Support during painful procedures and pain assessment


Oude-Reimer M, Frauenfelder O, Binter J, Cámba F, Ceccatelli M, Hankes-Drielsma I, Jørgensen E, Silva E

Target group

Infants and parents

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

All infants in neonatal and paediatric units receive optimal comfort to minimise stress and pain, supported by their parents.


Provision of optimal comfort, recognition, and treatment of pain are core skills underpinning all clinical care. Infants may be subjected to a large number of painful and stressful, although necessary, procedures during their care. (1,2) Infants depend on others to recognise, to assess and to treat pain and discomfort. (3–9) The situation for the preterm infant is more complex than that of the full term infant, since they often require intensive or high dependency care for many weeks, and their immature stage of neuromotor development may minimise the external manifestations of distress. Compared to older children and adults, infants are less able to communicate their pain and discomfort and are at greater risk for inadequate analgesia. Although awareness of symptoms of pain and stress is increasing, they are still often underestimated. (10)

Pain and stress may be minimised by regular expert prospective observation, respect for the infant’s behavioural cues of pain and discomfort, attention to positioning, the immediate environment and timing of intervention, and appropriate use of pain relief strategies, including non-pharmacological strategies (5) (e.g. tuck, wrap, giving individualised supportive care and use of pacifiers) and analgesics. For some non-urgent procedures, you can expect the parents of the infant in the NICU and apply with them the non-pharmacological pain relief procedures, programming the timing of the intervention. (11)


Short-term benefits

  • Improved sleep (12)
  • Improved digest of feeding (13)
  • Improved weight gain (13)
  • Improved cortisol levels (13)
  • Improved physiologic stability (14)

Long-term benefits

  • Improved brain structure and development (6)
  • Improved behaviour (6,12)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about strategies to optimise comfort, minimise painful stimuli and manage unavoidable pain during care. A (High quality)
B (High quality)
Patient information sheet
2. Parents are informed by healthcare professionals about and offered the opportunity to be present and assist during procedures, when appropriate. (10) A (High quality)
B (High quality)
Audit report, patient information sheet
3. Parents are educated by healthcare professionals to recognise pain and discomfort signals in their infant and how to comfort the infant. (15) A (High quality)
B (High quality)
Patient information sheet, training documentation
For healthcare professionals    
4. A unit guideline on the importance of appropriate pharmacologic and non-pharmacologic pain relief strategies during care and procedures is adhered to by all healthcare professionals. B (High quality) Audit report, guideline
5. Training to recognise pain and distress in term and preterm infants is attended by all responsible healthcare professionals. (3) A (High quality)
B (High quality)
Audit report, training documentation
6. Training to avoid any non-essential painful and discomfort procedures is attended by all healthcare professionals. (3) A (High quality)
B (High quality)
Training documentation
7. Pain and stress are assessed using validated tools. (6,9) A (High quality)
B (High quality)
Assessment tools
8. All infants receive appropriate pharmacological and non-pharmacological pain relief. (3,15–21) A (High quality)
B (High quality)
Audit report, guideline
For neonatal unit    
9. A unit guideline for maintaining comfort, avoiding unnecessary pain and discomfort and use of appropriate pharmacological and non-pharmacological pain relief is available and regularly updated. (4,6,9) A (High quality)
B (High quality)
10. Each unit recognises and utilises an individualised developmental care approach when reducing and avoiding pain and discomfort experiences during infants stay in the hospital. (22) A (High quality)
B (High quality)
Audit report
For hospital    
11. Training to recognise pain and distress in term and preterm infants and to avoid any non-essential painful and discomfort procedures is ensured. (4,6,9) A (High quality)
B (High quality)
Training documentation
For health service    

Where to go

Further development Grading of evidence
For parents and family  
  • Psychological support is offered to parents to cope with a stressful experience of their infant pain. (23,24)
A (Moderate quality)
For healthcare professionals  
For neonatal unit  
For hospital  
For health service  
  • Promote strategies to license new preparations of pharmacological agents to relieve pain in infants. (14,25)
A (Moderate quality)
  • Promote research into new approaches to pharmacological and non-pharmacological support during painful procedures in infants.
B (High quality)

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about strategies to optimise comfort, minimise painful stimuli and manage unavoidable pain during care.
  • Planned procedures are verbally discussed with parents.
For healthcare professionals
  • Attend training to recognise pain and distress and to avoid any non-essential painful and discomfort procedures in infants.
For neonatal unit
  • Develop and implement a unit guideline on pain assessment and treatment
  • Develop information material on strategies to optimise comfort, minimise painful stimuli and manage unavoidable pain during care for parents.
  • Use a validated pain assessment tool and a flowchart.
For hospital
  • Support healthcare professionals to participate in training on pain management.
For health service
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  2. Simons SHP, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003 Nov;157(11):1058–64.
  3. Pillai Riddell RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2015 Dec 2;(12):CD006275.
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November 2018 / 1st edition / next revision: 2023 Recommended citation

EFCNI, Oude-Reimer M, Frauenfelder O et al., European Standards of Care for Newborn Health: Support during painful procedures and pain assessment. 2018.

Cindy Whitehead, to allow for those treatments to enter the market