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What Facial Features Does the Pediatrician Look to Decide That a Newborn Is Feeling Pain?Funding The study received its financial support from Fundação de Amparo à Pesquisa do Estado de São Paulo and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (grant numbers: 2012/50157-0 and 2018/13076-9).
Objective The study aimed to analyze the gaze fixation of pediatricians during the decision process regarding the presence/absence of pain in pictures of newborn infants.
Study Design Experimental study, involving 38 pediatricians (92% females, 34.6 ± 9.0 years, 22 neonatologists) who evaluated 20 pictures (two pictures of each newborn: one at rest and one during a painful procedure), presented in random order for each participant. The Tobii-TX300 equipment tracked eye movements in four areas of interest of each picture (AOI): mouth, eyes, forehead, and nasolabial furrow. Pediatricians evaluated the intensity of pain with a verbal analogue score from 0 to 10 (0 = no pain; 10 = maximum pain). The number of pictures in which pediatricians fixed their gaze, the number of gaze fixations, and the total and average time of gaze fixations were compared among the AOI by analysis of variance (ANOVA). The visual-tracking parameters of the pictures' evaluations were also compared by ANOVA according to the pediatricians' perception of pain presence: moderate/severe (score = 6–10), mild (score = 3–5), and absent (score = 0–2). The association between the total time of gaze fixations in the AOI and pain perception was assessed by logistic regression.
Results In the 20 newborn pictures, the mean number of gaze fixations was greater in the mouth, eyes, and forehead than in the nasolabial furrow. Also, the average total time of gaze fixations was greater in the mouth and forehead than in the nasolabial furrow. Controlling for the time of gaze fixation in the AOI, each additional second in the time of gaze fixation in the mouth (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.08–1.46) and forehead (OR: 1.16; 95% CI: 1.02–1.33) was associated with an increase in the chance of moderate/severe pain presence in the neonatal facial picture.
Conclusion When challenged to say whether pain is present in pictures of newborn infants' faces, pediatricians fix their gaze preferably in the mouth. The longer duration of gaze fixation in the mouth and forehead is associated with an increase perception that moderate/severe pain is present.
Neonatal pain assessment is intrinsically subjective.
Visual tracking identifies the focus of attention of individuals.
Adults' gaze in neonates' mouth and forehead is associated with pain perception.
G.V.T.S., J.C.A.S., T.M.H., and R.C.X.B. supported in study design, patient screening and enrollment, data collection, data analysis and interpretation, and revising the manuscript. M.C.M.B., C.E.T., and R.G. involved in the conception and design of the study, data analysis and interpretation, and writing the manuscript. L.P.C. and R.N.O. focused on study design, data collection, data analysis and interpretation, and for revising the manuscript.
Received: 22 March 2021
Accepted: 12 May 2021
30 June 2021 (online)
© 2021. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
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- 1 Hadjistavropoulos T, Craig KD, Duck S. et al. A biopsychosocial formulation of pain communication. Psychol Bull 2011; 137 (06) 910-939
- 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; 157 (11) 1058-1064
- 3 Schiavenato M, Butler-O'Hara M, Scovanner P. Exploring the association between pain intensity and facial display in term newborns. Pain Res Manag 2011; 16 (01) 10-12
- 4 Grunau RE. Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity. Rambam Maimonides Med J 2013; 4 (04) e002
- 5 Walker SM, Melbourne A, O'Reilly H. et al. Somatosensory function and pain in extremely preterm young adults from the UK EPICure cohort: sex-dependent differences and impact of neonatal surgery. Br J Anaesth 2018; 121 (03) 623-635
- 6 Raja SN, Carr DB, Cohen M. et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 2020; 161 (09) 1976-1982
- 7 Maxwell LG, Fraga MV, Malavolta CP. Assessment of pain in the newborn: AN Update. Clin Perinatol 2019; 46 (04) 693-707
- 8 Zamzami G, Pai C, Goldgof D. et al. An approach for automated multimodal analysis of infants' pain. 2016 23rd International Conference on Pattern Recognition (ICPR). 4148-4153 Accessed 2016 at: https://ieeexplore.ieee.org/document/7900284
- 9 Vervoort T, Trost Z, Prkachin KM, Mueller SC. Attentional processing of other's facial display of pain: an eye tracking study. Pain 2013; 154 (06) 836-844
- 10 Weinberg DD, Newman H, Fishman CE. et al. Visual attention patterns of team leaders during delivery room resuscitation. Resuscitation 2020; 147: 21-25
- 11 Heiderich TM, Leslie ATFS, Guinsburg R. Neonatal procedural pain can be assessed by computer software that has good sensitivity and specificity to detect facial movements. Acta Paediatr 2015; 104 (02) e63-e69
- 12 Grunau RE, Oberlander T, Holsti L. et al. Bedside application of the Neonatal Facial Coding System in pain assessment of premature neonates. Pain 1998; 76 (03) 277-86
- 13 Berde CB, Lehn BM, Yee JD, Sethna NF, Russo D. Patient-controlled analgesia in children and adolescents: a randomized, prospective comparison with intramuscular administration of morphine for postoperative analgesia. J Pediatr 1991; 118 (03) 460-466
- 14 Stevens B, Johnston C, Petryshen P, Taddio A. Premature infant pain profile: development and initial validation. Clin J Pain 1996; 12 (01) 13-22
- 15 Holsti L, Grunau RE. Initial validation of the behavioral indicators of infant pain (BIIP). Pain 2007; 132 (03) 264-272
- 16 Craig KD, Hadjistavropoulos HD, Grunau RVE, Whitfield MF. A comparison of two measures of facial activity during pain in the newborn child. J Pediatr Psychol 1994; 19 (03) 305-318
- 17 Calvo MG, Fernández-Martín A, Gutiérrez-García A, Lundqvist D. Selective eye fixations on diagnostic face regions of dynamic emotional expressions: KDEF-dyn database. Sci Rep 2018; 8 (01) 17039
- 18 Zhi R, Zamzmi GZD, Goldgof D, Ashmeade T, Sun Y. Automatic infants' pain assessment by dynamic facial representation: effects of profile view, gestational age, gender, and race. J Clin Med 2018; 7 (07) 173
- 19 Stevens B, McGrath P, Dupuis A. et al. Indicators of pain in neonates at risk for neurological impairment. J Adv Nurs 2009; 65 (02) 285-296
- 20 Robinson MD. Running from William James' Bear: a review of preattentive mechanisms and their contributions to emotional experience. CognEmot. 1998; 12 (05) 667-696
- 21 Katz TA, Weinberg DD, Fishman CE. et al. Visual attention on a respiratory function monitor during simulated neonatal resuscitation: an eye-tracking study. Arch Dis Child Fetal Neonatal Ed 2019; 104 (03) F259-F264
- 22 Browning M, Cooper S, Cant R. et al. The use and limits of eye-tracking in high-fidelity clinical scenarios: a pilot study. Int Emerg Nurs 2016; 25: 43-47
- 23 Schiavenato M, Byers JF, Scovanner P. et al. Neonatal pain facial expression: evaluating the primal face of pain. Pain 2008; 138 (02) 460-471
- 24 Grunau RVE, Craig KD. Pain expression in neonates: facial action and cry. Pain 1987; 28 (03) 395-410
- 25 Pinheiro IO, Lima FE, Magalhães FJ. et al. Pain evaluation in newborns using the Neonatal Facial Activity Codingscale during blood gases analysis. Rev Dor 2015; 16 (03) 176-180
- 26 Heiderich TM, Barros MCM, Guinsburg R. Inter-observer agreement in the identification of pain faces in full-term and late pretermnewborns: cross-sectional study. Br J Pain 2020; 3 (04) 348-353