VIEWPOINT ARTICLE Should we assess pain in newborn infants using a scoring system or just a detection method? Carlo Valerio Bellieni (cvbellieni@gmail.com), Monica Tei, Giuseppe Buonocore Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Siena, Italy Keywords Analgesia, Newborn, Pain, Pain scale Correspondence Carlo V. Bellieni, MD, Neonatal Intensive care Unit, University Hospital of Siena, Viale M. Bracci 16, 53100 Siena, Italy. Tel: 0039 0577 586550 | Fax: 0039 0577 586182 | Email: cvbellieni@gmail.com Received 11 May 2014; revised 13 September 2014; accepted 25 November 2014. DOI:10.1111/apa.12882 ABSTRACT Newborn infants’ pain should be scored indirectly using dedicated pain scales. Unfortunately, while some scales for prolonged pain have given good results, a gold standard to assess acute pain does not exist. Acute pain scales still have weak points, most are complex and are scarcely used in neonatal departments. Moreover, carefully scoring pain in clinical practice seems redundant, because any avoidable pain is a concern. This suggests that researchers must find new ways to assess acute pain. A possible approach is to settle for pain detection instead of pain scoring in selected cases. Here, we describe a two-point method that illustrates this approach. Conclusion: For everyday practice, detecting pain is more useful than scoring it; acute pain scales should be reserved for research, for those clinical settings where the personnel has received a careful training and where overcrowding and hurry are absent. It is quite difficult to measure infant pain. Infants cannot verbally express themselves, and no single parameter – heart rate, body movement, or crying intensity for instance – is pain specific enough. Thus, to study acute procedural pain, pain during heel pricks, intramuscular injections, tracheal suctioning and so on, researchers must create scales which take into account multiple parameters. Scales for the assessment of prolonged pain exist as well, but they are beyond the scope of this paper. Most acute pain scales incorporate both behavioural indicators such as facial actions, body movements and crying, and physiological indicators such as heart rate, respiratory rate, blood pressure and oxygen saturation. These parameters must accurately be recorded and calcu- lated in real time. Although more than 40 acute pain scales are available (1,2), none is so superior so as to become a standard. Several reports describe that pain scales are still scarcely used (3,4) and some researchers still choose to use nonvalidated parameters to score pain (5). Some researchers (6) argue that acute pain scales are still far from satisfactory because of the discrepancy between behaviour and electrophysiological responses to pain (7–9). LIMITATIONS OF ACUTE PAIN SCALES Current acute pain scales have several limitations that can reduce their usefulness in clinical practice and in experi- mental settings. It is difficult for caregivers to use acute pain scales that require the simultaneous measurement of several parameters, some of which require calculation in real time. The number of parameters that a nurse is expected to monitor during a painful procedure using acute pain scales ranges from three to ten, for instance crying time, oxygen saturation changes, several facial movements and arm movements. It thus becomes difficult for a single caregiver to measure them accurately. Moreover, some studies sug- gest that a nurse who is at the same time performing a painful procedure and measuring pain will give different scores than one solely engaged in monitoring pain, and both will give different results than an observer looking at a video clip (10,11). Several trials resolve this issue by recording the procedure, and only scoring pain afterwards in a calmer environment. A second group of issues concerns the validation of current pain scales. While a number of pain scales have shown both clinical utility and, more importantly, feasibil- ity, few or none have demonstrated a total agreement of all ©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 1 Acta Pædiatrica ISSN 0803-5253