title: Indicators of pain in neonates at risk for neurological impairment.
abstract: OBJECTIVE
  This paper is a report of a study to compare the importance and usefulness ratings of physiological and behavioural indicators of pain in neonates at risk for neurological impairment by nurse clinicians and pain researchers.
  
  
  BACKGROUND
  Neonates at risk for neurological impairment have not been systematically included in neonatal pain measure development and how clinicians and researchers view pain indicators in these infants is unknown.
  
  
  METHODS
  Data triangulation was undertaken in three Canadian Neonatal Intensive Care Units using data from: (a) 149 neonates at high, moderate and low risk for neurological impairment, (b) 95 nurse clinicians from the three units where infant data were collected and (c) 14 international pain researchers. Thirteen indicators were assessed following heel lance in neonates and 39 indicators generated from nurse clinicians and pain researchers were assessed for importance and accuracy. Data were collected between 2004 and 2005.
  
  
  RESULTS
  Across risk groups, indicators with the highest accuracy for discriminating 'pain' among neonates were: brow bulge (77-83%), eye squeeze (75-84%), nasolabial furrow (79-81%), and total facial expression (78-83%). Correlations between nurse ratings and neonatal accuracy scores ranged from moderate to none (mild risk r = 0.52, P = 0.07; moderate r = 0.43, P = 0.15; high r = -0.12, P = 0.69). Researchers demonstrated a better understanding of the importance of pain indicators (mild risk, r = 0.91, P < 0.001; moderate 0.85, P < 0.001; 0.0002; high r = 0.64, P = 0.019) than nurse clinicians.
  
  
  CONCLUSIONS
  Facial actions were rated as the most important indicators of neonatal pain. However, as neurological impairment risk increased, physiological indicators were rated more important by nurse clinicians and pain researchers, opposite to pain indicators demonstrated by neonates.
authors.affiliation: The Hospital for Sick Children, 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: Annie
authors.initials: A
authors.lastname: Dupuis
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: Gordon Allen
authors.initials: GA
authors.lastname: Finley
authors.forename: Linda S
authors.initials: LS
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
authors.forename: Janet
authors.initials: J
authors.lastname: Yamada
mesh_terms: D002170:Canada; D005149:Facial Expression; D006801:Humans; D018730:Infant Behavior / Q000502:physiology*; D007231:Infant, Newborn; D007234:Infant, Premature / Q000502:physiology*; D015931:Intensive Care, Neonatal; D009422:Nervous System Diseases / Q000175:diagnosis; D010146:Pain / Q000175:diagnosis* / Q000209:etiology; D010147:Pain Measurement / Q000379:methods / Q000592:standards*; D012307:Risk Factors