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Neonatal Pain, Agitation, and Sedation Scale’s use, reliability, and validity: a systematic review

Journal of Perinatology volume 40, pages 1753–1763 (2020)Cite this article

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Abstract

The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) is recommended by the American Academy of Pediatrics to measure neonatal pain and sedation. However, little is known regarding its reliability and validity for diverse neonatal subpopulations. Twenty-nine studies were included in our review, demonstrating broad application of N-PASS and good or excellent reliability and validity for various neonatal subpopulations. Our systematic review found N-PASS to be valid and reliable for many but not all neonatal subpopulations. There is a lack of support for N-PASS reliability and validity for measuring prolonged pain and sedation in nonmechanically ventilated infants and for acute pain in postoperative infants in any gestational age category. Overall, N-PASS is a psychometrically sound and pragmatic instrument evaluating pain and sedation for most neonatal populations. Future research using N-PASS is encouraged to evaluate and report its validity and reliability, especially for neonatal subpopulations not included in this review.

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Fig. 1: PRISMA flow diagram.
Fig. 2: N-PASS validity and reliability by gestational age and infant status.

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References

  1. Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care, 2007–2012. JAMA Pediatr. 2015;169:855–62.

    PubMed  Google Scholar 

  2. Anand KJS, Aranda JV, Berde CB, Buckman S, Capparelli EV, Carlo W, et al. Summary proceedings from the neonatal pain-control group. Pediatrics. 2006;117:S9–22.

    PubMed  Google Scholar 

  3. Hall RW. Anesthesia and analgesia in the NICU. Clin Perinatol. 2012;39:239–54.

    PubMed  PubMed Central  Google Scholar 

  4. Borenstein-Levin L, Synnes A, Grunau RE, Miller SP, Yoon EW, Shah PS. Narcotics and sedative use in preterm neonates. J Pediatr. 2017;180:92–8.

    PubMed  Google Scholar 

  5. American Academy of Pediatrics. Prevention and management of pain in the neonate: an update. Pediatrics. 2006;118:2231–41.

    Google Scholar 

  6. Horbar JD, Soll RF, Edwards WH. The Vermont Oxford Network: a community of practice. Clin Perinatol. 2010;37:29–47.

    PubMed  Google Scholar 

  7. Giordano V, Edobor J, Deindl P, Wildner B, Goeral K, Steinbauer P, et al. Pain and sedation scales for neonatal and pediatric patients in a preverbal stage of development: a systematic review. JAMA Pediatr. 2019;173:1186–97.

    Google Scholar 

  8. Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992;17:95–109.

    CAS  PubMed  Google Scholar 

  9. Hummel P, Puchalski ML, Creech SD, Weiss MG. N-PASS: Neonatal Pain, Agitation and Sedation Scale—reliability and validity. 2004. http://www.anestesiarianimazione.com/2004/06c.asp. Accessed 2 May 2020.

  10. Desai SA, Nanavati RN, Jasani BB, Kabra N. Comparison of Neonatal Pain, Agitation, and Sedation scale with premature infant pain profile for the assessment of acute prolonged pain in neonates on assisted ventilation: a prospective observational study. Indian J Palliat Care. 2017;23:287–92.

    PubMed  PubMed Central  Google Scholar 

  11. Huang X-Z, Li L, Zhou J, He F, Zhong C-X, Wang B. Evaluation of three pain assessment scales used for ventilated neonates. J Clin Nurs. 2018;27:3522–9.

    PubMed  Google Scholar 

  12. Kimberlin CL, Winterstein AG. Validity and reliability of measurement instruments used in research. Am J Health Syst Pharm. 2008;65:2276–84.

    PubMed  Google Scholar 

  13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.

    PubMed  PubMed Central  Google Scholar 

  14. OCEBM levels of evidence working group. Oxford Center for Evidence Based Medicine 2011 levels of evidence. 2011. https://www.cebm.net/wp-content/uploads/2014/06/CEBM-Levels-of-Evidence-2.1.pdf. Accessed 25 Aug 2020.

  15. World Health Organization. Preterm birth. 2018. https://www.who.int/news-room/fact-sheets/detail/preterm-birth. Accessed 11 Apr 2020.

  16. Howson CP, Kinney MV, McDougall L, Lawn JE. Born too soon: preterm birth matters. Reprod Health. 2013;10:S1.

    PubMed  PubMed Central  Google Scholar 

  17. Burnsed JC, Heinan K, Letzkus L, Zanelli S. Gabapentin for pain, movement disorders, and irritability in neonates and infants. Dev Med Child Neurol. 2020;62:386–9.

    PubMed  Google Scholar 

  18. Jiang J-B, Strauss R, Luo X-Q, Nie C, Wang Y, Zhang J, et al. Anaesthesia modalities during laser photocoagulation for retinopathy of prematurity: a retrospective, longitudinal study. BMJ Open. 2017;7:e01334.

    Google Scholar 

  19. Munsters J, Wallstróm L, Ågren J, Norsted T, Sindelar R. Skin conductance measurements as pain assessment in newborn infants born at 22-27weeks gestational age at different postnatal age. Early Hum Dev. 2012;88:21–6.

    PubMed  Google Scholar 

  20. Novitskaya ES, Kostakis V, Broster SC, Allen LE. Pain score assessment in babies undergoing laser treatment for retinopathy of prematurity under sub-tenon anaesthesia. Eye. 2013;27:1405–10.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Hummel P, Lawlor-Klean P, Weiss MG. Validity and reliability of the N-PASS assessment tool with acute pain. J Perinatol. 2009;88:474–8.

    Google Scholar 

  22. Kurdahi Badr L, Demerjian T, Daaboul T, Abbas H, Hasan Zeineddine M, Charafeddine L. Preterm infants exhibited less pain during a heel stick when they were played the same music their mothers listened to during pregnancy. Acta Paediatr. 2017;106:438–45.

    PubMed  Google Scholar 

  23. O’Sullivan A, O’Connor M, Brosnahan D, McCreery K, Dempsey EM. Sweeten, soother and swaddle for retinopathy of prematurity screening: a randomised placebo controlled trial. Arch Dis Child Fetal Neonatal Ed. 2010;95:F419–22.

    PubMed  Google Scholar 

  24. Kappesser J, Kamper-Fuhrmann E, De Laffolie J, Faas D, Ehrhardt H, Frank LS, et al. Pain-specific reactions or indicators of a general stress response? Clin J Pain. 2019;35:101–10.

    PubMed  Google Scholar 

  25. Patil S, Saini SS, Kumar P, Shah R. Comparison of intra-procedural pain between a novel continuous arteriovenous exchange and conventional pull-push techniques of partial exchange transfusion in neonates: a randomized controlled trial. J Perinatol. 2014;34:693–7.

    CAS  PubMed  Google Scholar 

  26. Al Qahtani R, Abu-Salem LY, Pal K. Effect of lidocaine-prilocaine eutectic mixture of local anaesthetic cream compared with oral sucrose or both in alleviating pain in neonatal circumcision procedure. Afr J Paediatr Surg. 2014;11:56–61.

    PubMed  Google Scholar 

  27. Vu-Ngoc H, Uyen NCM, Thinh OP, Don LD, Danh NVT, Truc NTT, et al. Analgesic effect of non-nutritive sucking in term neonates: a randomized controlled trial. Pediatr Neonatol. 2020;61:106–13.

    PubMed  Google Scholar 

  28. McGinnis K, Murray E, Cherven B, McCracken C, Travers C. Effect of vibration on pain response to heel lance: a pilot randomized control trial. Adv Neonatal Care. 2016;16:439–48.

    PubMed  Google Scholar 

  29. Tekin M, Yıldırım Ş, Aylanç H, Kaymaz H, Battal F, Topaloğlu N, et al. Does intrauterine tobacco exposure increase the pain perception of newborns? J Pain Res. 2016;9:319–23.

    PubMed  PubMed Central  Google Scholar 

  30. Hummel P. Psychometric evaluation of the Neonatal Pain, Agitation, and Sedation (N-PASS) Scale in infants and children up to age 36 months. Pediatr Nurs. 2017;43:175–84.

    Google Scholar 

  31. Drolet C, Roy H, Laflamme J, Marcotte M-E. Feasibility of a comfort care protocol using oral transmucosal medication delivery in a palliative neonatal population. J Palliat Med. 2016;19:442–50.

    PubMed  Google Scholar 

  32. Veneziano G, Iliev P, Tripi J, Martin D, Aldrink J, Bhalla T, et al. Continuous chloroprocaine infusion for thoracic and caudal epidurals as a postoperative analgesia modality in neonates, infants, and children. Paediatr Anaesth. 2016;26:84–91.

    PubMed  Google Scholar 

  33. Hummel P, Puchalski M, Creech SD, Weiss MG. Clinical reliability and validity of the N-PASS: Neonatal Pain, Agitation and Sedation Scale with prolonged pain. J Perinatol. 2008;28:55–60.

    CAS  PubMed  Google Scholar 

  34. Giordano V, Deindl P, Fuiko R, Unterasinger L, Waldhoer T, Cardona F, et al. Effect of increased opiate exposure on three years neurodevelopmental outcome in extremely preterm infants. Early Hum Dev. 2018;123:1–5.

    CAS  PubMed  Google Scholar 

  35. Deindl P, Giordano V, Fuiko R, Waldhoer T, Unterasinger L, Berger A, et al. The implementation of systematic pain and sedation management has no impact on outcome in extremely preterm infants. Acta Paediatr. 2016;105:798–805.

    PubMed  Google Scholar 

  36. Hillman BA, Tabrizi MN, Gauda EB, Carson KA, Aucott SW. The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse’s assessment of neonates. J Perinatol. 2015;35:128–31.

    CAS  PubMed  Google Scholar 

  37. Khan J, Sundaram V, Murki S, Bhatti A, Saini SS, Kumar P. Nasal injury and comfort with jet versus bubble continuous positive airway pressure delivery systems in preterm infants with respiratory distress. Eur J Pediatr. 2017;176:1629–35.

    PubMed  Google Scholar 

  38. Sacha GL, Foreman MG, Kyllonen K, Rodriguez RJ. The use of gabapentin for pain and agitation in neonates and infants in a neonatal ICU. J Pediatr Pharmacol Ther. 2017;22:207–11.

    PubMed  PubMed Central  Google Scholar 

  39. Garten L, Deindl P, Schmalisch G, Metze B, Bührer C. Parallel assessment of prolonged neonatal distress by empathy-based and item-based scales. Eur J Pain. 2010;14:878–81.

    PubMed  Google Scholar 

  40. Abiramalatha T, Mathew SK, Mathew BS, Shabeer MP, Arulappan G, Kumar M, et al. Continuous infusion versus intermittent bolus doses of fentanyl for analgesia and sedation in neonates: an open-label randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2019;104:F433–39.

    PubMed  Google Scholar 

  41. Giordano V, Deindl P, Kuttner S, Waldhör T, Berger A, Olischar M. The Neonatal Pain, Agitation and Sedation Scale reliably detected oversedation but failed to differentiate between other sedation levels. Acta Paediatr. 2014;103:e515–21.

    CAS  PubMed  Google Scholar 

  42. Chrysostomou C, Schulman SR, Castellanos MH, Cofer BE, Mitra S, da Rocha MG, et al. A phase II/III, multicenter, safety, efficacy, and pharmacokinetic study of dexmedetomidine in preterm and term neonates. J Pediatr. 2014;164:276–82.

    CAS  PubMed  Google Scholar 

  43. Giordano V, Deindl P, Goeral K, Czaba C, Weninger M, Berger A, et al. The power of N-PASS, aEEG, and BIS in detecting different levels of sedation in neonates: a preliminary study. Paediatr Anaesth. 2018;28:1096–104.

    PubMed  Google Scholar 

  44. Shuman CJ, Ploutz-Snyder RJ, Titler MG. Development and testing of the nurse manager EBP competency scale. West J Nurs Res. 2018;40:175–90.

    PubMed  Google Scholar 

  45. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15:155–63.

    PubMed  PubMed Central  Google Scholar 

  46. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med. 2012;22:276–82.

    Google Scholar 

  47. Mukaka M. A guide to appropriate use of correlation coefficient in medical research. Malawi Med J. 2012;24:69–71.

    CAS  PubMed  PubMed Central  Google Scholar 

  48. Stevens M, McGrath P, Gibbins S, Beyene J, Breau L, Camfield C, et al. Procedural pain in newborns at risk for neurologic impairment. Pain. 2003;105:27–35.

    PubMed  Google Scholar 

  49. Stevens M, McGrath P, Gibbins S, Beyene J, Breau L, Camfield C, et al. Determining behavioural and physiological responses to pain in infants at risk for neurologic impairment. Pain. 2007;127:94–102.

    PubMed  Google Scholar 

  50. Deindel P, Unterasinger L, Kappler G, Werther T, Czaba C, Giordano V, et al. Successful implementation of a pain and sedation protocol at 2 NICUs. Pediatrics. 2013;132:211–8.

    Google Scholar 

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Author information

Authors and Affiliations

  1. School of Nursing, University of Michigan, Ann Arbor, MI, USA

    Mikayla E. Morgan & Clayton J. Shuman

  2. Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, MI, USA

    Stephanie Kukora

  3. Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA

    Stephanie Kukora & Clayton J. Shuman

  4. University of Michigan Pediatric-Perinatal Nursing, C.S. Mott Children’s Hospital, Ann Arbor, MI, USA

    Michelle Nemshak

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  1. Mikayla E. Morgan
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  3. Michelle Nemshak
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  4. Clayton J. Shuman
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Contributions

MEM conceptualized, designed, and implemented the study, analyzed the results, and drafted the initial paper; SK provided clinical content expertise, revised the manuscript, reviewed analysis of data, and provided substantial comment and critical critique on the paper; MN helped conceptualize the study, provided clinical content expertise, revised the paper, reviewed analysis of data, and provided substantial comment and critical critique on the paper; CJS conceptualized, designed, and implemented the study, analyzed the results, and mentored the initial paper draft.

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Correspondence to Mikayla E. Morgan.

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Morgan, M.E., Kukora, S., Nemshak, M. et al. Neonatal Pain, Agitation, and Sedation Scale’s use, reliability, and validity: a systematic review. J Perinatol 40, 1753–1763 (2020). https://doi.org/10.1038/s41372-020-00840-7

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