title: Identification of pain indicators for infants at risk for neurological impairment: a Delphi consensus study.
abstract: BACKGROUND
  A number of infant pain measures have been developed over the past 15 years incorporating behavioural and physiologic indicators; however, no reliable or valid measure exists for infants who are at risk for neurological impairments (NI). The objective of this study was to establish consensus about which behavioural, physiologic and contextual indicators best characterize pain in infants at high, moderate and low levels of risk for NI.
  
  
  METHODS
  A 39- item, self-administered electronic survey that included infant physiologic, behavioral and contextual pain indicators was used in a two round Delphi consensus exercise. Fourteen pediatric pain experts were polled individually and anonymously on the importance and usefulness of the pain indicators for the 3 differing levels of risk for NI.
  
  
  RESULTS
  The strength of agreement between expert raters was moderate in Round 1 and fair in Round 2. In general, pain indicators with the highest concordance for all three groups were brow bulge, facial grimace, eye squeeze, and inconsolability. Increased heart rate from baseline in the moderate and severe groups demonstrated high concordance. In the severe risk group, fluctuations in heart rate and reduced oxygen saturation were also highly rated.
  
  
  CONCLUSIONS
  These data constitute the first step in contributing to the development and validation of a pain measure for infants at risk for NI. In future research, we will integrate these findings with the opinions of (a) health care providers about the importance and usefulness of infant pain indicators and (b) the pain responses of infants at mild, moderate and high risk for NI.
authors.affiliation: Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada. b.stevens@utoronto.ca
authors.forename: Bonnie
authors.initials: B
authors.lastname: Stevens
authors.forename: Patrick
authors.initials: P
authors.lastname: McGrath
authors.forename: Janet
authors.initials: J
authors.lastname: Yamada
authors.forename: Sharyn
authors.initials: S
authors.lastname: Gibbins
authors.forename: Joseph
authors.initials: J
authors.lastname: Beyene
authors.forename: Lynn
authors.initials: L
authors.lastname: Breau
authors.forename: Carol
authors.initials: C
authors.lastname: Camfield
authors.forename: Allen
authors.initials: A
authors.lastname: Finley
authors.forename: Linda
authors.initials: L
authors.lastname: Franck
authors.forename: Alexandra
authors.initials: A
authors.lastname: Howlett
authors.forename: Celeste
authors.initials: C
authors.lastname: Johnston
authors.forename: Patricia
authors.initials: P
authors.lastname: McKeever
authors.forename: Karel
authors.initials: K
authors.lastname: O'Brien
authors.forename: Arne
authors.initials: A
authors.lastname: Ohlsson
mesh_terms: D001291:Attitude of Health Personnel; D003697:Delphi Technique; D006801:Humans; D007223:Infant; D018730:Infant Behavior; D009422:Nervous System Diseases / Q000209:etiology*; D010147:Pain Measurement / Q000379:methods*; D011795:Surveys and Questionnaires