. Assess the patient’s pain status using a validated, developmentally appropriate pain scale.

    Both behavioral and physiologic pain indicators may be decreased or absent in certain patients (e.g., those who are neurologically impaired, extremely premature, or on neuromuscular blocking agents).


    All neonatal patients experience pain and therefore require pain prevention or management. High-risk preterm and medically unstable neonatal patients are subjected to multiple painful procedures while in the neonatal intensive care unit (NICU) because of their physiologic variability and disease processes. Their care frequently requires painful procedures (e.g., heel sticks; peripheral venous lines; nasal, oral, and tracheal suctioning; arterial lines; endotracheal intubation; chest tubes; lumbar punctures).

    A thorough assessment of pain includes both physiologic and behavioral cues.undefined#ref2">2 Physiologic pain cues may include changes in heart rate, respiratory rate, oxygen saturation, and blood pressure. Behavioral pain cues may include altered facial expressions, change in activity level, agitation, and crying.3 Extremely immature, fragile patients and chronically ill patients who have been exposed to repeated painful experiences have difficulty generating a pain response. Caution should be taken not to interpret this response as an indication that the patient is not in pain.

    Many different pain assessment instruments are available. Pain assessment instruments should be chosen based on reliability and validity testing, neonatal population and developmental age, and ease of use (Table 1)Table 1.3 One reliable and valid instrument available for the preterm neonate is the Premature Infant Pain Profile (PIPP).2 This instrument has been used to assess procedural as well as surgical pain, has been repeatedly validated, and is unique because it includes contextual (gestational age), physiologic, and behavioral states.3

    Pain management is multimodal and consists of pharmacologic and nonpharmacologic interventions. Nonpharmacologic interventions include thoughtful planning of care, prevention of pain, and behavioral measures. Planning of care involves the clustering of interventions to allow the patient adequate rest periods. Prevention measures include reducing the total number of painful procedures the patient is exposed to by evaluating all aspects of care, such as minimizing tape and adhesives on the skin as much as possible, grouping laboratory tests and diagnostic procedures, ensuring premedication before painful procedures, and avoiding performing painful procedures and routine care at the same time. For example, if the diaper is changed while removing tape from the skin, the patient may begin to perceive the diaper change as a painful procedure.3 Facilitated tucking, swaddling, nonnutritive sucking or breastfeeding, skin-to-skin care, and oral sucrose administration are all examples of nonpharmacologic interventions to reduce pain.3

    Pharmacologic approaches to pain management should be used when moderate, severe, or prolonged pain is assessed or anticipated. Adverse effects of pain medication must be considered when managing pain. Pharmacologic approaches to analgesia include the use of opioids for severe pain, nonopioid analgesia for mild to moderate pain, and topical therapy. When sedatives or neuromuscular blocking agents are used, the patient’s pain must be managed proactively because these medications suppress the behavioral expression of pain, but do not treat it.3

    Untreated or undertreated pain may cause both short- and long-term adverse consequences. Short-term consequences may include increased heart rate, increased oxygen requirements, and oxygen desaturation.3 Long-term consequences may include depressed immune response and altered neurodevelopmental, social, and emotional function.3

    Collaborating with the family members will give insight into their perception of the neonatal patient’s behavior and expressions of pain. Communication with the family and other health care team members is essential for a comprehensive assessment, which allows for provision of the best possible pain relief for the patient.


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    • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
    • If a painful procedure is scheduled, explain the procedure to the family before beginning it.
    • Explain to the family the behavioral and physiologic cues that indicate the patient is in pain.
    • Explain that consistent and accurate assessments of pain are necessary to treat the patient’s pain appropriately.
    • Select an appropriate pain scale and explain how it is used.
    • Provide information about the physiological and psychological effects of undertreated pain.
    • Educate the family about nonpharmacologic and pharmacologic interventions their neonate may receive and how pain may be reassessed.
    • Encourage the family to participate in nonpharmacologic pain relief for their neonate.
    • Explain and demonstrate nonpharmacologic techniques that the family can use to help with pain management.
    • Explain changes in the patient’s pain management plan as they occur.
    • Encourage questions and answer them as they arise.



    1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
    2. Introduce yourself to the family and caregivers.
    3. Verify the correct patient using two identifiers.
    4. Review the patient’s record for factors that may influence response to pain, including gestational age, illness severity, sleep and wake states, response to previous painful procedures, and previous handling.
      Rationale: Developmental maturity, illness severity, and sleep states may cause the patient to have a subtle reaction to pain.3
    5. Assess the family’s understanding of pain cues for the high-risk preterm and medically unstable patient (Figure 1)Figure 1.
    6. Determine the family’s cultural and religious beliefs about pain.
    7. Determine the family’s ability to participate in nonpharmacologic pain management techniques.


    1. Select and obtain a developmentally appropriate and organization-approved pain scale.


    1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
    2. Verify the correct patient using two identifiers.
    3. Explain the procedure to the family and ensure that they agree to treatment.
    4. Determine if the procedure to be performed is likely to result in pain (e.g., IV injection, heel stick, gastric tube placement, suctioning, urinary catheterization, tape removal, lumbar puncture, percutaneous line insertion, intubation or extubation, chest tube insertion or removal, intramuscular injection, circumcision, eye examination).
      Cluster painful procedures together throughout the day to minimize the patient’s daily painful experiences.3
    5. Assess the patient, including vital signs, percentage of oxygen delivered, and oxygen saturation.
      Rationale: Although vital signs are not specific to pain alone, baseline measurements of vital signs, oxygen usage, and oxygen saturation are helpful because these parameters may increase or decrease based on the patient’s individual response to pain.
      A valid pain assessment tool is not available for patients receiving a neuromuscular blocking agent.1 Assume pain is present and provide analgesic measures.
    6. Assess the patient’s pain status using a validated, developmentally appropriate pain scale (Table 1)Table 1.
    7. If appropriate, provide or support nonpharmacologic interventions (e.g., swaddling, nonnutritive sucking, sucrose, facilitated tuck, decreased lights, decreased noise, positioning, skin-to-skin contact, breastfeeding, breast milk) for all painful procedures.
    8. Administer ordered pharmacologic interventions.
    9. Reassess the patient’s pain status, allowing for sufficient onset of action per the medication, route, and the patient’s condition. Assess for adverse reactions to the medication (e.g., respiratory depression).
      Be aware that pain scores should return to the preprocedure baseline after a painful procedure. If pain scores do not return to baseline, follow up with nonpharmacologic and pharmacologic interventions as needed and as ordered, then reassess the patient for pain. If the patient remains in pain, notify the practitioner.
    10. Discard supplies, remove PPE, and perform hand hygiene.
    11. Document the procedure in the patient’s record.


    1. Monitor the patient’s physiologic stability.
      Rationale: Changes in the patient’s vital signs may indicate that the patient is in pain.
      Notify the practitioner of bradycardia, tachycardia, increased temperature, apnea, and desaturation.
    2. Monitor the patient’s behavioral cues.
    3. Assess, treat, and reassess pain.
    4. Monitor the patient’s sleep patterns and ability to self-calm.
      Rationale: Periods of calm and adequate sleep result in improved weight gain and duration of rapid eye movement sleep. The ability to self-calm promotes self-regulation and tolerance of painful procedures.
      Notify the practitioner of the patient’s need for extended time to recover after painful procedures and of poor weight gain.


    • Adequate pain management achieved for the patient
    • Stable vital signs
    • Family understanding of pain assessment and pain-management plan of care
    • Discussion of pain-management plan among providers


    • Inadequate pain management
    • Unstable vital signs
    • Oversedation or undersedation
    • Family misunderstanding of the pain-management plan of care
    • No discussion of pain-management plan among providers


    • Education
    • Pain assessment instrument used and pain score (assessment and reassessments)
    • Nonpharmacologic interventions (time, type)
    • Pharmacologic interventions (time, dose level, route, side effects)
    • Response to nonpharmacologic and pharmacologic interventions
    • Changes to pain management plan
    • Unexpected outcomes and related interventions


    1. Devsam, B.U., Kinney, S. (2021). The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates. Australian Critical Care, 34(4), 333-339. doi:10.1016/j.aucc.2020.09.005 (Level V)
    2. Hellsten, M. (2022). Chapter 5: Pain assessment and management in children. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 114-147). St. Louis: Elsevier.
    3. Walden, M. (2021). Chapter 16: Pain assessment and management. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 270-287). St. Louis: Elsevier. (Level VII)


    Carachi, P., Williams, G. (2020). Acute pain management in the neonate. Anaesthesia & Intensive Care Medicine, 21(2), 99-104. doi:10.1016/j.mpaic.2019.11.006

    Maxwell, L.G., Fraga, M.V., Malavolta, C.P. (2019). Assessment of pain in the newborn: An update. Clinics in Perinatology, 46(4), 693-707. doi:10.1016/j.clp.2019.08.005

    Elsevier Skills Levels of Evidence

    • Level I - Systematic review of all relevant randomized controlled trials
    • Level II - At least one well-designed randomized controlled trial
    • Level III - Well-designed controlled trials without randomization
    • Level IV - Well-designed case-controlled or cohort studies
    • Level V - Descriptive or qualitative studies
    • Level VI - Single descriptive or qualitative study
    • Level VII - Authority opinion or expert committee reports

    Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

    Published: February 2024

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