Newborn ’ s pain under the mother ’ s perception

BACKGROUND AND OBJECTIVES: Pain can generate important complications for the newborn. The mother, inserted in this context, becomes an important ally during the hospitalization since she stays with the. Thus, the study aimed to identify the mother’s perception of pain in her hospitalized child in the Neonatal Intensive Care Unit and to compare the mothers’ reports with a range of behavioral and physiological signs. METHODS: This is a qualitative study in a tertiary hospital in the State of Ceará. Fifteen mothers who were with their children hospitalized at the Neonatal Intensive Care Unit participated in the study, where they were placed in front of their children in two different moments: at rest and handling, in order to identify signs of pain. The data were analyzed by approximation of the speeches as proposed by Minayo. RESULTS: The results showed that the mothers did not perceive signs of pain in the newborn at rest. However, when handled, the mothers were able to identify the signs of pain through the characteristics presented in the newborn: facial expression, strong crying and the movement of arms and legs. CONCLUSION: Mothers are able to identify signs of pain in the child during painful procedures, mainly through crying and face changes. Thus, it points out the relevance of using pain evaluation scales to measure the behavioral and physiological signs of the newborn in a Neonatal Intensive Care Unit.


INTRODUCTION
The pain felt by a newborn has been undervalued for many years since it was believed that they could not feel it.This irrelevance was due to some assumptions, such as the neurological immaturity of the newborn; the absence of memory in this age group, and the great toxicity of the analgesics and anaesthetics 1 .It is known that the fetus' cortical and subcortical centers, important in the perception of pain, are well developed around the 30th week of the gestational age.Thus, the newborn is perfectly capable of feeling pain, which can even be more intense than in an adult 2 .Due to the formation and maturity, the complex of pain transmission has its inhibitory mechanisms more immature than the excitatory, leading to exacerbated responses and likelihood for sequels 3 .
The newborns express their physical and emotional needs, since their birth, through tears, body movements, facial expression, where crying is the most expressive behavioral parameter to start the pain intervention control 4 .In this scenario, in addition to the healthcare professional, we can rely on the mother who remains next to the child during their stay in the Neonatal Intensive Care Unit (NICU).The non-verbal complaint by the newborn is one of the biggest obstacles to diagnosis, and consequently to properly treat pain in the NICU 5 .The development of NICUs together with the modernity of the therapeutical technologies is providing a reduction in the mortality of the newborns.However, we have noticed a higher number of invasive procedures necessary to guarantee the survival of these children.The struggle for survival brings consequences such as increased exposure to pain.Newborns, in the phase of greater instability, are subject to various painful procedures necessary to their hemodynamic stabilization, such as intubation, arterial puncture, venipuncture, lumbar puncture, aspiration, mechanical ventilation, chest drainage 6 .If left untreated, the pain can lead to major complications to the newborn such as a delayed brain development, behavioral and psychiatric disorders.In a NICU, about 50 to 150 procedures considered painful are performed in the newborn during the hospitalization and the more premature, this number tends to increase, that's why it is important to identify and to intervene 7 .Since it is a personal and subjective experience, pain cannot be measured like pulse, temperature, blood pressure, among others 8 .To facilitate the intervention, pain scales are used in the NICUs to assess the behavioral and physiological signs, one of these scales is the Neonatal Infant Pain Scale(NIPS) 9 .Pain is considered as the fifth vital sign, as important as the others, which must always be recorded and assessed in the clinical setting, along with other vital signs: temperature, pulse, respiration and blood pressure.The effectiveness of the treatment and its follow-up depends on a reliable and valid pain assessment and measurement.After detection, the intervention is required to interrupt or reduce this stimulus, with pharmacological or non-pharmacological approaches 10 .The mother, inserted in this context, becomes an ally during hospitalization since when participating in the care she is able to perceive the signs of this subjective experience 10 .Thus, the mothers' participation in the care and their reports about their child deserves greater attention from the health team 11 .This questioning becomes relevant for the nursing professionals because it makes early intervention possible facing a pain experience and consequently provide quality of life and good development for the newborn.Therefore, the motivation of the researchers to conduct this study was the awareness-raising, and the search for the quality of life of newborns exposed to painful stimulation since the pain in the newborn has a direct influence in its stability and clinical evolution.Due to the reality of the NICU, of the several procedures considered painful, of the difficulty of the nursing team in diag-nosing pain, the mothers' contribution would be suitable and beneficial in this process, pointing out to the professionals the possible signs of pain.Ten comes the question: what is the mother´s perception concerning her child´s signs of pain in the neonatal unit?This study aimed to identify the mother's perception of her child´s pain in the NICU and compare the mother´s report with a behavioral and physiological pain scale (NIPS).

METHODS
This is a descriptive study with a qualitative approach, conducted in a tertiary public hospital which is a reference to the care of high-risk newborns.The sample was composed of 15 mothers of newborns who were hospitalized in the NICU.Mothers of premature newborns with gestational age (GA) up to 37 weeks were included.Mothers of newborns who remained in the unit only at the time of the hospital visit were excluded.In that institution, the mothers living in the city of Fortaleza were instructed to stay at least for one shift in the unit.The data was collected between August and October 2013.Initially, the mothers were invited to participate in the study, and those who met the inclusion criteria established were interviewed in a communal area to obtain the research data.The interview lasted 20 minutes on average.At a second moment, the researcher followed the mother who was with her child inside the unit.The mother was asked to describe how she perceived the signs of pain expressed by the child.Two distinct moments were evaluated: 1 st moment: newborn at rest; 2 nd moment: newborn being managed.The mothers had 10 minutes to observe their child´s signs of pain.Based on the mothers´ report, the researchers applied the NIPS using the behavioral indicator to compare with the signals reported by the mothers.The instruments used to assess pain can be multidimensional, assessing behavioral and physiological changes, but can also be unidimensional only assessing one of the answers.The NIPS is a scale used to assess pain signs in the newborn.It has six pain indicators, one physiological and five behavioral, including facial expression, crying, movement of arms and legs, sleep/alertness state and respiratory pattern 12 .The interviews were recorded and then transcribed upon the mothers´ authorization.The data obtained were organized into theme categories and grouped by the approximation of the speeches, which consists in finding out the core meaning that makes up communication, which presence or frequency mean something for the targeted object 13 .The mothers were identified by the letter M and the newborns by the letters RN.Both preceded by an Arabic numeral according to the order in which the interviews were conducted.The study followed the precepts of Resolution 466/12 of the National Council of Health/Ministry of Health that deals with research involving humans 14 with opinion number 259.657.All the participants signed the Free and informed Consent Form (FICT), and the teenager girls, the Free and Informed Acknowledge Form (FIAF).

RESULTS
Of the 15 participant mothers of the study, the age range varied between 16 and 36 years, two were single, and the others were married.In relation to education, two had a complete higher education; two, incomplete higher education, six, complete high school; two, incomplete high school, one complete elementary school; one, incomplete elementary school, and one was illiterate.Six mothers were primiparous.With regard to the gestational age, this varied between 26 and 37 weeks.As for occupation, only six had any labor occupation.The length of stay of the newborn varied from seven days to 2 months and 12 days.Table 1 shows the signs of pain identified by the mothers of the premature newborn at two moments: observation at rest and during management.These data were recorded and compared with the NIPS scores.The results obtained were arranged in two categories based on the participants' responses: signs of pain in the mother´s perception and; the mother´s perception in relation to the care to minimize pain.

Category 1 -Signs of pain in the mother´s perception
The speeches describe the mother's perception concerning the pain felt by their child:

[…] generally when he feels pain, he frowns the forehead, and he gasps (M3; M6). […] it is the cry when the cry is very high, he stretches entirely, becomes red, and I see that there´s really something bothering him (M1; M7; M15). […] I notice when he is stretching like this, stretching, I see that he is in pain, one small pain thus (M13, M14. [...] when I realize she's in pain, it is usually through crying or some physical reactions, like a grimace or too much movement (M2; M8; M9). […] well, I think that when he is upset with the tube in his mouth, he tries to move the nurse´s hand away, he tries to mimic a cry, ah that´s how I see it, and it is exactly what I feel, it´s something really instinctive (M5).
observed during management, the mothers observed signs of pain, such as facial expression, vigorous cry, and movement of the limbs.Such signs meet the scores established in the NIPS.In a study conducted in the NICU of Feira de Santana, on the identification, evaluation, and intervention of newborn pain, the professionals interviewed reported crying as the most observed characteristic in relation to the newborn pain, followed by body movements and face expression 15 .In this study, the cry was the most reported pain sign.For the mothers, the characteristics of the cry and the baby's behavior are sources of information about their state of health.From the changes in behavior, the mothers are able to identify where the pain is 16 .The facial expression was the second most reported sign of pain by the mothers.Facial changes are the main elements in the study of pain in premature newborns, as it is in this age group that the facial expressions express the pain with greater precision.About 95 to 98% of the premature newborns present at least three pain indicators, such as protruding forehead, nasolabial deepen groove and chin tremor as indicative of pain 17 .The nursing staff is responsible for checking the pain, and with some methods, they can identify the pain manifestations and their characteristics, which are indispensable means in the care premature newborns.Therefore, it is important to note that the signs of pain that the mothers perceive in their children can collaborate with the nursing care 18 .In this study, the identification of the signs of pain was based on the mothers´ reports and later compared with the NIPS parameters.The results showed that the mothers were able to identify what can cause pain to their children.The NIPS has been used not only as a parameter to assess the analgesic effectiveness of pharmacological and non-pharmacological interventions but also to evidence that certain procedures in newborns are painful 17 .Although the use of the scales to measure pain has shown to be relevant, a survey conducted in the city of Maceió with 15 nurses of the Intermediate Neonatal Care Unit (UCI NEO) and the NICU showed that only one interviewed used the scale to assess pain.Therefore, the lack of use of multidimensional instruments, like the NIPS, can directly intervene in the quality of the nursing care and lead to an inadequate treatment of pain 19 .In a study carried with nurses 15 about the knowledge and use of the specific pain scales for the neonate, the majority affirmed not knowing them, and those that knew, do not use them.This situation evidences that perhaps pain assessment in the healthcare service is not being performed in a systematic way and probably it is based on subjective criteria, without scientific basis 15 .Following this line of thought, and analyzing the speech reported in this study, it is possible that the mother recognizes the needs signaled by her child, considering the intersubjective relation between mother and child that goes beyond the technical care sometimes observed in the nurse/newborn relationship 20 .Thus, it is important that the nurse appreciates the reports on the newborn pain expressed by the mother who has her child in the NICU because they can tell from small suggestive behavioral changes the discomfort of the newborn that is not compatible with the NIPS.

CONCLUSION
According to the results, the mothers recognize that their children are in pain, facilitating the identification and the appropriate treatment of neonatal pain.