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. 2025 Apr 14;4(4):MR000064.
doi: 10.1002/14651858.MR000064.pub2.

Clinical rating scales for assessing pain in newborn infants

Kenneth Färnqvist  1 , Emma Olsson  2   3 , Andrew Garratt  4 , Themistoklis Paraskevas  5 , Roger F Soll  6 , Matteo Bruschettini  7   8 , Emma Persad  9   10
Affiliations

Clinical rating scales for assessing pain in newborn infants

Kenneth Färnqvist et al. Cochrane Database Syst Rev. .

Abstract

Background: Six to nine per cent of all newborn infants require admission to a neonatal intensive care unit (NICU) due to either illness or prematurity. During their stay, these infants are often subjected to many painful procedures that can cause negative long-term consequences. To reduce the negative effects of pain exposure and ensure optimal and safe pain treatment, accurate assessment of pain is necessary. To achieve this, clinicians are dependent on the use of reliable, objective, and standardised clinical rating scales of pain, henceforth referred to as 'rating scales'. Numerous rating scales have been published; however, discrepancies in validity limit their overall applicability in clinical practice and research. Such limitations may lead to an over- or underestimation of pain, resulting in unnecessary sedation or inadequately treated pain, potentially jeopardising infant safety through treatment side effects, including withdrawal symptoms or prolonged discomfort. To date, the majority of rating scales have been developed to assess procedural pain, whilst fewer scales for prolonged pain are available. Premature infants further complicate matters, as they often have a reduced ability to display robust pain behaviour due to their immaturity. Research has also shown that the use of rating scales in clinical practice is suboptimal, due to both inadequate and infrequent implementation alongside inappropriate choice of scale for the specific pain, population, or setting under evaluation. Despite numerous studies investigating the burden of pain in newborn infants, little work has been done to summarise the current evidence on the appropriateness of rating scales for specific types of pain or infant conditions. This has likely been limited by the subjectivity of pain assessment and further complication of assessing such a non-verbal and immature patient population. The immense burden of neonatal pain worldwide has also led to the development of numerous rating scales in various languages, further hindering evidence summation.

Objectives: To systematically review the literature to compile and describe the development, content, and measurement properties of clinical rating scales for the assessment of pain in newborn infants.

Search methods: An Information Specialist systematically searched CENTRAL, PubMed, Embase, and CINAHL. The latest update search is current to July 2023.

Selection criteria: We included all study designs that involved the development or testing of a rating scale for assessing pain in newborn infants. We included preterm (born before week 37) and term (born at week 37 or beyond) infants undergoing pain assessment for any medical indication. We also included studies that included healthcare professionals.

Data collection and analysis: We evaluated clinical rating scales assessing pain in newborn infants using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology evaluating content validity, structural validity, internal consistency, reliability, measurement error, hypothesis testing, and cross-cultural validation. We used a modified GRADE approach to assess risk of bias, inconsistency, imprecision, and indirectness.

Main results: We included 79 studies involving a total of 7197 infants, 326 nurses, and 12 physicians. Twenty-seven clinical rating scales were used in 26 countries, with 14 studies evaluating preterm infants, 11 on term infants, 46 on both preterm and term infants, four solely on medical staff, and four on preterm and/or term infants plus medical staff. Following the COSMIN checklist, we found all rating scales to be of very low-certainty evidence, raising concerns regarding their validity, reliability, and applicability in this vulnerable population across diverse clinical settings.

Authors' conclusions: Clinical staff should be vigilant when applying the currently available neonatal rating scales. Further development of rating scale content and testing for structural validity are necessary and should be prioritised. Together, they determine the content and structure of rating scales, underpin further testing, including reliability, and their prioritisation will make the greatest contribution to the evidence base for rating scales to assess neonatal pain. Collaborative efforts between clinicians and methodology experts will prevent methodological pitfalls and contribute to improving the validity and reliability of pain-rating scales in neonatology.

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Conflict of interest statement

KF has no conflicts to declare.

EO has no conflicts to declare.

AG has no conflicts to declare.

TP has no conflicts to declare.

RS is the Co‐ordinating Editor of Cochrane Neonatal, Vice President and Director of Clinical Trials of the Vermont Oxford Network, and Professor at the Larner College of Medicine, University of Vermont. He did not take part in the editorial processes for this review. He has a grant from Gerber Foundation to update reviews on interventions for pain and discomfort.

MB has no known conflicts of interest. MB is an Associate Editor with Cochrane Neonatal, but did not take part in the editorial acceptance or processing of this manuscript.

EP is an elected Governing Board Trustee.

Update of

  • doi: 10.1002/14651858.MR000064

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Uyan 2008 {published data only}
    1. Uyan ZS, Bilgen H, Topuzoğlu A, Akman I, Ozek E. Comparison of three neonatal pain scales during minor painful procedures. Journal of Maternal-Fetal & Neonatal Medicine 2008;21(5):305-8. [DOI: 10.1080/14767050802034107] - DOI - PubMed
van Dijk 2009 {published data only}
    1. Dijk M, Roofthooft DW, Anand KJ, Guldemond F, Graaf J, Simons S, et al. Taking up the challenge of measuring prolonged pain in (premature) neonates: the COMFORTneo scale seems promising. Clinical Journal of Pain 2009;25(7):607-16. [DOI: 10.1097/AJP.0b013e3181a5b52a] - DOI - PubMed
Vederhus 2006 {published data only}
    1. Vederhus BJ, Eide GE, Natvig GK. Psychometric testing of a Norwegian version of the Premature Infant Pain Profile: an acute pain assessment tool. A clinical validation study. International Journal of Nursing Practice 2006;12(6):334-44. [DOI: 10.1111/j.1440-172X.2006.00592.x] - DOI - PubMed
Vederhus 2023 {published data only}
    1. Vederhus BJ, Olsen MS, Eide GE, Storm H, Guthe HJ. ALPS-Neo pain and stress assessment scale for neonates – a measure for procedural pain. Acta Paediatrica 2023;112(6):1220-5. [DOI: 10.1111/apa.16759] - DOI - PubMed
Woragidpoonpol 2018 {published data only}
    1. Woragidpoonpol P, Tiansawad S, Mesukko J, Klunklin P. Development of a clinical pain scale for preterm neonates. Pacific Rim International Journal of Nursing Research 2018;22(4):347-59.
Xie 2021 {published data only}
    1. Xie W, Wang X, Huang R, Chen Y, Guo X. Assessment of four pain scales for evaluating procedural pain in premature infants undergoing heel blood collection. Pediatric Research 2021;89(7):1724-31. [DOI: 10.1038/s41390-020-1034-z] - DOI - PubMed
Zengin 2021 {published data only}
    1. Zengin D, Ardahan Sevgili S, Yardimci F, Calkavur S, Basbakkal Z. Psychometric properties of the Turkish version of the neonatal infant acute pain assessment scale. Journal of Pediatric Nursing 2021;61:e87-92. [DOI: 10.1016/j.pedn.2021.05.006] - DOI - PubMed

References to studies excluded from this review

Ahola Kohut 2009 {published data only}
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Alberice 2021 {published data only}
    1. Alberice RM, Silva SC, Leite AC, Manzo BF, Simão DA, Marcatto JO. Assessment of newborn pain during arterial puncture: an observational analytical study. Revista Brasileira de Terapia Intensiva 2021;33:434-9. [DOI: 10.5935/0103-507X.20210058] - DOI - PMC - PubMed
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Andersen 2014 {published data only}
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Avila‐Alvarez 2016 {published data only}
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Bachiller Carnicero 2022 {published data only}
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Buchholz 1998 {published data only}
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Bueno 2013 {published data only}
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Büttner 1998 {published data only}
    1. Buttner W, Finke W, Hilleke M, Reckert S, Vsianska L, Brambrink A. Development of an observational scale for the assessment of postoperative pain in infants. Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie 1998;33(6):353-61. [DOI: 10.1055/s-2007-994263] - DOI - PubMed
Büttner 2000 {published data only}
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Buyuktiryaki 2018 {published data only}
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Cheng 2003 {published data only}
    1. Cheng S, Hester NO, Foster RL, Wang J. Assessment of the convergent validity of pain intensity in the Pain Sensory Tool. Journal of Nursing Research (Taiwan Nurses Association) 2003;11(2):93-100. [DOI: 10.1097/01.jnr.0000347624.49605.7b] - DOI - PubMed
Cheng 2022 {published data only}
    1. Cheng X, Zhu H, Mei L, Luo F, Chen X, Zhao Y, et al. Artificial intelligence based pain assessment technology in clinical application of real-world neonatal blood sampling [w]. Diagnostics (Basel, Switzerland) 2022;12(8):1831. [DOI: 10.3390/diagnostics12081831] - DOI - PMC - PubMed
Craske 2013 {published data only}
    1. Craske J, Dooley F, Griffiths L, McArthur L, White E, Cunliffe M. Introducing LAPPS (Liverpool Anticipatory Procedural Pain Score): The pragmatic development of an innovative approach to predicting and treating procedural pain and distress in children. Journal of Child Health Care 2013;17(2):114-124. [DOI: 10.1177/1367493512456112] - DOI - PubMed
Da Motta 2015 {published data only}
    1. Motta Gde C, Schardosim JM, Cunha ML. Neonatal infant pain scale: cross-cultural adaptation and validation in Brazil. Journal of Pain and Symptom Management 2015;50(3):394-401. - PubMed
de Jong 2010 {published data only}
    1. Jong A, Baartmans M, Bremer M, Komen R, Middelkoop E, Tuinebreijer W, et al. Reliability, validity and clinical utility of three types of pain behavioural observation scales for young children with burns aged 0-5 years. Pain 2010;150(3):561-567. [DOI: 10.1016/j.pain.2010.06.016] - DOI - PubMed
de Jong 2012 {published data only}
    1. Jong AE, Tuinebreijer WE, Bremer M, Komen R, Middelkoop E, Loey N, et al. Construct validity of two pain behaviour observation measurement instruments for young children with burns by Rasch analysis. Pain 2012;153(11):2260-2266. [DOI: 10.1016/j.pain.2012.07.021] - DOI - PubMed
Desai 2018 {published data only}
    1. Desai A, Aucott S, Frank K, Silbert-Flagg J. Comparing N-PASS and NIPS: improving pain measurement in the neonate. Advances in Neonatal Care 2018;18(4):260-6. - PubMed
Dietrich 2020 {published data only}
    1. Dietrich S, Bürger F, Kugler C. Implementierung eines neonatalen Schmerzassessmentinstruments auf einer neonatologischen Intensivstation – Ein Qualitätsentwicklungsprojekt. Pflege 2020;33(6):385-395. [DOI: 10.1024/1012-5302/a000769] - DOI - PubMed
Elias 2008 {published data only}
    1. Elias LS, Guinsburg R, Peres CA, Balda RC, Santos AM. Disagreement between parents and health professionals regarding pain intensity in critically ill neonates. Jornal de Pediatria 2008;84(1):35-40. - PubMed
Fortney 2020 {published data only}
    1. Fortney CA, Sealschott SD, Pickler RH. Behavioral O=observation of infants with life-threatening or life-limiting illness in the neonatal intensive care unit. Nursing Research 2020;69:S29-35. - PMC - PubMed
Franck 2011 {published data only}
    1. Franck LS, Ridout D, Howard R, Peters J, Honour JW. A comparison of pain measures in newborn infants after cardiac surgery. Pain 2011;152(8):1758-1765. [DOI: 10.1016/j.pain.2011.03.017] - DOI - PubMed
Fuller 2000 {published data only}
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Fuller 2001 {published data only}
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Gallo 2003 {published data only}
    1. Gallo AM. The fifth vital sign: implementation of the Neonatal Infant Pain Scale. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2003;32(2):199-206. [DOI: 10.1177/0884217503251745] - DOI - PubMed
Ganguly 2016 {published data only}
    1. Ganguly A, Bhadesia P, Nimbalkar S, Phatak A, Nimbalkar A. Do routine procedures in the neonatal intensive care unit (NCU) cause pain: a video based assessment using premature infant pain profile (PIPP). European Journal of Pediatrics 2016;175(11):1825. [DOI: 10.1007/s00431-016-2785-8] - DOI
Ganguly 2020 {published data only}
    1. Ganguly A, Bhadesia PJ, Phatak AG, Nimbalkar AS, Nimbalkar SM. Pain profile of premature infants during routine procedures in neonatal intensive care: an observational study. Journal of Family Medicine and Primary Care 2020;9(3):1517-1521. [DOI: 10.4103/jfmpc.jfmpc_1033_19] - DOI - PMC - PubMed
Garten 2010 {published data only}
    1. Garten L, Deindl P, Schmalisch G, Metze B, Buhrer C. Parallel assessment of prolonged neonatal distress by empathy-based and item-based scales. European Journal of Pain (London, England) 2010;14(8):878-81. [DOI: 10.1016/j.ejpain.2010.01.004] - DOI - PubMed
Ge 2015 {published data only}
    1. Ge X, Tao JR, Wang J, Pan SM, Wang YW. Bayesian estimation on diagnostic performance of Face, Legs, Activity, Cry, and Consolability and Neonatal Infant Pain Scale for infant pain assessment in the absence of a gold standard. Paediatric Anaesthesia 2015;25(8):834-839. [DOI: 10.1111/pan.12664] - DOI - PubMed
Gimenez 2020 {published data only}
    1. Gimenez IL, Arakaki VDSNM, Correa RM, Santos RSD, Peres RT, Sant'Anna CC, Ferreira HC. Neonatal pain: characterization of the physiotherapist's perception in the neonatal intensive care unit. Revista Paulista de Pediatria 2020;38:e2018178. [DOI: 10.1590/1984-0462/2020/38/2018178] - DOI - PMC - PubMed
Giordano 2014a {published data only}
    1. Giordano V, Deindl P, Kuttner S, Waldhor T, Berger A, Olischar M. The Neonatal Pain, Agitation and Sedation Scale reliably detected oversedation but failed to differentiate between other sedation levels. Acta Paediatrica 2014;103(12):e515-21. [DOI: 10.1111/apa.12770] - DOI - PubMed
Giordano 2014b {published data only}
    1. Giordano V, Deindl P, Kuttner S, Waldhor T, Werther T, Czaba C, et al. Validation of the neonatal pain, agitation and sedation scale for the assessment of sedation in neonatal intensive care patients. Archives of Disease in Childhood 2014;99:A69. [DOI: 10.1136/archdischild-2014-307384.181] - DOI
    1. Giordano V, Deindl P, Waldhor T, Werther T, Czaba C, Berger A, et al. Validation of the Neonatal Pain, Agitation and Sedation Scale for the assessment of sedation in neonatal intensive care patients. Monatsschrift fur Kinderheilkunde 2013;161:278. [DOI: 10.1007/s00112-013-2992-6] - DOI
    1. Giordano V, Deindl P, Werther T, Czaba C, Berger A, Pollak A, et al. Validation of the neonatal pain, agitation and sedation scale for the assessment of sedation in neonatal intensive care patients. Monatsschrift fur Kinderheilkunde 2014;162(1):6. [DOI: 10.1007/s00112-014-3151-4] - DOI
Heng 2014 {published data only}
    1. Heng RM, Poon WB, Ho SK. Flacc is a valid and reliable tool as compared to the PIPP for assessment of neonatal pain. Archives of Disease in Childhood 2014;99:A491. [DOI: 10.1136/archdischild-2014-307384.1362] - DOI
Hillman 2015 {published data only}
    1. Hillman BA, Tabrizi MN, Gauda EB, Carson KA, Aucott SW. The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse's assessment of neonates. Journal of Perinatology 2014;35(2):128-31. [DOI: 10.1038/jp.2014.154] - DOI - PMC - PubMed
    1. Hillman BA, Tabrizi MN, Gauda EB, Carson KA, Aucott SW. The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse's assessment of neonates. Journal of Perinatology 2015;35(2):128-31. [DOI: 10.1038/jp.2014.154] - DOI - PMC - PubMed
Horgan 1996 {published data only}
    1. Horgan M, Choonara I, Al-Waidh M, Sambrooks J, Ashby D. Measuring pain in neonates: an objective score. Paediatric Nursing 1996;8(10):24-27. - PubMed
Horgan 2002 {published data only}
    1. Horgan MF, Glenn S, Choonara I. Further development of the Liverpool infant distress scale. Journal of Child Health Care 2002;6(2):96-106. [DOI: 10.1177/136749350200600203] - DOI - PubMed
Hoshino 2019 {published data only}
    1. Hoshino H, Sakuramoto H, Matsuishi Y, Shimojo N, Enomoto Y, Ohto T, et al. Development of the Japanese version of the State Behavioral Scale for critically ill children. Acute Medicine and Surgery 2019;6(2):101-108. [DOI: 10.1002/ams2.379] - DOI - PMC - PubMed
Hughes 2023 {published data only}
    1. Hughes JD, Chivers P, Hoti K. The clinical suitability of an artificial intelligence-enabled pain assessment tool for use in infants: feasibility and usability evaluation study. Journal of Medical Internet Research 2023;25:e41992. [DOI: 10.2196/41992] - DOI - PMC - PubMed
Hummel 2014 {published data only}
    1. Hummel P. Psychometric evaluation of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) tool in infants and children age one to thirty-six months in the post-anesthesia care unit. Loyola, University of Chicago 2014.
Hummel 2017 {published data only}
    1. Hummel P. Psychometric evaluation of the neonatal pain, agitation, and sedation (N-PASS) scale in infants and children up to age 36 months. Pediatric Nursing 2017;43(4):175-184.
Hünseler 2011 {published data only}
    1. Hunseler C, Merkt V, Gerloff M, Eifinger F, Kribs A, Roth B. Assessing pain in ventilated newborns and infants: validation of the Hartwig score. European Journal of Pediatrics 2011;170(7):837-43. [DOI: 10.1007/s00431-010-1354-9] - DOI - PubMed
Ilhan 2022 {published data only}
    1. Ilhan E, Pacey V, Brown L, Spence K, Van Ganzewinkel CJ, Pillai Riddell R, et al. What is the definition of acute episodic and chronic pain in critically ill neonates and infants? A global, four-stage consensus and validation study. BMJ Open 2022;12(3):e055255. [DOI: 10.1136/bmjopen-2021-055255] - DOI - PMC - PubMed
Joyce 1994 {published data only}
    1. Joyce BA, Schade JG, Keck JF, Gerkensmeyer J, Raftery T, Moser S, et al. Reliability and validity of preverbal pain assessment tools. Issues in Comprehensive Pediatric Nursing 1994;17(3):121-135. - PubMed
Kleiber 2005 {published data only}
    1. Kleiber C, Bartruff L, Berends S, Crowley L, Geyer J, Gordon S, et al. Validation of the Children's Hospital of Iowa Infant Pain (CHIIP) scale. No conference or journal specified 2005:1-1.
Lyngstad 2022 {published data only}
    1. Lyngstad LT, Steinnes S, Le Marechal F. Improving pain management in a neonatal intensive care unit with single-family room – a quality improvement project. Paediatric & Neonatal Pain 2022;4(2):69-77. [DOI: 10.1002/pne2.12075] - DOI - PMC - PubMed
Matsuishi 2018 {published data only}
    1. Matsuishi Y, Hoshino H, Shimojo N, Enomoto Y, Kido T, Hoshino T, et al. Verifying the validity and reliability of the Japanese version of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale. PLOS ONE 2018;13(3):e0194094. [DOI: 10.1371/journal.pone.0194094] - DOI - PMC - PubMed
McNair 2004 {published data only}
    1. McNair C, Ballantyne M, Dionne K, Stephens D, Stevens B. Postoperative pain assessment in the neonatal intensive care unit. Archives of Disease in Childhood. Fetal and Neonatal Edition 2004;89(6):F537-41. [DOI: 10.1136/adc.2003.032961] - DOI - PMC - PubMed
Meesters 2019 {published data only}
    1. Meesters N, Dilles T, Simons S, Dijk M. Do pain measurement instruments detect the effect of pain-reducing interventions in neonates? A systematic review on responsiveness. Journal of Pain 2019;20(7):760-770. [DOI: 10.1016/j.jpain.2018.12.005] - DOI - PubMed
Menegol 2022 {published data only}
    1. Menegol NA, Ribeiro SN, Paula AC, Montemezzo D, Sanada LS. A cross-cultural adaptation and content validity of comfortneo scale into Brazilian Portuguese. Journal of Pain and Symptom Management 2022;64(6):e323-e330. [DOI: 10.1016/j.jpainsymman.2022.08.006] - DOI - PubMed
Messerer 2010 {published data only}
    1. Messerer B, Weinberg AM, Sandner-Kiesling A, Gutmann A, Mescha S, Meissner W. Quality improvement of postoperative pain management in infants QUIPSI) - A pilot study. Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie 2010;45(9):592-4. [DOI: 10.1055/s-0030-1265752] - DOI - PubMed
Min 2018 {published data only}
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Morgan 2020 {published data only}
    1. Morgan ME, Kukora S, Nemshak M, Shuman CJ. Neonatal Pain, Agitation, and Sedation Scale's use, reliability, and validity: a systematic review. Journal of Perinatology 2020;40(12):1753-1763. [DOI: 10.1038/s41372-020-00840-7] - DOI - PubMed
Olsson 2018 {published data only}
    1. Olsson E, Anderzén-Carlsson A, Atladóttir SM, Axelin A, Campbell-Yeo M, Eriksson M, et al. Cultural adaptation and harmonization of four Nordic translations of the revised Premature Infant Pain Profile (PIPP-R). British Medical Council Pediatrics 2018;18(1):349. - PMC - PubMed
Peipoch 2014 {published data only}
    1. Peipoch L, Breinig S, Pelluau S, Berthomieu L, Gineste M, Bloom MC, et al. Premature infant pain profile (PIPP) in neonatal intensive care unit: A pilot study. Archives of Disease in Childhood 2014;99:A69. [DOI: 10.1136/archdischild-2014-307384.183] - DOI
Peters 2003 {published data only}
    1. Peters JW, Koot HM, Grunau RE, Boer J, Druenen MJ, Tibboel D, et al. Neonatal Facial Coding System for assessing postoperative pain in infants: item reduction is valid and feasible. Clinical Journal of Pain 2003;19(6):353-63. [DOI: 10.1097/00002508-200311000-00003] - DOI - PubMed
Pillai Riddell 2014 {published data only}
    1. Pillai Riddell R, Flora DB, Stevens S, Greenberg S, Garfield H. The role of infant pain behaviour in predicting parent pain ratings. Pain Research & Management 2014;19(5):e124-32. [DOI: 10.1155/2014/934831] - DOI - PMC - PubMed
Ramelet 2007a {published data only}
    1. Ramelet AS, Rees NW, McDonald S, Bulsara MK, Huijer Abu-Saad H. Clinical validation of the multidimensional assessment of pain scale. Paediatric Anaesthesia 2007;17(12):1156-65. [DOI: 10.1111/j.1460-9592.2007.02325.x] - DOI - PubMed
Ramelet 2007b {published data only}
    1. Ramelet AS, Rees N, McDonald S, Bulsara M, Abu-Saad HH. Development and preliminary psychometric testing of the Multidimensional Assessment of Pain Scale: MAPS. Paediatric Anaesthesia 2007;17(4):333-40. [DOI: 10.1111/j.1460-9592.2006.02115.x] - DOI - PubMed
Roué 2018 {published data only}
    1. Roue JM, Rioualen S, Gendras J, Misery L, Gouillou M, Sizun J. Multi-modal pain assessment: are near-infrared spectroscopy, skin conductance, salivary cortisol, physiologic parameters, and Neonatal Facial Coding System interrelated during venepuncture in healthy, term neonates? Journal of Pain Research 2018;11:2257-2267. [DOI: 10.2147/jpr.S165810] - DOI - PMC - PubMed
Salekin 2022 {published data only}
    1. Salekin MS, Zamzmi G, Goldgof D, Mouton PR, Anand KJ, Ashmeade T, et al. Attentional generative multimodal network for neonatal postoperative pain estimation. Medical Image Computing and Computer-Assisted Intervention – MICCAI 2022 2022;13433:749-759. [DOI: 10.1007/978-3-031-16437-8_72] - DOI - PMC - PubMed
Schiavenato 2013 {published data only}
    1. Schiavenato M, Antos SA, Bell FA, Freedman BR, Kozak AJ, Kroot TB, et al. Development of a scale for estimating procedural distress in the newborn intensive care unit: the Procedural Load Index. Early Human Development 2013;89(9):615-9. [DOI: 10.1016/j.earlhumdev.2013.04.007] - DOI - PubMed
Snoek 2015 {published data only}
    1. Snoek KG, Timmers M, Albertyn R, Dijk M. Pain indicators for persisting pain in hospitalized infants in a South African setting: an explorative study. Journal of Pain & Palliative Care Pharmacotherapy 2015;29(2):125-32. [DOI: 10.3109/15360288.2015.1035830] - DOI - PubMed
Sparshott 1996 {published data only}
    1. Sparshott MM. The development of a clinical distress scale for ventilated newborn infants: identification of pain and distress based on validated behavioural scores. Journal of Neonatal Nursing 1996;2(2):5-11.
Stenkjaer 2014 {published data only}
    1. Stenkjaer R, Andersen M, Scheutz M, Hundrup Y. Translation comfortneo – a pain assessment tool. Archives of Disease in Childhood 2014;99:A545. [DOI: 10.1136/archdischild-2014-307384.1523] - DOI
Stokowski 2008 {published data only}
    1. Stokowski LA. Validation of the N-PASS. Advances in Neonatal Care 2008;8(2):75. [DOI: 10.1097/01.Anc.0000317250.45707.87] - DOI - PubMed
Taddio 2009 {published data only}
    1. Taddio A, O'Brien L, Ipp M, Stephens D, Goldbach M, Koren G. Reliability and validity of observer ratings of pain using the visual analog scale (VAS) in infants undergoing immunization injections. Pain 2009;147(1-3):141-6. [DOI: 10.1016/j.pain.2009.08.027] - DOI - PubMed
Taddio 2010 {published data only}
    1. Taddio A, Hogan M, Moyer P, Girgis A, Ipp M, Stephens D. Reliability and validity of three scales for pain assessment in infants undergoing immunization injections. Canadian Journal of Infectious Diseases and Medical Microbiology 2010;21(4):194.
Tannous Elias 2014 {published data only}
    1. Tannous Elias LS, Dos Santos AM, Guinsburg R. Perception of pain and distress in intubated and mechanically ventilated newborn infants by parents and health professionals. BioMed Central Pediatrics 2014;14:44. - PMC - PubMed
Tasca 2016 {published data only}
    1. Tasca T, Spata M, Badon P, Pellegatta F, Buchini S, Monterosso A, et al. La scala algometrica PIPP: valutazione dell'accuratezza per la rilevazione del dolore procedurale nel neonato. Pain Nursing Magazine 2016;5(3):121-126. [DOI: 10.19190/PNM2016.3ao121] - DOI
Tischler 2022 {published data only}
    1. Tischler M, Kappesser J, Utsch B, Ehrhardt H, Hermann C, Zimmer KP, et al. Item reduction to improve practicability of neonatal pain assessment tools – comparison of nfcsshort and PIPP in daily clinical practice. Klinische Padiatrie 2022;234(2):68-73. [DOI: 10.1055/a-1550-2765] - DOI - PubMed
Tristão 2013 {published data only}
    1. Tristao RM, Garcia NV, Jesus JA, Tomaz C. COMFORT behaviour scale and skin conductance activity: what are they really measuring? Acta Paediatrica 2013;102(9):e402-6. [DOI: 10.1111/apa.12325] - DOI - PubMed
Uberos 2022 {published data only}
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