COSMIN database

A systematic integrative review of infant pain assessment tools

Duhn, L. J. and Medves, J. M.
PURPOSE: To examine the issue of pain assessment in infants by acquiring all available published pain assessment tools and evaluating their reported reliability, validity, clinical utility, and feasibility.

DESIGN AND METHODS: A systematic integrative review of the literature was conducted using the following databases: MEDLINE and CINAHL (through February 2004), and Health and Psychosocial Instruments, and Cochrane Systematic Reviews (through 2003). MeSH headings searched included "pain measurement," with limit of "newborn infant"; "infant newborn"; and "pain perception."

SUBJECTS: Thirty-five neonatal pain assessment tools were found and evaluated using predetermined criteria. The critique consisted of a structured comparison of the classification and dimensions measured. Further, the population tested and reports of reliability, validity, clinical utility, and feasibility were reviewed.

RESULTS: Of the 35 measures reviewed, 18 were unidimensional and 17 were multidimensional. Six of the multidimensional measures were published as abstracts only, were not published at all, or the original work could not be obtained. None of the existing instruments fulfilled all criteria for an ideal measure; many require further psychometric testing.

CONCLUSIONS: When choosing a pain assessment tool, one must also consider the infant population and setting, and the type of pain experienced. The decision should be made after carefully considering the existing published options. Confidence that the instrument will assess pain in a reproducible way is essential, and must be demonstrated with validity and reliability testing. Using an untested instrument is not recommended, and should only occur within a research protocol, with appropriate ethics and parental approval. Because pain is a multidimensional phenomenon, well-tested multidimensional instruments may be preferable.
Adv Neonatal Care
1536-0903 (Print)
Publication year:
Symptom status:
Physical state
Children (0-18)
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
PRO / non-PRO:
Non-patient Reported Outcome
Type of measurement instrument:
6 - Clinical rating scales
7 - Observations
APN - Acute Pain Rating Scale for Neonates
BCSS - Basic Clinical Scoring System
BPS - Behavioural Pain Scale
CHIPPS - Children’s and Infants’ Postoperative Pain Scale
COMFORT Scale    
CRIES - Crying Requires oxygen Increased vital signs Expression Sleep   
DAN - Douleur Aigue du Nouveau-né
DSVNI - Distress Scale for Ventilated Newborn Infants (DSVNI)
EDIN - Échelle Douleur Inconfort Nouveau-Né (= Neonatal Pain and Discomfort Scale)   
FACS - Facial Action Coding System (versions: Baby FACS)
IBCS - Infant Body Coding System (versions: IBCS NAPE)
IPEC - Infant Pain Evaluation Criteria
LIDS - Liverpool Infant Distress Scale
MAX - Maximally Discriminative Facial Movement Coding System Revised version
MBPS - Modified Behavioral Pain Scale
Mills Infant/Toddler Pain Index
MIPS - Modified Infant Pain Scale
modified PCS - Modified Postoperative Comfort Score
NFCS - Neonatal Facial Coding System   
NIPS - Neonatal Infant Pain Scale   
NPAS - Neonatal Pain Assessment Scale
N-PASS - Neonatal Pain, Agitation, & Sedation Scale   
Objective Pain Scale
Pain Assessment Tool
Pain/ Discomfort Scale
PAIN - Pain Assessment Inventory for Neonates
PRS - Pain Rating Scale
RIPS - Riley Infant Pain Scale
SUN - Scale for Use in Newborns
Wielenga Observation Scale for Pain in Neonates