Identification of pain indicators for infants at risk for neurological impairment: A Delphi consensus study

A 39- item, self-administered electronic survey that included infant physiologic, behavioral and contextual pain indicators was used in a two round Delphi consensus exercise. Fourteen pediatric pain experts were polled individually and anonymously on the importance and usefulness of the pain indicators for the 3 differing levels of risk for NI.The strength of agreement between expert raters was moderate in Round 1 and fair in Round 2. In general, pain indicators with the highest concordance for all three groups were brow bulge, facial grimace, eye squeeze, and inconsolability. Increased heart rate from baseline in the moderate and severe groups demonstrated high concordance. In the severe risk group, fluctuations in heart rate and reduced oxygen saturation were also highly rated.These data constitute the first step in contributing to the development and validation of a pain measure for infants at risk for NI. In future research, we will integrate these findings with the opinions of (a) health care providers about the importance and usefulness of infant pain indicators and (b) the pain responses of infants at mild, moderate and high risk for NI.Assessment of pain in infants has remained somewhat of an enigma over the past two decades. Although a plethora of infant pain measures has been developed [1], they are infrequently and inconsistently used in clinical practice. This paucity of assessment is particularly evident in infants who are the most vulnerable; such as those at risk for neurological impairment (NI). Infants at varying levels of risk for NI are exposed to multiple painful procedures during their initial days in the NICU [2]. Stevens et al [2], found that during the first day of life, neonates at highest risk for NI experienced the greatest number of painful procedures (e.g., suctioning, heel lances, intravenous starts) compared to lower risk groups and were administered the least amount of opiods [2]. To appropriately manage these at-risk infants, a relia