Pain management in the hospitalized infant.

Ask the Expert provides research-based answers to practice questions submitted by JSPN readers.

Question: Due to a recent reconfiguration of our nursing division, we are now caring for infants admitted with medical and surgical diagnoses. The nursing staff is unfamiliar with how to assess and manage pain in this nonverbal population. What are current recommendations for providing comfort for hospitalized infants?

Diane Hudson responds: Great progress has been made over the past 20 years in improving the assessment and management of pain in the pediatric population. Identification of pain in infants has been uniquely challenging, as infants cannot put their pain experiences into words, which is considered to be the single most reliable indicator of the existence/intensity of acute pain (Acute Pain Management Guideline Panel [APMGP], 1992). Researchers and clinicians have been challenged to identify other cues exhibited by infants to express their pain experiences.

Infants are believed to communicate their pain experiences via physiological and behavioral cues. Physiological indicators include tachycardia, increased blood pressure, pallor, sweating, increased respiratory rate, decreased oxygen saturation, and metabolic changes (APMGP, 1992). These physiological cues also can occur in non-pain situations and vary greatly between individual infants. The Acute Pain Management Guideline Panel recommended these cues should be used only as an adjunct to the clinical context and other methods of assessment. Behavioral observation has been recommended as the primary pain assessment method for the nonverbal child. Negative facial expressions (including frowns, grimaces, a strongly negative face), crying, and intense body movements (including kicking, thrashing, limb/trunk rigidity, or withdrawal of affected area) are the three categories of behaviors identified in studies of minor procedural and post-operative pain in infants (APMGP, 1992; Hester, 1994; Hudson, Duffey, Holditch-Davis, Funk, & Frauman, 1996). Mills (1989) found these three categories (as well as changes in interaction and self-consolation behaviors) to remain constant for the 0-3, 3-6, 6-9, and 9-12-month-old infant, but, as the infant matures, more behaviors were seen in each category. Those behaviors seen at younger ages …