Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Abstract

Accurate pain assessment in preterm infants in the neonatal intensive care unit (NICU) is complex. Infants who are born at early gestational ages (GA), and who have had greater early pain exposure, have dampened facial responses which may lead to under-treatment. Since behavioral and physiological responses to pain in infants are often dissociated, using multidimensional scales which combine these indicators into a single score may limit our ability to determine the effects of interventions on each system. Our aim was to design a unidimensional scale which would combine the relatively most specific, individual, behavioral indicators for assessing acute pain in this population.The Behavioral Indicators of Infant Pain (BIIP) combines sleep/wake states, 5 facial actions and 2 hand actions. Ninety two infants born between 23-32 weeks GA were assessed during 3, one minute Phases of blood collection. Outcome measures included changes in BIIP and in Neonatal Infant Pain Scale (NIPS) scores coded in real time from continuous bedside video recordings; changes in heart rate (HR) were obtained using custom physiological processing software.Scores on the BIIP changed significantly across Phases of blood collection (p < 0.01). Internal consistency (0.82) and inter-rater reliability (0.80-0.92) were high. Correlations between the BIIP and NIPS were modest (r = 0.64, p < 0.01) as were correlations between the BIIP and mean heart rate (r = 0.45, p < 0.01). In this initial study, the BIIP has been shown to be a reliable, valid scale for assessing acute pain in preterm infants in the NICU. Keywordspremature; infant; pain; assessment IntroductionPreterm infants undergo repeatedly painful diagnostic and therapeutic procedures to ensure their survival. In order to provide appropriate pain management in this population, accurate assessment of pain is necessary (Anand et al., 2005), yet complex because we are limited to indirect measures of pain responses. And although infant pain responses have both behavioralCorresponding author: Dr. Liisa Holsti, Centre for Community Child Health Research, F611, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4. Canada, Phone: 604-875-2000, local 5200, Fax: 604-875-2384, E-mail address: lholsti@cw.bc.ca. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. and physiological components, dissociations between behavioral and physiological pain responses are common (Barr, 1998;Morison et al., 2001). Furthermore, facial actions are the relatively most specific behavioral pain indicators in preterm infants, yet these responses may be dampened. Grunau et al...

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“…In neonatal intensive care, facial actions were found to be more reliable than physiological measures for evaluating pain responses (Stevens, Franck et al, 2007), but may be dampened in preterm neonates (Holsti & Grunau, 2007) in whom cortical responses to pain have been demonstrated in the absence of a change in facial expression (Slater et al, 2008).…”

Sucrose and Warmth for Analgesia in Healthy Newborns: An RCT

“…45,46 Because sleep state was controlled for at the onset of the study, this allowed us to focus on facial action as the most sensitive behavioral indicator of infant pain. 47 Scorers were uninformed as to experimental condition when scoring cry from the auditory portion of the tape. For grimacing, the video camera was focused on the infant's face to record facial actions only and prevent accidental unblinding of subjects during coding.…”

Invasive Procedures in Preterm Children: Brain and Cognitive Development at School Age

“…Future research with larger samples is needed to address whether recurrent lifethreatening complications such as necrotizing enterocolitis may also have predisposed infants to ischemia and related myelination disturbances. Preterm infant responses to invasive proceduresvary depending on GA, sleepwake state, illness severity, and previous exposures to pain, [55][56][57][58][59][60][61][62] therefore it is difficult to determine the extent of pain perceived for a specific procedure. Furthermore, although we adjusted for cumulative morphine exposure in our models, we could not account for pain management that may have been provided during a given procedure.…”