Research PapersBedside application of the Neonatal Facial Coding System in pain assessment of premature infantsGrunau, Ruth Ecksteina,b,c,*; Oberlander, Tima,b; Holsti, Liisac; Whitfield, Michael F.b,c Author Information aCentre for Community Child Health Research, B.C. Research Institute for Children's and Women's Health, Vancouver, BC V6H 3V4, Canada bDepartment of Paediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada cB.C.’s Children's Hospital, Vancouver, BC V6H 3V4, Canada *Corresponding author. Rm. L408, 4480 Oak Street St., Vancouver, BC V6H 3V4, Canada. Tel.: +1 604 8753570; fax: +1 604 8753569; e-mail: [email protected] Submitted May 27, 1997; revised January 30, 1998; accepted February 17, 1998. Pain: June 1998 - Volume 76 - Issue 3 - p 277-286 doi: 10.1016/S0304-3959(98)00046-3 Buy Metrics Abstract Assessment of infant pain is a pressing concern, especially within the context of neonatal intensive care where infants may be exposed to prolonged and repeated pain during lengthy hospitalization. In the present study the feasibility of carrying out the complete Neonatal Facial Coding System (NFCS) in real time at bedside, specifically reliability, construct and concurrent validity, was evaluated in a tertiary level Neonatal Intensive Care Unit (NICU). Heel lance was used as a model of procedural pain, and observed with n=40 infants at 32 weeks gestational age. Infant sleep/wake state, NFCS facial activity and specific hand movements were coded during baseline, unwrap, swab, heel lance, squeezing and recovery events. Heart rate was recorded continuously and digitally sampled using a custom designed computer system. Repeated measures analysis of variance (ANOVA) showed statistically significant differences across events for facial activity (P<0.0001) and heart rate (P<0.0001). Planned comparisons showed facial activity unchanged during baseline, swab and unwrap, then increased significantly during heel lance (P<0.0001), increased further during squeezing (P<0.003), then decreased during recovery (P<0.0001). Systematic shifts in sleep/wake state were apparent. Rise in facial activity was consistent with increased heart rate, except that facial activity more closely paralleled initiation of the invasive event. Thus facial display was more specific to tissue damage compared with heart rate. Inter-observer reliability was high. Construct validity of the NFCS at bedside was demonstrated as invasive procedures were distinguished from tactile. While bedside coding of behavior does not permit raters to be blind to events, mechanical recording of heart rate allowed for an independent source of concurrent validation for bedside application of the NFCS scale. © Lippincott-Raven Publishers.