BEDSIDE APPLICATION OF THE NEONATAL-FACIAL-CODING-SYSTEM IN PAIN ASSESSMENT OF PREMATURE NEONATES

Assessment of infant pain is a pressing concern, especially within the context of neonatal intensive care where infants may be exposed to pr olonged and repeated pain during lengthy hospitalization. In the prese nt study the feasibility of carrying out the complete Neonatal Facial Coding System (NFCS) in real time at bedside, specifically reliability , construct and concurrent validity, was evaluated in a tertiary level Neonatal Intensive Care Unit (NICU). Heel lance was used as a model o f procedural pain, and observed with n = 40 infants at 32 weeks gestat ional age. Infant sleep/wake state, NFCS facial activity and specific hand movements were coded during baseline, unwrap, swab, heel lance, s queezing and recovery events. Heart rate was recorded continuously and digitally sampled using a custom designed computer system. Repeated m easures analysis of variance (ANOVA) showed statistically significant differences across events for facial activity (P < 0.0001) and heart r ate (P < 0.0001). Planned comparisons showed facial activity unchanged during baseline, swab and unwrap, then increased significantly during heel lance (P < 0.0001), increased further during squeezing (P < 0,00 3), then decreased during recovery (P < 0.0001). Systematic shifts in sleep/wake state were apparent, Rise in facial activity was consistent with increased heart rate, except that facial activity more closely p aralleled initiation of the invasive event. Thus facial display was mo re specific to tissue damage compared with heart rate. Inter-observer reliability was high. Construct validity of the NFCS at bedside was de monstrated as invasive procedures were distinguished from tactile. Whi le bedside coding of behavior does not permit raters to be blind to ev ents, mechanical recording of heart rate allowed for an independent so urce of concurrent validation for bedside application of the NFCS scal e. (C) 1998 International Association for the Study of Pain. Published by Elsevier Science B.V.