Download PDF
Am J Perinatol 2023; 40(08): 851-857
DOI: 10.1055/s-0041-1731453
Original Article

What Facial Features Does the Pediatrician Look to Decide That a Newborn Is Feeling Pain?

Giselle Valério Teixeira da Silva
1   Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
,
Marina Carvalho de Moraes Barros 
1   Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
,
Juliana do Carmo Azevedo Soares
1   Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
,
Lucas Pereira Carlini
2   Image Processing Laboratory, Department of Electrical Engineering, Centro Universitario FEI, São Bernardo do Campo, São Paulo, Brazil
,
Tatiany Marcondes Heiderich
1   Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
,
Rafael Nobre Orsi
2   Image Processing Laboratory, Department of Electrical Engineering, Centro Universitario FEI, São Bernardo do Campo, São Paulo, Brazil
,
Rita de Cássia Xavier Balda
1   Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
,
Carlos Eduardo Thomaz
2   Image Processing Laboratory, Department of Electrical Engineering, Centro Universitario FEI, São Bernardo do Campo, São Paulo, Brazil
,
Ruth Guinsburg
1   Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
› Author Affiliations 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).
› Further Information
    Permissions and Reprints

Abstract

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.

Key Points

  • 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.

Keywords

infant newborn - pain measurement - fixation ocular - facial expression

Authors' Contributions

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.




Publication History

Received: 22 March 2021

Accepted: 12 May 2021

Article published online:
30 June 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hadjistavropoulos T, Craig KD, Duck S. et al. A biopsychosocial formulation of pain communication. Psychol Bull 2011; 137 (06) 910-939
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 7 Maxwell LG, Fraga MV, Malavolta CP. Assessment of pain in the newborn: AN Update. Clin Perinatol 2019; 46 (04) 693-707
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 10 Weinberg DD, Newman H, Fishman CE. et al. Visual attention patterns of team leaders during delivery room resuscitation. Resuscitation 2020; 147: 21-25
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 15 Holsti L, Grunau RE. Initial validation of the behavioral indicators of infant pain (BIIP). Pain 2007; 132 (03) 264-272
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 24 Grunau RVE, Craig KD. Pain expression in neonates: facial action and cry. Pain 1987; 28 (03) 395-410
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar