Commonly used neonatal pain assessment tools

Tool	Type of tool (unidimensional versus multidimensional)^*	Parameters included in the tool	Clinical application or type(s) of pain assessed	Score range
BIIP (Behavioral Indicators of Infant Pain)	Unidimensional	Behavioral state Facial expression Hand movements	Acute postoperative or procedural pain	0 to 9
BPSN (Bernese Pain Scale for Neonates)	Multidimensional	Alertness Duration of crying Time to calm Skin color Facial expression Posture/tone Breathing pattern Vital sign changes (HR and SpO₂)	Acute procedural pain	0 to 27
COMFORTneo	Unidimensional	Level of alertness Agitation Respiratory response Crying Body movements Facial expression Muscle tone	Prolonged pain (eg, invasive mechanical ventilation) Routine NICU pain assessment	6 to 30
COVERS (Crying, Oxygen requirement, Vital signs, Expression, Resting, Signaling distress)	Multidimensional	Crying Oxygen requirement Vital signs Facial expression Level of alertness Body movements	Acute procedural pain	0 to 10
CRIES (Crying, Requires increased oxygen administration, Increased vital signs, Expression, Sleeplessness)	Multidimensional	Crying Oxygen requirement Vital signs Facial expression Level of alertness	Acute postoperative or procedural pain	0 to 10
DAN (Douleur Aiguë Nouveau-né)	Unidimensional	Facial expression Limb movements Vocal expression	Acute procedural pain	0 to 10
EDIN (Echelle de Douleur et d'Inconfort du Nouveau-né)	Unidimensional	Facial expression Body movements Quality of sleep Interaction with environment/caregivers Consolability	Prolonged pain	0 to 15
NFCS (Neonatal Facial Coding System)	Unidimensional	8 different facial actions	Acute procedural pain	0 to 8
NIPS (Neonatal Infant Pain Scale)	Multidimensional	Facial expression Cry Breathing pattern Arm and leg movements State of arousal	Acute procedural pain	0 to 7
N-PASS (Neonatal Pain Agitation and Sedation Scale)	Multidimensional	Crying and irritability Behavioral state Facial expression Extremities and tone Vital signs	Acute pain Prolonged pain Sedation level (eg, in neonates receiving invasive mechanical ventilation)	–10 to +10
PAT (Pain Assessment Tool)	Multidimensional	Posture/tone Cry Sleep pattern Facial expression Color Vital signs (respiratory rate, HR, SpO₂) Nursing perception of pain	Acute procedural pain	0 to 20
PIPP-R (Premature Infant Pain Profile-Revised)	Multidimensional	Change in vital signs (HR and SpO₂) Duration of pain expression on the neonate's face Contextual factors: Gestational age Baseline behavioral state	Acute postoperative or procedural pain	0 to 21

This table summarizes pain assessment tools used in neonatal practice. Commonly used tools are listed here; the list is not comprehensive. The choice of pain assessment tool should be tailored to the neonatal population being cared for and the types of pain being evaluated. The choice of pain assessment tool(s) varies considerably from center to center. Tools that have been subjected to the most rigorous validation testing include BIIP, CRIES, DAN, N-PASS, and PIPP-R. Refer to UpToDate topic on pain assessment in neonates for additional details.

HR: heart rate; NICU: neonatal intensive care unit; SpO₂: peripheral oxygen saturation.

* Unidimensional tools are those that evaluate only one type of pain response (either behavioral or physiologic responses). Multidimensional tools evaluate both behavioral and physiologic responses to pain.

Graphic 80078 Version 22.0

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Commonly used neonatal pain assessment tools