Development And Evaluation Of The Neonatal Faces Pain Scale

BackgroundHospitalized neonates experience various acute painful procedures.Repeated and persistent painful stimuli have a short-term and long-term adverse effect on neonates.But pain assessment and treatment are still insufficient.Identification and accurate assessment of pain is a prerequisite for effective treatment.As neonates are unable to report pain,assessment of pain in this population is a challenge.The guidelines recommend that neonatal pain should be assessed by combining pain behavior with changed physiological indicators caused by pain.Until now,more than 40 pain assessment scales have been developed for medical staff to identify and quantify neonatal pain,but most of them are rarely used in clinical practice.Morever,the main pain behavior indicator,facial expression,relies on text description,which are troublesome and time consuming.ObjectivesTo develop a faces pain scale suitable for Chinese newborns,and test the reliability,validity,feasibility and clinical utility of the NFPS.Methods1.ParticipantsA convenience sample of 123 neonates and 43 nurses were recruited from the Neonatal Intensive Care Unit(NICU)in a Grade III hospital in Guangzhou.2.DevelopmentBased on the Facial Action Coding System(FACS),five facial expressions were developed from eight items in the Neonatal Facial Coding System(NFCS)after the establishment of the facial expression database,combined with heart rate and SpO2 to form the Neonatal Faces Pain Scale(NFPS).3.Assessment ToolsThe resulting NFCS consisted of 10 items,with total score ranged from 0 to10.The Neonatal Infant Pain Scale(NIPS)consisted of 6 items,with total score ranged from 0 to 7.Feasibility and clinical utility questionnaire consisted of 10 items,with total score ranged from 10 to 50 points.4.ProcedureA total of 123 preterm and full-term neonates with arterial puncture were enrolled and videotaped 1 min before the procedure,during the procedure,and 1 min after the procedure.Twenty of the neonates5 videos were taken every three seconds for establishing the neonatal facial expression database.A total of 1053 facial expressions in the database were assessed by three evaluators with the NFCS and be graded according to pain scores.The NFPS was developed by Point-Pair Method and Photoshop.The pain procedures of another 103 neonates were evaluated by the NFPS,the NFCS and the NIPS,to test their reliability and validity.Feasibility,clinical utility,and preference of the three scales were investigated in 43 nurses.Results1.The Neonatal Faces Pain Scale(NFPS)The NFPS was developed consisting of two dimensions of facial expression and physiological indicators,and three items of facial expressions with score ranged from 0 to 8,heart rate and SpO2 with score ranged from 0 to 1.Total score ranged from 0 to 10.2.Score of the 103 neonates with arterial puncture by three scalesThere were significant differences between scores of the NFPS,the NFCS,the NIPS during and after the neonatal arterial puncture(Z=-5.447,Z =-5.002,Z =-5.359,P<0.001).Pain scores during the procedure were higher using the three scales,9.0(8.0,10.0),9.0(6.0,9.0),7.0(6.3,7.0),respectively.3.Reliability of the NFPSThe inter-rater correlation coefficients of the NFPS,the NFCS,the NIPS were 0.994,0.994,0.989,respectively.The test-retest reliability of the NFPS were 0.989.4.Validity of the NFPSThe Cronbach a coefficient of facial expression and physiological indicators were 1.000 and 0.717,respectively.The correlation coefficient r,between each dimension,item and dimension,dimension and total scale ranged from 0.337 to 1.000(P<0.01).The r values of criterion validity were 0.952,0.944,respectively.5.Feasibility and clinical utility evaluation of three scales by nursesThe feasibility and clinical utility scores of the NFPS,the NFCS,the NIPS scales were 50(47,50),49(40,50),48(40,50),respectively.The preference rates of the three scales were 79.1%,16.3%,and 4.6%,respectively.ConclusionsWith good reliability,validity,feasibility,and clinical utility,the NFPS could be used to assess acute pain in preterm and full-term Chinese newborns.