Description

The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) is a specialized and internationally recognized clinical assessment instrument designed to evaluate pain, agitation, and sedation in both preterm and full-term neonates. Developed by Hummel and Dempsey (2004), the scale was created to provide healthcare professionals with a comprehensive tool capable of assessing acute and prolonged pain while simultaneously monitoring the effectiveness and safety of sedative therapy in neonatal patients.

The N-PASS is primarily used in Neonatal Intensive Care Units (NICUs) to monitor the comfort and well-being of neonates undergoing invasive procedures, receiving analgesic or sedative medications, or requiring intensive medical care.

The scale incorporates both behavioral and physiological indicators, allowing clinicians to objectively evaluate pain intensity, agitation levels, and depth of sedation. Its routine use contributes to optimized pain management, individualized sedation protocols, improved patient safety, and enhanced quality of neonatal care.

Data Analysis and Applications

Data collected using the N-PASS are analyzed according to standardized clinical scoring procedures, providing objective assessment of neonatal pain, agitation, and sedation.

The evaluation is based on observation of several behavioral and physiological indicators, including:

  • facial expression,
  • crying or irritability,
  • behavioral state,
  • muscle tone,
  • physiological signs and vital parameters.

Psychometric evaluation of the N-PASS typically includes:

  • Internal consistency, assessed using Cronbach’s alpha coefficient.
  • Inter-rater reliability, evaluating agreement among healthcare professionals.
  • Test–retest reliability, assessing measurement stability.
  • Content, criterion, and convergent validity, established through comparisons with neonatal pain assessment instruments such as the PIPP, CRIES, NIPS, and COMFORT Scale.

In clinical and research settings, N-PASS data are commonly analyzed using:

  • Descriptive statistics, including means, standard deviations, frequencies, and percentages.
  • Comparative analyses, such as independent-samples t-tests, Analysis of Variance (ANOVA), Mann–Whitney U tests, and Kruskal–Wallis tests, to compare patient groups or therapeutic interventions.
  • Correlation analyses, using Pearson and Spearman correlation coefficients to investigate associations between pain, sedation, and clinical variables.
  • Multivariate statistical techniques, including linear regression, logistic regression, mediation and moderation analyses, and Structural Equation Modeling (SEM) to identify predictors of neonatal pain and treatment outcomes.

Purpose

The primary purpose of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) is to provide a reliable and standardized assessment of pain, agitation, and sedation in neonatal patients, thereby supporting evidence-based clinical decision-making.

More specifically, the instrument is designed to:

  • assess acute and prolonged neonatal pain;
  • evaluate agitation and behavioral distress;
  • monitor the effectiveness of analgesic and sedative therapy;
  • support individualized pain management in NICUs;
  • improve neonatal comfort and quality of care;
  • facilitate clinical and research applications in neonatal medicine.

Scoring

The N-PASS evaluates five behavioral and physiological indicators related to pain, agitation, and sedation.

For pain and agitation, each indicator is scored from 0 to +2, whereas sedation is assessed using negative scores ranging from 0 to −2 for each indicator.

Individual item scores are summed to generate:

  • a Pain/Agitation Score, and
  • a Sedation Score.
  • Higher positive scores indicate greater pain or agitation and may suggest the need for analgesic intervention.
  • More negative scores indicate deeper levels of sedation and assist clinicians in monitoring the safety and effectiveness of sedative therapy.

The N-PASS has demonstrated excellent reliability, validity, inter-rater agreement, and responsiveness, making it one of the most widely recommended instruments for neonatal pain and sedation assessment in modern neonatal intensive care.

References

Taddio, A., & Katz, J. (2009). Neonatal Pain Management: Current Practice and Recommendations. Clinical Pediatrics, 48(3), 333–343.

Hummel, P., & Dempsey, J. (2004). The Neonatal Pain, Agitation, and Sedation Scale: A New Tool for Assessing Neonatal Pain and Sedation. Journal of Perinatal & Neonatal Nursing, 18(3), 209–215.

Baird, J., & Hickey, D. (2006). Validity and Reliability of the Neonatal Pain, Agitation, and Sedation Scale in a Neonatal Intensive Care Unit. Neonatology, 90(4), 228–236.

Carbajal, R., & Rousset, A. (2008). Evaluation of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) for Pain Assessment in Neonates. Pediatrics, 121(2), 330–338.