Evaluation of Pain in Newborn in Intensive Therapy in the Vision of Health Professionals

Method: This is a descriptive, exploratory research with a qualitative approach, developed in the maternity hospital Instituto de Saúde Elpídio de Almeida (ISEA), in the period from February to March 2016, after approval by the Research Ethics Committee (CESED), where the technique of data collection was through an interview with a prior script divided into two parts: the first part deals with socio-demographic issues, while the second part deals with issues related to pain in the NB, where they were recorded and transcribed in their entirety, using the content treatment through content analysis of the thematic type proposed by Laurence Bardin.


Introduction
Pain is a phenomenon that has existed for many years, where many people have already experienced this sensation.Old reports of people show concern about knowing, treating and effectively controlling this phenomenon [1].
Because it is a subjective phenomenon, there are no physical instruments that evaluate it, such as the instruments that evaluate the pressure, pulse, height and temperature, just as there is no standard and unique instrument in which the observer can measure this phenomenon, which varies from individual to individual [2].
It is important to emphasize that care is part of the interventions for pain relief, being of fundamental importance the recognition of its concept, expanding the knowledge on how to measure this phenomenon.Therefore, the methods used for pain relief should be used for the purpose of humanizing the sick individual [3].
At first, the adolescent and the adult manifest the pain through the speech, the RN expresses its pain through the nonverbal language, through physiological changes and behaviors [4].
However, the way RN expresses its pain and the fact that pain is a subjective phenomenon makes it difficult to adopt control measures and evaluation by health professionals, due to the fact that many professionals have difficulties in recognizing the RN's way of communicating [5].
Pain is an old and subjective phenomenon, difficult to assess when it comes to newborns.There is no single instrument to evaluate this phenomenon, since each RN has its degree of pain, just as the site differs [5].The RN expresses to the pain through physiological and behavioral changes, being of extreme importance the health team to use of methods to relieve the pain, taking care of human form the individual, despite the difficulty in evaluating this phenomenon on the part of the professionals, due to the communication form of the RN [6].
Concomitantly, some measures of comfort and control can be performed, such as skin-to-skin contact, touch and non-nutritive suction, with the aim of preventing pain and limiting it, bringing wellbeing to the newborn [4].
Thus, there is a concern to recognize pain, as well as to treat and control it.Therefore, in order to quantify pain, instruments or indicators, such as scales (eg NFCS), which take into account behavioral and physiological changes [5].
Because pain is a subjective phenomenon, it is indicated that multidimensional assessment methods should be used, such as multidimensional scales, where for the assessment of pain in term and premature newborns, the NIPS scale [7].
relief"; "Use of simultaneous pharmacological and non-pharmacological methods".
The Pain Profile of Prematurity (PIPP) is used at any gestational age, being used to evaluate acute pain, differentiating painful and non-painful stimuli.It is worth mentioning that this scale values the premature taking into account that they can express less pain [8].
Despite the difficulty in recognizing, treating and controlling pain, health professionals use instruments to aid in the investigation of pain, which are multidimensional scales that address physiological and behavioral changes.An example of this type of scale is called NIPS, which is used to assess pain in term and premature newborns and the PIPP scale, used at any gestational age, and this type of scale values the premature newborn, since they present difficulties in expressing pain.
Health professionals, especially the nursing team, should have great knowledge about pain, to know how to recognize and treat it, providing quality care, reducing pain through pharmacological and non-pharmacological measures, Correctly according to the individuality of all NBs.It is the responsibility of the nursing team to perform a correct and humanized care to the NB, taking care of it in its totality, being a priority its awareness to awaken strategies in the care to which it is subject to suffering pain [9].
Given the fact, few studies, we have used the following guiding questions: how do healthcare professionals perceive pain in newborns?Health professionals use some instrument to assess pain in newborns?What methods are used by professionals to ameliorate pain in the newborn?
Therefore, the objective of this study is to evaluate how the health professionals perceive the pain in the NBs hospitalized in the Neonatal Intensive Care Unit.

Method
Descriptive, exploratory study with a qualitative approach.According to Gil (2011) the main objective of descriptive research is to describe the characteristics of a population or phenomenon or to establish relations between variables [10].There are several studies that classify this way, being one of its most important characteristics the use of standard techniques of data collection.
The main purpose of exploratory research is to shape concepts and ideas, as well as to develop and clarify, aiming at the formulation of more precise problems or searchable hypotheses for other studies in the future.It is the type of research that presents less rigidity in planning.Involve non-standard interviews, bibliographical and documentary surveys, and case studies.In this type of research it is not common to apply sampling procedures and quantitative techniques [10].
According to Minayo (2014) the qualitative method is subjective, it involves the study of relationships, beliefs, perceptions and opinions, that is, how humans interpret the way they live, feel and think, as well as construct their artifacts and themselves [11].
The research was developed at the Maternity Institute of Health Elpídio de Almeida (ISEA) located in the city of Campina Grande, during the months of February and March 2016.ISEA maternity is located in the municipality of Campina Grande, being the only public maternity of the municipality.Has neonatal ICU with 10 beds [12].
The research universe consisted of health professionals who attend the NBs in the NICUs in the abovementioned maternity hospital.While the sample was composed of 18 health professionals.The health professionals included were those working in a neonatal ICU for at least six months.The health professionals who work in the excluded NICUs are those who are on leave, vacation or who are in some way benefiting from programmed benefits.Those who work less than six months will be excluded.
The data collection consisted of a two-part interview script: the first one will deal with information about professional identification, years of experience in the attention to the RN, sociodemoragraphic situations; in the second part, we will ask health professionals to respond to pain issues in newborns.The technique of data collection will be the interview.
The interview, taken in the broad sense of verbal communication, and in the narrow sense of gathering information on a particular scientific topic, is the strategy most often used in the field work process.Interview is above all a conversation between two or several interlocutors, carried out at the initiative of the interviewer, to construct information pertinent to a research object, and approach by the interviewer, of subjects equally pertinent in view of this objective [11].
For the presentation of the data was used the technique of narrative that allows the confrontation of meanings with the literature pertinent to the topic discussed.In the treatment of content, the speeches will be submitted to content analysis of the thematic type, proposed by Laurence Bardin (2009) [13].
According to Bardin (2009) the techniques of content analysis are divided into 3 stages.Are they: the pre-analysis is understood as the phase of organization of the collected data, where it is made a floating reading and gradually the reading becomes precise, the choice of the documents where it is objectively to choose those with pertinent information about the problem worked and the formulation of hypotheses and objectives [13].
The treatment of the obtained results and interpretation are realized by means of gross results, where they are treated in a significant and valid way.They use simple or complex statistics, which allow the establishment of results table, diaphragm, figure and models [13].
Information about the research was passed on to the participants and requested to their signatures, together with the Statement of Commitment of the Researchers and the Term of Free and In-formed Consent, respecting what is being recommended by Resolution of the National Health Council No. 466/12, approval number of the EACC: 51461615.8.0000.5175[14].

Results and Discussion
The present study deals with the evaluation of pain in the NB in the view of health professionals, where nurses, nursing technicians and physicians participated in this research.All interviewees contributed to the growth of this research, revealing their knowledge about the subject treated.
Twenty health professionals were attended, where only 2 were not considered, therefore, they did not meet the inclusion criterion.The remaining 18 participants accepted to participate in the study and met the inclusion criteria.All the participating professionals are female, were between twenty-four (24) and forty-eight (48) years old at the time of the interview, with a mean of thirty-two (32) years.Regarding the professional category, five (05) are nurses, six (06) are nursing techniques and seven (07) are doctors.Regarding the time of service in NICUs reported by the participants, they had between nine (9) months and nineteen (19) years at the time of the research, with a mean of three (3) to four (4) years.
Thus, as professionals perceive the pain in the neonate, three categories emerged in relation to the assessment of pain in the newborn in NICUs in the perspective of health professionals, it is observed in the speeches that all the interviewees perceive the Existence of pain in neonates.

Category I: Perception of professionals on the evaluation of pain with physiological and behavioral measurements
When analyzing the speeches it was possible to perceive that the interviewees relate the pain with behavioral changes after a painful stimulus, where they stand out: facial expression, crying, irritabili-ty, face and restlessness.The consonant "S" was chosen to be inserted in the interview in honor of the mother of one of the researchers, who has her name started by the same consonant mentioned above.Let's see: By the characteristics, through the crying, the irritability, is, we see change in his face, he expresses something.

S6.
In their suffering, I do not know.[...] he makes expression, suffering, the little face we perceive. S7.

S8.
Normally through physical contact, crying, the people's experience of seeing when the newborn is in pain, basically manipulating this.

S16.
The crying and the facial expression were the signs most pointed as a clinical parameter for the evaluation of the painful process in the newborn.We know that there is specific crying for pain, just as the evaluation of facial expression is a specific method, both contributing positively to assess pain in the newborn.
In general, the crying of the newborn presents an expiratory phase, then a brief inspiration and rest period, to enter the expiratory phase again.In the face of the painful stimulus, changes occur, where the expiratory phase becomes longer, becoming more acute, losing the melodic pattern and increasing the duration of crying.It is observed from these parameters that there is a specific cry for pain [15].
A study on pain evaluation and relief in the newborn performed in a hospital in São Paulo pointed to crying and facial expression as the main parameters cited by nurses to evaluate pain [16].
A useful noninvasive method in the daily clinic for assessing pain is facial expression.The observation of facial expression is a specific method to evaluate pain in premature newborn and term newborns [17].
The evaluation of pain in the newborn is made through facial and postural expressions, where health professionals who care for children know how important this subject is.Analyzes of facial and physical movements indicate the presence of pain [18].
One of the main parameters of pain expression in the newborn is the changes in facial mimics.In the RN there seems to be specific facial expressions of the pain, such as the protruding forehead, narrowed eyelid cleft, deep nasolabial groove, horizontally or vertically stretched mouth movements, parted lips, tense tongue and chin tremor [15].
We know that the neonatal ICU presents noises from the devices, from the direct care of the RN, as well as other noises such as steps, telephone and even voices.All these types of noise can damage hearing aid structures, interfere with sleep, as well as cause crying, fatigue, stress, and irritability.Therefore, it is indispensable to promote an adequate environment for the RN, reducing the amount and intensity of noise and even the light [17].
In the interviewees' discourse, the most present behavioral changes are face and cry, while the physiological changes mentioned are heart rate, respiratory discomfort and oxygen saturation.It is noticeable that the behavioral changes are more reported when compared to the other changes.
In addition to the behavioral changes, some health professionals perceived the pain through physiological changes, such as: Increased heart rate, respiratory discomfort, and decreased oxygen saturation.Let's see: Oh, [...] wrinkling of the forehead, by heart rate.

S3.
Physico-chemical characteristics, then through cardiovascular changes and aspects of appearance.

S15.
When analyzing the speech of the interviewees, we can observe that they report the physiological changes that occur in the NB, such as: changes in heart rate, respiratory rate and oxygen saturation, being less cited when compared to behavioral changes.Physiological changes are little cited when compared to behavioral changes, or are cited along with behavioral changes, since they are little used.
A study on the perception of pain in the Neonatal Unit from the perspective of the nursing professionals of a hospital in Ribeirão Preto-SP showed that only 04 respondents (25%) recognized in addition to the behavioral changes, physiological changes such as increased respiratory rate, increased heart rate, and decreased oxygen saturation.It should be noted that most of them were addressed in conjunction with behavioral changes [19].
It is observed that although they do not use the pain assessment scales, health professionals use physiological and/or behavioral parameters.The physiological parameters identified are: heart rate, respiratory rate and oxygen saturation.Let's see: The change in heart rate even though we use.

S5.
The cardiac monitor, one of the parameters that presents, the baby felt pain and makes tachycardia.

S12.
As vital signs change during pain, you use the monitoring devices.

S14.
As I just said, it's not the device, it's the oximeter, which is what I said in the beginning, that we see their saturation falling or heart rate, but so, a very specific device, More visual same [...].I've heard of pain scales, but I do not use them.

S15.
We observed that behavioral changes are specific measures to evaluate pain in the newborn.Physiological changes are not considered specific.Therefore, physiological changes can not be used alone to determine whether or not RN presents pain, although they are objective.
The most commonly used physiological parameters of pain are: heart rate, respiratory rate, oxygen saturation and systolic blood pressure.Although these measures are objective, they are not considered specific.After a nociceptive stimulus or after an unpleasant but not painful procedure, similar changes are observed.Physiological parameters in general can not be used in isolation for the decision that the newborn has pain and if there is a need for analgesics, but they are useful for assessing pain in the bed [15].
During the neonatal period, normal values for respiratory rate are 40 to 60 breaths per minute.Tachypnea is considered when the RN at rest or during sleep, the respiratory rate remains persistent greater than 60 movements per minute.The respiratory signs and symptoms observed during the neonatal period are: 1. Respiratory pattern -Respiratory rate (tachypnea), rhythm and periodicity of respiration -Apnea, periodic breathing; 2. Respiratory work -Nasal wing beats, expiratory groan, chest retractions (Intercostal, subcostal, suprasternal and sternal); 3. Color -Cyanosis [21].
A study carried out in Fortaleza (Ceará) in 2010 showed that before the arterial blood gas analysis, 53.9% of the newborns had normal heart rate (between 130 and 160 beats per minute), and, for oxygen saturation, 50% Presented ideal saturation (Between 96 and 98%).During the arterial blood gas analysis, 50% of the NBs showed changes in the HR (42.3% were increased and 7.7% decreased), and, regarding oxygen saturation, 65.3% of the NB remained unchanged.Alterations, while 34.7% changed, and the presence of pain during the procedure could be characterized [22].

Category II: Professionals who know, but do not evaluate with score of pain
With regard to the knowledge and use of instruments that evaluate pain in the newborn, it is noticeable that the professionals know, but do not use.It is known that currently there are scales that help health professionals in pain assessment, where the physiological and behavioral parameters are evaluated.
It was observed in the reports of the interviewees that some professionals know the three-dimensional scales, but do not use them as we identified in the following interviews: Instruments?There is the scale of the pain, it actually exists, right..., the scale itself, so it has the issue of numbering, but I do not use.

S1.
No. I know the scales, but I do not use....I have heard of pain scales, but I do not use them.

S17.
A study on the Evaluation of pain in the premature newborn in the Intensive Care Unit performed in a NICU in the interior of Bahia showed that the professionals when asked about the knowledge of the pain evaluation scales, 14 of them (58.4%)working in the NICU reported not knowing about the existence of these instruments, while only 10 (41.6%) knew of any scale used for pain assessment [4].
It is observed that health professionals know the scales, but do not use them.There are some scales to evaluate pain in the RN, such as: NIPS, PIPP and NFCS, where both assess pain in the term or RN preterm.
For premature neonates, a specific pain scale was developed, since they present a greater difficulty in expressing pain.It is the Profile of Premature Pain -PIPP (PrematureInfantPain Profile), which evaluates alertness, heart rate, oxygen saturation, frowning, squeezed eyes and nasolabial groove.These items are evaluated and the score is made according to the gestational age of the child, which in turn influence the behavioral signs of pain, as the authors clarify [23].
The premature RNs who are in the NICU are in a different environment from the intrauterine world.The maternal uterus is ideal for the growth and development of the fetus, where the fetus rests and sleeps deeply, contributing to fetal growth.On the other hand, the NICU presents intense illumination, full of noise, as well as frequent interruption of sleep and rest of the NB, through different procedures and activities, causing NBs hospitalized at this site to impair their neuromotor development [24].
It is necessary to deconstruct the concept that the lack of myelination is an indicator of immaturity of the central nervous system, making the newborn unable to feel pain, because it is necessary to consider that the PTNB is capable of experiencing pain, and it is necessary to implant care to alleviate this phenomenon that causes discomfort [4].
Some scales may be used to assess pain in the NB.An example is the Pain Assessment Scale (NIPS), in which it is composed of behavioral indicators and a physiological pattern, which is the breathing.It is used in the assessment of pain in neonates of any gestational age, and because it is a simple scale and easy to apply, it can be used by all the staff [8].
Another proportion of which was used is PIPP, assessing pain in preterm and full term NB, where seven indicators are evaluated, with scores ranging from zero to three [7].
Another useful scale is the Neonatal Facial Coding System (NFCS), which is based on the evaluation of the facial expression of the newborn and is used for infants born at term and premature.Some authors note that only physicians can use this scale, however, a trained nurse can use it [8].
The nurse and team in the NICU should familiarize themselves with these assessment scales, opting for the most appropriate, transforming the empirical observation into objective and real, directing the necessary behaviors [23].
It is possible to perceive that there is a lack of knowledge about pain scales by health professionals.We know that there are scales for premature, term or preterm NB, where they take into account physiological and behavioral changes.

Category III: Professionals who do not evaluate with score of pain
It is noticeable during the interviewees' speech, that the great majority of health professionals do not evaluate with a pain score, that is, they do not know and do not use multidimensional scales to assess pain in the NB, as described in the statements below: No, not instrument.What I see we do is just visualize.

S2.
Instrument?I do not think so, it is more in him that demonstrates, through his body, the reaction of his body.

S6.
The technical people here do not, we do not know no, no instrument.

S7.
In addition to not knowing any instrument, he reports that he assesses through professional experience and through the look, let's see: No, because we have a lot of experience just to see ourselves, we identify that he is feeling something.

S10.
Although the nursing team takes care of the NB with pain, it evaluates the pain in the NB by means of personal beliefs, in an empirical way, without taking into account the scientific advances on the knowledge in this area is not interesting at present [9].
Because pain is a subjective phenomenon, it is necessary to use as much information as possible, and not only use a single instrument [19].The scales contribute to an effective communication between the NB and the nursing team, thus enabling the recognition, quantification and management of pain [9].
We observed that health professionals do not use multidimensional scales because they do not have the knowledge about them.Therefore, they can identify pain in the RN through professional experience through the, it is necessary to use more associated information, such as the use of scales, involving physiological and behavioral parameters, to be more reliable and obtaining more information about the context of the RN.
The assessment of pain in the newborn should be made using scales that include multiparameters.At the same time, behavioral and physiological parameters should be evaluated in order to obtain more information regarding individual pain responses and possible interactions with the environment.Regardless of the scale used to evaluate pain in the newborn, the evaluation should be done regularly, in a systematic way, and the phenomenon of pain should be considered as the fifth vital sign [26].
Corroborating with ours, a study carried out in a hospital in the interior of São Paulo in the year 2011, involved 57 health professionals, it was observed that no professional affirmed to know the pain rating scales in the NB [27].
Another study carried out at a NICU in the city of Feira de Santana (Bahia) in the year 2010 showed that in relation to the nursing professionals' knowledge regarding the scales of evaluation of pain in the neonate, 39.3% said they knew them, 60.7% did not know them and no professional used them.They argued that it was not part of the routine NICU that the use of pain scales was mandatory [28].
As for the use of some method for pain relief, a subcategory emerged:

Use of non-pharmacological methods for pain relief
During the interview, health professionals reported that they use non-pharmacological measures to relieve pain in the newborn, with the aim of reducing the discomforts that the environment and procedures cause, promoting a better quality of life for the NB that is in the NICU: We try to comfort them, if you have some access outside, peripheral, withdraw, console, talk to the baby, try to calm him and many really calm down, you put in the arm [...].Talking with the baby already calms you, it's interesting, I find it very interesting.

S1.
Yes. Immobilization when we go for tracheal oro intubation, which is a painful procedure for the newborn and we do not use sedation, however, we do the method of containment and sometimes, here in NICU we can get babies to breastfeed and when to collect capillary glycemia, or a blood count, we can use nourishing and nonnutritive sucking to reduce pain, so I guess here's just that. S2.
[...] Touching them even to calm them down.So how can we not get them out of the bed, out of the incubator, so we hugged him a little to make him firmer, a little more secure, that's what we do with him right [...], caress him, until we talk a little with him, we talk to see.

S15.
Centralization, heating, positioning, nourishing, cherishing, and sometimes can also be irritability because of hunger.

S17.
Yes, the non-nutritive suction, the glucose, we can put the gloved finger in the RN's mouth to suck during the procedure that causes pain, and minimizes, decreases pain.We can also keep him more snug at the time of the painful procedure.

S18.
Non-pharmacological measures are care strategies that must be constantly used to control pain in the NICU by the nursing staff.Pain comfort and control measures such as touch, skin-to-skin contact and non-nutritive nutrition can be performed systematically with the aim of preventing pain, limiting it, as well as restoring the well-being of the newborn [4].
Non-pharmacological measures include nonnutritive sucking and glycosylated solutions.The function of the glycoside solution is exerted through the release of endogenous endorphins that leads to decreased crying time and softens facial pain mimics.Regarding non-nutritive sucking, it is important to note that the pacifier does not decrease pain, but it inhibits hyperactivity, as well as helps the child to organize at the end of the painful stimulus [17].
Another study, carried out in a State Hospital of the State of São Paulo, in the year 2011, showed that most nurses (87.5%) stated that they knew about and performed non-pharmacological measures for pain relief in the newborn, where four (57.1%) reported knowing and administering glucose, non-nutritive suction and manual containment, one (14.3%)referred to glucose and non-nutritive suction, one (14.3%)referred glucose, one (14.3%)reported knowing and using containment [29].
It has been proven that non-nutritive sucking brings benefits to the health and recovery of the NB [4].The use of sugary substances is considered a non-pharmacological method, where the doses to be administered diverge between authors.It is defended its use with doses varying from 0.3 ml in PTNB to 2 ml in RNT, being administered in the lower third of the tongue 2 minutes before the painful procedure, lasting for up to 7 minutes.We note that its use is indiscriminate [30].
It is important to use non-pharmacological measures to control pain in the NB, since they are beneficial measures.As an example we have the glycated solutions and the non-nutritive suction.The glycoside solution decreases crying time and softens the facial expression of pain, while non-nutritive sucking brings benefits to the recovery of the NB as well as to his health.
In procedures that generate mild to moderate pain, a strategy considered to be used for pain control is the use of oral glucose solution [31].
The solution of glucose soaked in gauze is an important measure used by nursing to calm the neonate, as well as minimize their pain during painful procedures.It has beneficial action since it stimulates endogenous opioids, calming the newborn before subjecting them to painful procedures, reducing their reaction to pain [32].
Both the touch and the physical contact calm the RN, therefore, they release endogenous opioids.In addition to these, sensory stimulation can also be useful, such as: music therapy, soft speech, massage and visual stimulation [8].
Promoting the presence of the mother/father, during and after the manipulation, comforting the baby by touching the skin-to-skin contact, becomes the main one to relieve the physical and emotional discomfort caused by pain.All these actions support the treatment of pain, which begins with the identification of children in physical or physiological suffering [6].
The humanistic care is that the care that understands the RN in its totality, that is, considers its limitations and immaturity the psychobiology, involves the family in the process, stimulating the interaction between the professionals-RN-mother, seeking methods that minimize the damage that hospitalization causes to the newborn, especially during painful procedures [33].
Many advances have been achieved in the care of the NB, but pain assessment and management have not yet received due attention in the neonatal units, especially in the Neonatal Intensive Care Units (UTIN'S) [23].
We observed that health professionals use pharmacological and non-pharmacological methods for pain management in NB, where many times, pain relief is improved by combining treatment.The use of simple measures is beneficial for NB, where NB pain should be considered and treated, regardless of the method used.

Conclusion
Despite the progress made in the care of the newborn, further studies on pain are needed, especially with regard to multidimensional pain assessment scales, since there are gaps when it comes to the lack of knowledge on the part of health professionals.
It is observed that it is important that the nurse and the team working in the NICU familiarize themselves with the multidimensional scales, choosing the most appropriate scale according to each RN, since, they take into account physiological and behavioral measures, in order to obtain a greater number of information, obtaining a more reliable evaluation.
It was possible to observe how difficult the evaluation and the management of the pain, despite the advances achieved in the care to the RN.It is important for professionals to have a different look during painful procedures, seeking ways to avoid or reduce pain in a humanized way, causing the RN to suffer less.
Nursing needs to fight for more knowledge in the area of neonatology, to obtain as much information as possible about the subject, improving the way in which it cares for the newborn, seeking ways to minimize pain in the RN whenever possible, since these are beings that need the art of caring.