Within the last decade, it has been clearly demonstrated that newborns are capable of perceiving pain from procedures such as heel sticks, circumcision, and other invasive procedures. Both physiologic and behavioral parameters associated with neonatal pain have been well documented in the literature. A number of tools to evaluate children's pain have been developed and are currently in use throughout the United States and Europe. Among those are the Objective Pain Scale (OPS), developed primarily to measure pain in older preverbal children; the Neonatal Infant Pain Scale (NIPS), designed to document neonates' pain responses to invasive procedures; the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), developed to measure pain responses in children from ages one to seven; the postoperative pain scale (POPS) developed by Attia (1987); and the CRIES postoperative pain scale. These tools have enabled bedside nurses, clinicians, and practitioners to objectively document neonatal pain responses to painful procedures and implement appropriate therapeutic management. While it is significant that these tools have been developed, it is imperative that nurses continue to objectively evaluate each tool's usage regarding the appropriate age group and situation.
The CRIES tool, according to published reports, has been significantly well received by nurses and physicians working with neonates, and has demonstrated a high reliability for assessing neonatal postoperative pain with relative ease. CRIES, an instrument designed to be similar to the "Apgar," was designed for the specific purpose of reliably measuring infant pain responses in the postoperative period. The five parameters represented are as follows: C-crying; R-requires oxygen to maintain saturation greater than 95%; I-increased vital signs; E-expression; and S-sleepless. The maximum score of 10 points is calculated in a similar manner as the Apgar score -- a score of four or more represents pain requiring intervention to reduce pain and maintain comfort. Initial validity for CRIES was established by comparing it to the OPS pain scale. In addition, reliability and validity were established by measuring pain after administering analgesics, with a significant decrease in measured pain observed following treatment. Nurses in the study preferred the CRIES scale over the OPS scale for ease of use. The researchers concluded that the CRIES postoperative pain assessment scale was a valid and reliable measure of postoperative pain in neonates 32 to 60 weeks gestation.
Possible weaknesses of the study include the use of the oxygen requirement, which may be affected by respiratory conditions unrelated to pain; lack of blood pressure measurement, which can be highly variable postoperatively due to a number of conditions other than pain; and the limited usefulness of the tool in measuring pain in neonates who remain intubated and/or paralyzed postoperatively. However, in comparison with other scales, the CRIES tool has increased the potential for better managing postoperative and procedural pain in small, weak infants who otherwise may not have received any analgesic or been undermedicated for pain. The researchers further developed a vital sign form to accompany each infant's chart, incorporating the CRIES scale to effectively evaluate the status of each child postoperatively.
One concern often presented in relation to neonatal pain and procedures is overmedication and subsequent respiratory depression. The researchers point out that since the scale's inception in December 1992, there has been no evidence of increased occurrence of respiratory depression in neonates medicated for postoperative pain (Krechel and Bildner, 1995; Bildner and Krechel, 1996).
Nurses continue to be the bedside specialists who are constantly on the alert for subtle changes in the critically ill neonate's condition requiring subsequent intervention. Neonates in the NICU commonly require painful invasive procedures and even surgical intervention to survive. The quality of the infant's survival can be positively enhanced with effective pain assessment and management. Ongoing research on neonatal pain assessment and management with tools such as CRIES will further enable nurses to effectively deal with neonatal pain.
See Chapters 11 and 26 in
Nursing Care of Infants and
Children, 5th and 6th editions.
See Chapters 9 and 21 in
Essentials of Pediatric
Nursing, 5th edition.
March 15, 2002
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