According to a wide range of comments published this week in the Cochrane database for Systematic Reviews, the methods doctors and nurses rely on to assess pain in newborn babies lack reliable scientific support.
Researchers at the Karolinska Institute found that none of the 27 clinical rating scales examined—a strict validation standard expected by modern medicine, used by medical professionals to assess pain in babies who cannot communicate verbally.
“In this review, more than 70% of the rating scales did not evaluate content and structural validity, and both factors are essential when selecting measurement tools,” said Kenneth Färnqvist, a physical therapist and doctoral candidate in the Department of Molecular Medicine and Surgery at the Karolinska Institute in Sweden.
These findings raise concerns about an estimated 6% to 9% of care in neonates who are expected to be admitted to the neonatal intensive care unit. These vulnerable patients usually endure multiple painful surgeries a day as part of their medical care.
The international research team analyzed 79 studies involving more than 7,000 infants in 26 countries. The most disturbing thing is the discovery that current approaches may lead to overtreatment or insufficient pain treatment.
Unlike adults who can describe themselves discomfort, medical staff must rely on baby’s physical cues such as facial expressions, body movements, and vital sign changes. For premature babies, the challenge is even greater.
“It is important to remember that the clinical rating scale is just a replacement for pain measurement,” noted Roger F. Soll, a professor of neonatology at the University of Vermont, who contributed to the study. “Given the uncertainty highlighted in this review, clinical staff should avoid relying too much on the scoring scales in current practice and work on procedures that minimize pain in this vulnerable population.”
The situation of premature babies becomes more complicated, and because of their dysplasia, they usually have the ability to show obvious painful behaviors. Similar restrictions exist in sedative or seriously ill infants.
As newborn care develops worldwide, the timing of this review is very important. As survival rates in premature babies increase, accurate pain assessment becomes increasingly important in preventing potential long-term neurological consequences.
Despite these findings, researchers have seen opportunities for progress. Emma Persad of the Karolinska Institute for Women and Children’s Health, a doctor and doctoral candidate, sees it as a catalyst for change.
“This is what we bring together clinicians and methodologists to develop a rigorously validated scale from scratch, and it meets all the necessary examinations before it is implemented in research and practice,” Persad said. “We look forward to starting this influential work and what it will mean in assessing and managing newborn pain globally.”
At the same time, experts recommend that medical professionals be cautious when interpreting the results of current pain assessment tools and minimize pain procedures as much as possible.
The study represents one of the most comprehensive examinations of neonatal pain measurements to date. Its findings suggest that although modern medicine has made significant progress in caring for our youngest patients, there are still large gaps in understanding their suffering.
The full review, titled “Clinical Rating Scale for Assessing Pain in Newborn Babies”, was published on April 14, 2025, which includes contributions from researchers in Sweden, Norway, Greece, the United States, Italy and the United Kingdom.
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