Table 1.

Summary of Recommended Pain Assessment Scales for Neonates

Instrument	Items/Score Range	Clinical Utility	Reliability/Validity
NFCS - Neonatal Facial Coding System (Grunau et al., 1987)	9 items: Brow bulge, eye squeeze, naso-labial furrow, open lips, stretch mouth (vertical), stretch mouth (horizontal), lip purse, taut tongue, chin quiver Score: 0 – 9 (full-term); 0-10 (preterm)	Procedural pain; Preterm, Full-term	InterRR: 0.88 IntraRR: 0.83 Face, content, & construct validity: Yes
FLACC - Face, Legs, Activity, Cry, Consolability (Merkel, et al., 1997)	5 items: Face, legs, activity, cry, consolability Score: 0 – 10	Postoperative pain; Preverbal/nonverbal children < 7 years old	InterRR: 0.94 Content & construct vadility: Yes
COMFORTneo – modified from the COMFORT behavior scale (Van Dijk, et al., 2009)	7 items: Alertness, calmness/agitation, respiratory response (in mechanically ventilated children), crying (in spontaneously breathing children), body movement, facial tension, (body) muscle tone. Score: 6 - 30	Prolonged pain Sedation level; Preterm, Full-term 24 - 42 wks GA	InterRR: 0.79 Internal consistency: 0.84-0.88 Concurrent validity : Yes
NIPS - Neonatal Infant Pain Scale (Lawrence et al., 1993)	6 items: 5 behavioral items (facial expression, cry, arms, legs, and state of arousal) and 1 physiological item (breathing pattern) Score: 0 - 7	Procedural pain, Postoperative pain; Preterm, Full-term 26 - 47 wks GA	InterRR: 0.92 - 0.97 Internal consistency: 0.87 - 0.95 Concurrent validity: 0.53 - 0.84
N - PASS - Neonatal Pain, Agitation, and Sedation Scale (Hummel, et al., 2008)	5 items: 4 behavioral items (Crying/irritability, behavior/state, facial expression, extremities/tone, and 1 physiological item (vital signs: heart rate, RR, BP, SaO 2) Score: 0 – 10	Ongoing pain (ventilation Sedation level), Procedural pain, Postoperative pain, Preterm, Full-term 23 - 40 wks GA	Internal consistency: 0.85–0.95 InterRR: 0.88–0.93 Test –retest reliability: 0.87
PIPP - Premature Infant Pain Profile(Stevens et al., 1996); PIPP-R - Premature Infant Pain Profile – revised (Stevens, et al., 2014)	7 items: 3 behavioral items (brow bulge, eye squeeze, nasolabial furrow), 2 physiological items (heart rate, oxygen saturation), and 2 Contextual items (gestational age, behavioral state) Score: 0 – 18 (full-term); 21 (preterm)	Procedural pain, postoperative pain; Preterm, Full-term 28 - 42 wks GA The most commonly used tools in research studies.	InterRR: 0.93-0.96 IntraRR: 0.94-0.98 Content & construct validity: Yes

Note. wks = weeks; GA = gestational age; InterRR = inter-rater reliability; IntraRR = intra-rater reliability.