Pain assessment:  NIPS

Pain assessment in the newborn, particularly the premature neonate, is problematic given their neurologic immaturity and inconsistent and/or weak responses to stimuli, especially when ill.  However, nociception is intact at a very early gestational age, and appropriate pain management is an important part of neonatal intensive care.  Analgesia has unequivocally been shown to improve post-surgical outcomes; and potential benefits for long-term neurodevelopmental maturation, although still under investigation, are quite plausible.

Several observational/behavioral scales to quantify neonatal pain have been validated as sensitive to patient distress.  The tool currently in use at Vanderbilt is the Neonatal Infant Pain Scale (NIPS.)


Neonatal Infant Pain Scale (NIPS)


Facial expression

0 – Relaxed muscles                 Restful face, neutral expression

1 – Grimace                             Tight facial muscles, furrowed brow, chin, jaw


0 – No cry                               Quiet

1 – Whimper                            Intermittent mild moaning

2 – Vigorous cry                       Loud scream; continuous shrill crying

                                                (Note: A silent cry may be scored if the baby is intubated,        

                                                but crying is evidenced by facial movement.)

Breathing pattern         

0 – Relaxed                              Usual pattern for the individual baby

1 – Change in breathing            Retractions, irregular respirations, tachypnea, gagging, breath holding


0 – Relaxed                              No muscular rigidity, occasional random movements

1 – Flexed/Extended                 Tense straight arms, rigid and/or rapid extension/flexion


0 – Relaxed                              No muscular rigidity, occasional random movements

1 – Flexed/Extended                 Tense straight legs, rigid and/or rapid extension/flexion

State of arousal

0 – Sleeping/ Awake                Quiet, peaceful, sleeping or alert and settled

1 – Fussy                                 Alert, restless, thrashing



NIPS Interpretation

  0              No pain

<2              Mild discomfort

                             2-4              Mild to moderate pain

                             4-7              Moderate to severe pain

Changes in baseline physiologic parameters (tachycardia, tachypnea, apnea, desaturation, hypertension) may also represent pain, but are less reliable, as they are influenced by multiple variables.  However, the combination of tachycardia and hypertension in a post-op patient often is the first sign of awareness of pain. 

Timing and frequency of pain assessments

All patients in the NICU should have a pain assessment and a NIPS score recorded as part of their vital signs q shift.

Surgical patients:

For the first 3 days post-op, a pain assessment and NIPS score should be recorded q 4 hours.  After the first 3 post-op days, NIPS scoring may be reduced to q shift; unless the NIPS score is > 4 or there are physiologic signs of ongoing pain, in which case, pain assessment should continue q 4 hours.

Adequacy of pain control should also be assessed during and after major/minor intensive care procedures, including PICC or BROVIAC® catheter placement, chest tube placement, lumbar puncture, IV insertion, endotracheal intubation, circumcision, etc.


Anand, KJS and the International Evidence-Based Group for Neonatal Pain.   Consensus Statement for the Prevention and Management of Pain in the Newborn.  Archives of Pediatric and Adolescent Medicine 2001;155:173-180.  

Lawrence J, et al.  The development of a tool to assess neonatal pain.  Neonatal Network 1993;12(6):59-66.

BROVIAC® is a registered trademark of C.R.Bard, Inc. and its related company, BCR, Inc.

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