Table 2

Neonatal Pain Agitation and Sedation Scale

Assessment criteria−2−10/012
Crying irritabilityNo cry with painful stimuliMoans or cries minimally with painful stimuliNo sedation/no pain signsIrritable or crying at intervals
High-pitched or silent-continuous cry
Behaviour stateNo arousal to any stimuli
No spontaneous movement
Arouses minimally to stimuli
Little spontaneous movement
No sedation/no pain signsRestless, squirming
Awakens frequently
Arching, kickingConstantly awake or arouses minimally/no movement (not sedated)
Facial expressionMouth is lax
No expression
Minimal expression with stimuliNo sedation/no pain signsAny pain expression intermittentAny pain expression continual
Extremities toneNo grasp reflex
Flaccid tone
Weak grasp reflex
↓muscle tone
No sedation/no pain signsIntermittent clenched toes, fist or fingers splay
Body is not tense
Continual clenched toes, fists, or finger splay
Body is tense
Vital signs HR, RR, BP, SaO2No variability with stimuli
Hypoventilation or apnoea
<10% variability from baseline with stimuliNo sedation/no pain signs↑↑10–20% from baseline SaO2 76–85% with stimulation-quick recovery↑SaO2 <75% with stimulation-slow recovery↑
Out of sync with vent
  • The pain score is adjusted in premature infants according to gestational age categories: add 3 to infants <28 weeks; add 2 to infants 28–31 weeks; add 1 to infants 32–35 weeks.

  • BP, blood pressure; HR, heart rate; RR, respiratory rate; SaO2, arterial oxygen saturation.