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Identification of pain in neonates: the adults’ visual perception of neonatal facial features



To verify the visual attention of adults when assessing neonatal pain.

Study design

143 adults (59% health professionals) evaluated 20 pictures (2 pictures of 10 neonates’ faces: at rest; during a painful procedure). Tobii-TX300 tracked the participants’ eyes movement. For each picture, adults scored pain intensity (0 = no pain; 10 = maximum). Latent classes analysis was applied by cognitive diagnosis models—GDINA with two attributes (knowledge of pain presence/absence). Variables associated with belonging to the class of adults that correctly identified pictures of newborns with/without pain were identified by logistic regression.


To identify neonatal pain, adults look at the mouth, eyes, and forehead in facial pictures. The latent class analysis identified four classes of adults: those that identify painful/painless neonates (YY-Class; n = 80); only painful neonates (n = 28); only painless neonates (n = 34) and none (n = 1). Being a health professional (OR: 2.29; 95% CI: 1.16–4.51), and each look at the nasolabial furrow (2.07; 1.19–3.62) increased the chance of belonging to the YY-class.


Being a health professional and the visual fixation at the nasolabial furrow helped to identify the presence/absence of neonatal pain.

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Fig. 1: Image of the newborn: Areas of interest.

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  1. Hadjistavropoulos T, Craig KD, Duck S, Cano A, Goubert L, Jackson P, et al. A biopsychosocial formulation of pain communication. Psychol Bull. 2011;137:910–39.

    Article  PubMed  Google Scholar 

  2. Anand KJS, EUROPAIN survey working group of the Neo Opioid Consortium. Assessment of continuous pain in newborns admitted to NICUs in 18 European countries. Acta Paediatr. 2017;106:1248–59.

    Article  PubMed  Google Scholar 

  3. Olsson E, Ahl H, Bengtsson K, Vejayaram DN, Norman E, Bruschettini M, et al. The use and reporting of neonatal pain scales: a systematic review of randomized trials. Pain. 2021;162:353–60.

    Article  PubMed  Google Scholar 

  4. Boyle EM. Measuring and managing pain in the fetus and neonate—a new era and new challenges. Semin Fetal Neonatal Med. 2019;24:101018

    Article  PubMed  Google Scholar 

  5. Eriksson M, Campbell-Yeo M. Assessment of pain in newborn infants. Semin Fetal Neonatal Med. 2019;24:101003

    Article  PubMed  Google Scholar 

  6. Bruck R, Miller R. Sex, personality, and physiological variables in the communication off affect via facial expression. J Pers Soc Psychol. 1974;30:S87–S96.

    Article  Google Scholar 

  7. Elias LS, Guinsburg R, Peres CA, Balda RC, Santos AM. Disagreement between parents and health professionals regarding pain intensity in critically ill neonates. J Pediatr. 2008;84:35–40.

    Article  Google Scholar 

  8. Pillai Riddell RR, Horton RE, Hillgrove J, Craig KD. Understanding caregiver judgments of infant pain: contrasts of parents, nurses and pediatricians. Pain Res Manag. 2008;13:489–96.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pillai Riddell R, Flora DB, Stevens S, Greenberg S, Garfield H. The role of infant pain behavior in predicting parent pain ratings. Pain Res Manag. 2014;19:e124–32.

    Article  PubMed  Google Scholar 

  10. Priebe JA, Messingschlager M, Lautenbacher S. Gaze behavior when monitoring pain faces: an eye-tracking study. Eur J Pain. 2015;19:817–25.

    Article  CAS  PubMed  Google Scholar 

  11. Vervoort T, Trost Z, Prkachin KM, Mueller SC. Attentional processing of other’s facial display of pain: an eye tracking study. Pain. 2013;154:836–44.

    Article  PubMed  Google Scholar 

  12. Heiderich TM, Leslie AT, Guinsburg R. Neonatal procedural pain can be assessed by computer software that has good sensitivity and specificity to detect facial movements. Acta Paediatr. 2015;104:e63–9.

    Article  PubMed  Google Scholar 

  13. Grunau RE, Oberlander T, Holsti L, Whitfield MF. Bedside application of the Neonatal Facial Coding System in pain assessment of premature neonates. Pain. 1998;76:277–86.

    Article  PubMed  Google Scholar 

  14. Grunau RV, Craig KD. Pain expression in neonates: facial action and cry. Pain. 1987;28:395–410.

    Article  PubMed  Google Scholar 

  15. van Dijk M, Koot HM, Saad HHA, TibboeL D, Passchier J. Observational visual analog scale in pediatric pain assessment: useful tool or good riddance? Clin J Pain. 2002;18:310–6.

    Article  PubMed  Google Scholar 

  16. Berde CB, Lehn BM, Yee JD, Sethna NF, Russo D. Patient-controlled analgesia in children and adolescents: a randomized, prospective comparison with intramuscular administration of morphine for postoperative analgesia. J Pediatr. 1991;118:460–6.

    Article  CAS  PubMed  Google Scholar 

  17. Bray RJ, Woodhams AM, Vallis CJ, KellY PJ, Ward-Platt MP. A double-blind comparison of morphine infusion and patient-controlled analgesia in children. Paediatr Anaesth. 1996;6:121–7.

    Article  CAS  PubMed  Google Scholar 

  18. Dijk van M, Boer de JB, Koot HM, Tibboel D, Passchier J, Duivenvoorden HJ. The reliability, stability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants. Pain. 2000;84:367–77.

    Article  Google Scholar 

  19. Ma W de la TorreJ. GDINA: the generalized DINA model framework. R package version 2.7.9. 2020.

  20. Williams AC. Facial expression of pain: an evolutionary account. Behav Brain Sci. 2002;25:439–88.

    Article  PubMed  Google Scholar 

  21. Schiavenato M, Butler-O’Hara M, Scovanner P. Exploring the association between pain intensity and facial display in term newborns. Pain Res Manag. 2011;16:10–12.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Grunau RV, Johnston CC, Craig KD. Neonatal facial and cry responses to invasive and non-invasive procedures. Pain 1990;42:295–305.

    Article  PubMed  Google Scholar 

  23. Eisenbarth H, Alpers GW. Happy mouth and sad eyes: scanning emotional facial expressions. Emotion. 2011;11:860–5.

    Article  PubMed  Google Scholar 

  24. Guo K. Holistic gaze strategy to categorize facial expression of varying intensities. PLoS ONE. 2012;7:e42585

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Schurgin MW, Nelson J, Iida S, Ohira H, Chiao JY, Franconeri SL. Eye movements during emotion recognition in faces. J Vis. 2014;14:1–16.

    Article  Google Scholar 

  26. Stevens B, McGrath P, Dupuis A, Gibbins S, Beyene J, Breau L, et al. Indicators of pain in neonates at risk for neurological impairment. J Adv Nurs. 2009;65:285–96.

    Article  PubMed  Google Scholar 

  27. Craig KD, Korol CT, Pillai RR. Challenges of judging pain in vulnerable infants. Clin Perinatol. 2002;29:445–57.

    Article  PubMed  Google Scholar 

  28. Melloni M, Lopez V, Ibanez A. Empathy and contextual social cognition. Cogn Affect Behav Neurosci. 2014;14:407–25.

    Article  PubMed  Google Scholar 

  29. Cheng Y, Chen C, Decety J. How situational context impacts empathic responses and brain activation patterns. Front Behav Neurosci. 2017;11:165.

    Article  PubMed  PubMed Central  Google Scholar 

  30. ABEP. Associação Brasileira de empresas de Pesquisa. Critério padrão de classificação econômica do Brasil. São Paulo, 2015. Accessed 3 Nov 2020.

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We thank Fundação de Amparo à Pesquisa de São Paulo (FAPESP) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for the financial support. Fundação de Amparo à Pesquisa do Estado de São Paulo—Fapesp—Grant Nos. 2012/50157-0 and 2018/13076-9. The funder did not participate in the work.

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Authors and Affiliations



MCMB, CET, and RG: responsible for conception and design of the study, data analysis and interpretation, and writing the manuscript. GVTS, JCAS, TMH, and RCXB: responsible for study design, patient screening and enrollment, data collection, data analysis and interpretation, and for revising the manuscript. LPC, RNO, and PASOS: responsible for study design, data collection, data analysis and interpretation, and for revising the manuscript. AS and SO: responsible for the statistical data analysis and writing the manuscript.

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Correspondence to Marina Carvalho de Moraes Barros.

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The authors declare no competing interests.

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Barros, M.C.d.M., Thomaz, C.E., da Silva, G.V.T. et al. Identification of pain in neonates: the adults’ visual perception of neonatal facial features. J Perinatol 41, 2304–2308 (2021).

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