Neonatal pain, agitation, and sedation scale (N-PASS)

Variable	Sedation		Pain/agitation
Variable	Description	Score	Description	Score
Crying and irritability	No signs of sedation (does not under-react)	0	No signs of pain/agitation	0
	Moans, sighs, or cries (audible or silent) minimally with painful stimuli	–1	Irritable or crying at intervals but can be consoled If intubated: Intermittent silent cry	+1
	No response to painful stimuli	–2	Any of the following: High-pitched cry Cries inconsolably If intubated: Continuous silent cry	+2
Behavior state	No signs of sedation (does not under-react)	0	No signs of pain/agitation	0
	Little spontaneous movement Arouses minimally to stimuli	–1	Restless, squirming Awakens frequently/easily with minimal to no stimuli	+1
	No spontaneous movement Does not arouse or react to any stimuli	–2	Any of the following: Kicking Arching Constantly awake Inappropriate lack of movement or arousal in a patient not receiving sedation	+2
Facial expression	No signs of sedation (does not under-react)	0	No signs of pain/agitation	0
	Minimal expression with stimuli	–1	Any pain expression that is intermittent^*	+1
	Any of the following: Mouth is lax Drooling No facial expression at rest or with stimuli	–2	Any pain expression that is continuous^*	+2
Extremities and tone	No signs of sedation (does not under-react)	0	No signs of pain/agitation	0
	Weak palmar or plantar grasp reflex Decreased tone	–1	Intermittent clenching of toes and/or fists Intermittent finger splaying Body is not tense	+1
	No palmar or plantar grasp reflex can be elicited Flaccid tone	–2	Any of the following: Continual or frequent clenching of toes and/or fists Continual or frequent splaying of fingers Body is tense/stiff	+2
Vital signs (HR, RR, BP, SpO₂)	Within normal limits for GA (or at patient's baseline) with normal variability	0	Within normal limits for GA (or at patient's baseline) with normal variability	0
	Little variability with stimuli (<10% variability from baseline)	–1	Either of the following: HR, RR, and/or BP are increased 10 to 20% from baseline Neonate experiences mild to moderate desaturation (SpO₂ 76 to 85%) with care/stimuli, but recovers quickly	+1
	Any of the following: No variability with stimuli Hypoventilation Apnea If intubated: No spontaneous respiratory effort	–2	Any of the following: HR, RR, and/or BP are increased >20% from baseline Neonate experiences moderate to severe desaturation (SpO₂ ≤75%) with care/stimuli, and recovers slowly If intubated: Neonate is out of sync with the ventilator	+2
	Total sedation score: (range 0 to –10)		Total pain score^¶: (range 0 to +10)

This table summarizes the N-PASS tool, which is commonly used to assess pain, agitation, and sedation in hospitalized neonates, including preterm neonates. N-PASS can be used to assess pain (acute or prolonged) or the level of sedation.

For assessment of pain/agitation:

Pain should be assessed routinely with all vital sign measurements.
More frequent pain assessments may be warranted in the following circumstances:
- Neonates with indwelling tubes or lines which may cause pain, especially with movement (eg, chest tubes); these neonates should have assessments performed at least every 2 to 4 hours.
- Neonates who have received analgesic medication to treat acute pain; reassessment should be performed 30 to 60 minutes after the medication to assess the neonate's response.
- Neonates receiving ongoing analgesic/sedative medication; these neonates should have assessments performed at least every 2 to 4 hours.
- Neonates with postoperative pain; assessments are performed at least every 2 hours for 24 to 48 hours, then every 4 hours until off pain medications.
Pain is scored from 0 to +2 for each variable according to the criteria above. The scores for the 5 variables are then totaled (range 0 to +10).
For preterm neonates, additional points are added to the total according to GA, as described below.^¶
However, the total score should not exceed 10.
The usual target for pain management is a score ≤3; intervention is generally warranted for scores ≥4.
Preemptive intervention may be warranted before the score reaches 4 if the neonate is undergoing a painful procedure.

For assessment of sedation:

It is not necessary to assess sedation with every pain assessment; the frequency of assessments depends on the clinical circumstances.
Sedation is scored from 0 to –2 for each variable according to the criteria above. The scores of the 5 variables are then totaled (range 0 to –10).
Desired levels of sedation vary depending on the clinical circumstances:
- "Light sedation" is generally defined as a score of –2 to –5.
- "Deep sedation" is generally defined as a score of –6 to –10; deep sedation is associated with a high risk of apnea and hypoventilation and should be avoided in infants who are not receiving mechanical ventilation.
A negative score without the administration of opioids/sedatives may indicate:
- The preterm neonate's response to prolonged or persistent pain or stress.
- Neurologic insult, sepsis, or other pathology.

BP: blood pressure; GA: gestational age; HR: heart rate; RR: respiratory rate; SpO₂: peripheral oxygen saturation.

* Facial expressions of pain in neonates may include:

Eyes – Tightly closed
Eyebrows –Lowered and drawn together
Forehead – Bulging between the eyebrows with vertical furrows
Cheeks – Raised
Nose – Broadened or bulging
Mouth – Open in a squarish shape

¶ For preterm infants, points are added to the pain score based on GA to compensate for their limited ability to behaviorally or physiologically demonstrate pain:

If GA <28 weeks, add +3 points to the total pain score (total score should not exceed 10)
If GA 28 to <32 weeks, add +2 points to the total pain score (total score should not exceed 10)
If GA 32 to <35 weeks, add +1 point to the total pain score (total score should not exceed 10)

References:

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.
Hummel P, Lawlor-Klean P, Weiss MG. Validity and reliability of the N-PASS assessment tool with acute pain. J Perinatol 2010; 30:474.

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Neonatal pain, agitation, and sedation scale (N-PASS)