Research PaperQuantification of neonatal procedural pain severity: a platform for estimating total pain burden in individual infantsLaudiano-Dray, Maria Purezaa,*; Pillai Riddell, Rebeccab,c; Jones, Lauraa; Iyer, Rajeshwaria; Whitehead, Kimberleya; Fitzgerald, Mariaa; Fabrizi, Lorenzoa; Meek, JudithdAuthor Information aDepartment of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom bDepartment of Psychology, Faculty of Health, The O.U.C.H. Lab, York University, Toronto, ON, Canada cPsychiatry Research, Hospital for Sick Children, Toronto, ON, Canada dNeonatal Unit, Elizabeth Garrett Anderson Obstetric Wing, University College London Hospitals, London, United Kingdom *Corresponding author. Address: Department of Neuroscience, Physiology and Pharmacology, Medawar Building, Room G17, University College London, Gower St, London, WC1E 6BT, United Kingdom. Tel.: +44 (0)20 76793533. E-mail address: firstname.lastname@example.org (M.P. Laudiano-Dray). Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.painjournalonline.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. PAIN: June 2020 - Volume 161 - Issue 6 - p 1270-1277 doi: 10.1097/j.pain.0000000000001814 Buy SDC Metrics AbstractIn Brief There is increasing evidence that long-term outcomes for infants born prematurely are adversely affected by repeated exposure to noxious procedures. These interventions vary widely, for example, in the extent of damage caused and duration. Neonatal intensive care unit (NICU) procedures are therefore likely to each contribute differently to the overall pain burden of individual neonates, ultimately having a different impact on their development. For researchers to quantify the procedural pain burden experienced by infants on NICU, we aimed to estimate the pain severity of common NICU procedures using published pain scores. We extracted pain scores over the first minute (pain reactivity) from the literature, using 59 randomized controlled trials for 15 different procedures. Hierarchical cluster analysis of average pain scores resulted in 5 discrete severity groups; mild (n = 1), mild to moderate (n = 3), moderate (n = 7), severe (n = 3), and very severe (n = 1). The estimate of the severity of individual procedures provided new insight into infant pain reactivity which is not always directly related to the invasiveness and duration of a procedure; thus, both heel lance and skin tape removal are moderately painful procedures. This estimate of procedural pain severity, based on pain reactivity scores, provides a novel platform for retrospective quantification of an individual neonate's pain burden due to NICU procedures. The addition of measures that reflect the recovery from each procedure, such as brain activity and behavioural regulation, would further improve estimates of the pain burden of neonatal intensive care. A novel estimator, based on published pain reactivity scores, shows that common neonatal intensive care unit procedures fall into one of 5 severity groups from mild to severe. Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.