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Objective: The study aims to assess the inter-observer reliability and feasibility
of three neonatal pain scales among NICU residents, nurses and midwives.
Design: This is a prospective study.
Methods: Phase I - Pediatric Residents, Neonatal Nurses and Midwives at The
Medical City Neonatal Intensive Care Unit participated a Pain Scale Training
Seminar. Videos of 8 neonates undergoing the heel-prick procedure were
assessed using the Crying, Requires Oxygen Saturation, Increased Vital Signs,
Expression, Sleeplessness (CRIES) Scale, Neonatal Infant Pain Scale (NIPS),
and Face, Legs, Activity, Cry and Consolability (FLACC) Scale. Thereafter,
participants were asked to evaluate the three pain scales based on ease-of-use.
Preliminary inter-observer reliability was determined based on the data collected.
Phase II Two (2) Pediatric Residents used the 3 pain scales to assess, at
bedside, 30 healthy neonates undergoing heel-prick procedure at the NICU.
Inter-observer reliability was studied.
Results: Phase I - All 3 pain scales showed agreement among observers.
Based on the comparison of the mean scores of observers, there was no
significant difference noted as proven by all p values >0.05. As compared to the
CRIES Scale and FLACC Scale, the Neonatal Infant Pain Scale was chosen as
the easiest pain assessment tool to use at the NICU with 88.9% acceptability.
Phase II - The NIPS and CRIES scale scores given by 2 residents who observed
the neonates at bedside showed moderate agreement with a Kappa of 0.469 and
0.441 respectively. Scores using the FLACC scale showed fair agreement with a
Kappa of 0.221. NIPS had the best rate of agreement at 63.3% as compared to
the CRIES and FLACC scale with 50% and 40%, respectively.
Conclusion: The 3 pain scales had comparable inter-observer reliability among
residents, nurses and midwives. Regarding feasibility, the Neonatal Infant Pain
Scale was assessed as the easiest-to-use pain assessment tool at the NICU.
Bedside assessment done by 2 residents using the NIPS and CRIES scale
showed moderate agreement. The NIPS had the best rate of agreement at
63.3%.
in previous studies done abroad. The FLACC scale is currently being used by the
Department of Anesthesiology of TMC in assessing post-operative pain in pre-verbal
patients and children. The FLACC scale was included in the study to determine its
applicability among neonates exposed to procedural pain.
The CRIES (Crying, Requires Oxygen for Saturation >95%, Increased Vital
Signs, Expression, and Sleeplessness) Scale was developed by Judy Bildner, RNC,
MSN. This pain scale was designed to document a neonates pain response to invasive
procedures. The CRIES scale is a multidimensional scale which uses physiological and
behavioral variables previously shown to be associated with neonatal pain. The
variables evaluated are as follows:
>95%, (3) Increased Vital Signs, (4) Expression, and (5) Sleeplessness. Each variable is
scored 0, 1 or 2. The highest score possible for this scale is 10, indicating severe pain.16
Based on the initial testing of the CRIES scale done by SW. Krechel and J.
Bildner,
the scale was found to be a valid, reliable and well-accepted tool by neonatal
nurses and physicians to assess post-operative pain in neonates 32-60 weeks age of
gestation. Reliability and validity were established by measuring pain after administering
analgesics, with a significant decrease in measured pain observed following treatment.17
The Neonatal Infant Pain Scale (NIPS) is a multidimensional scale used in full
term and pre-term infants. The assessment scale is a neonatal adaptation of the
Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS). Five behaviors are
evaluated, namely: (1) facial expression, (2) cry, (3) arm, (4) legs, (5) state of arousal.
Each behavioral variable is scored 0 or 1 except cry which is scored 0, 1 or 2. One
physiological indicator, the breathing pattern, is evaluated also. The total score range
from 0-7. 18
Suraseranivongse et al recommend the NIPS as a valid, reliable and practical
tool. In the study, the NIPS was used to evaluate post-operative pain in 22 neonates.
The scale had excellent interrater reliability (intraclass correlation >0.9), high sensitivity
and specificity (>90%), and in terms of practicality, it was the most acceptable (65%). 19
The Face, Legs, Activity, Cry, and Consolability (FLACC) pain scale is an interval
scale that measures pain by quantifying pain behaviors. Five (5) categories of behavior
are included in the scale: facial expression, leg movement, activity, cry, and
consolability. Total score range from 0-10. The 0-10 score has been interpreted in terms
of absence of pain (0), mild pain (1-3), moderate pain (4-6), and severe pain (7-10).20
Research in a post-anesthesia unit, done by Merkel et al, showed that the
FLACC scale is a valid and reliable tool that was easy to use in patients 2 months to 7
years of age. Manworren and Hynan affirmed the evidence of the validity, reliability, and
clinical utility of the FLACC Pain Assessment Tool for assessing surgical pain intensity in
preverbal children.
assessed using the FLACC scale. Pre-analgesia FLACC scores were significantly higher
than post-analgesic scores.20
To give optimal pain management, there is a need for competent pain
assessment, which is especially difficult to perform in neonates.15 'The cornerstone to
adequate pain treatment in this population is the availability of adequate pain
assessment methods.'14 The Policy Statement of the American Academy of Pediatrics
on the Prevention and Management of Pain and Stress in the Neonate states that there
is a need for development and validation of neonatal pain assessment tools that are
easily applicable in the clinical setting.4 'The availability of adequate assessment tools is
critical for reducing the under treatment of neonatal pain'. 14
Every health care facility caring for neonates should implement an effective pain
prevention program which includes strategies for routinely assessing pain. Currently, no
studies are found in the local setting comparing available neonatal pain assessment
tools despite the growing number of research world-wide focused on refining these tools.
Validity and reliability are important characteristics of a pain assessment tool. However,
a tool that is highly valid and reliable in measuring pain may be too cumbersome to use
in the clinical setting. Therefore, when selecting a pain assessment tool, the clinical
utility or feasibility relative to the setting should be taken into consideration. This would
ensure compliance among health professionals and success in the implementation of a
standardized pain assessment and management.
Pain assessment in neonates is complex. There are innumerable challenges but
the opportunity to maximize the comfort and health of the neonate is great.
III. OBJECTIVES
General Objectives:
To evaluate the three pain assessment scales: (1) Neonatal Infant Pain Scale (NIPS),
(2)
Crying,
Requires
Oxygen
Saturation,
Increased
Vital
Signs,
Expression,
Sleeplessness (CRIES) Scale and Face, Legs, Activity, Cry and Consolability (FLACC)
Scale on neonates at The Medical City Neonatal Intensive Care Unit (TMC-NICU)
undergoing heel-prick procedures from July-September 2007
Specific Objectives:
1. To determine the inter-observer reliability of the three pain scales among NICU
residents, nurses and midwives
2. To determine the feasibility of the three pain scales among NICU residents,
nurses and midwives
B. Identification of Neonates
The subjects were identified and the following neonatal data were
registered: type of delivery, birth weight in grams, gestational age in weeks,
gender, APGAR score at one and five minutes, and postnatal age.
C. NICU Staff Participants (Subjects)
The participants consisted of four (4) NICU residents, eight (8) nurses
and six (6) midwives currently employed full time at The Medical City-NICU for
more than six (6) months. The study participants volunteered to attend the Pain
Scale Training Seminar.
D. Pain Scales
The three (3) pain scales were used with the following parameters:
1. CRIES Scale is defined by the following variables: (1) crying, (2)
requires Oxygen for saturation >95%, (3) increased vital signs, (4)
expression, and (5) sleeplessness. Each variable is scored 0, 1 or 2. The
highest score possible for this scale is 10
2. Neonatal Infant Pain Scale is defined by the following variables:(1)
facial expression, (2) cry, (3) breathing pattern, (4) arms, (5) legs, (6)
state of arousal. Each variable is scored 0 or 1, except cry which is
scored 0,1 or 2. The highest possible score for this scale is 7.
3. FLACC Scale is defined by the following variables: (1) facial
expression, (2) leg movement, (3) activity, (4) cry, and (5) consolability.
Each variable is scored 0,1 or 2. The highest score possible for this scale
is 10.
E. Videotaping
Consents were obtained from parents of the eight subjects to be recorded
on video. The videotaping of the procedure started after each subject was placed
under a radiant warmer, unswaddled and hooked to a pulse oximeter at the left
foot. The video focused on the subjects face and body. Sound was included with
the video to assess crying. The video recording was discontinued five (5) minutes
after the completion of the procedure.
H. Data Analysis
In Phase I of the study, data were encoded and tallied in SPSS version
10 for windows. Descriptive statistics were generated for all variables. For
nominal data, frequency and percentage were generated. Comparison of the
different variables under study was done using ANOVA. This is used to compare
more than two groups with numerical data (compares means).
In Phase II of the study, the agreement of all pain scales was analyzed
using the Kappa (K) statistic. Values of K were interpreted as follows: <0.2, poor
agreement; 0.21-0.4, fair agreement; 0.41-0.6, moderate agreement; 0.61-0.8,
good agreement; and 0.81-1.0, very good agreement.
10
V. RESULTS
PHASE I
In Phase I of the study, all three pain scales showed agreement among
observers. The results showed, based from the comparison of the mean scores of
observers, that there was no significant difference noted as proven by all p values >0.05.
Table 1. Observer Agreement on CRIES score
CRIES
(Subjects)
Resident (n= 6)
Mean SD
Nurses (n= 8)
Mean SD
Midwife (n= 4)
Mean SD
P value
6.00 1.78
7.18 2.01
7.67 0.58
0.35 (NS)
6.50 1.70
7.12 2.01
7.50 0.50
0.69 (NS)
5.42 2.15
5.81 1.53
7.00 2.18
0.50 (NS)
6.50 2.09
7.44 0.82
7.16 1.04
0.49 (NS)
5.25 2.32
6.06 1.05
5.33 0.76
0.60 (NS)
4.58 2.04
4.06 1.70
3.83 2.02
0.82 (NS)
5.33 2.42
4.94 1.59
6.16 0.76
0.62 (NS)
6.42 2.99
7.00 1.60
5.17 1.53
0.48 (NS)
Cries Over-all
5.75 1.80
6.20 1.12
6.23 0.69
0.80 (NS)
Table 1 shows the agreement among observers on CRIES score. The results
showed, based from the comparison of the mean scores of observers, that there was no
significant difference noted as proven by all p values >0.05. This means that all three
observers were comparable in their observation of CRIES. Both individual CRIES and
over-all scores for CRIES were not significantly different (p>0.05).
Resident (n= 6)
Mean SD
6.50 1.22
6.25 1.36
4.83 1.63
6.42 1.20
4.83 1.75
4.00 2.04
4.75 2.09
5.92 1.63
5.44 1.06
Nurses (n= 8)
Mean SD
6.31 0.59
5.18 1.39
5.25 1.56
6.38 0.92
5.88 1.33
2.62 1.38
4.19 0.75
6.75 0.71
5.32 0.68
Midwife (n= 4)
Mean SD
6.83 0.29
5.66 0.58
4.00 1.50
6.33 0.58
5.33 0.76
2.67 1.52
3.67 0.76
6.50 0.50
5.12 0.50
P value
0.66 (NS)
0.34 (NS)
0.52 (NS)
0.99 (NS)
0.42 (NS)
0.30 (NS)
0.54 (NS)
0.40 (NS)
0.86 (NS)
Table 2 shows the agreement among observers on NIPS score. The results showed,
based from the comparison of the mean scores of observers, that there was no
significant difference noted as proven by all p values >0.05. This means that all three
11
observers were comparable in their observation of NIPS. Both individual NIPS and overall scores for NIPS were not significantly different (p>0.05).
FLACC
Resident (n= 6)
Mean SD
Nurses (n= 8)
Mean SD
Midwife (n= 4)
Mean SD
P value
7.75 2.32
7.94 1.12
8.33 1.15
0.88 (NS)
7.75 1.37
6.81 2.37
5.83 0.58
0.36 (NS)
5.17 1.75
6.31 1.89
5.67 0.58
0.48 (NS)
8.92 2.20
8.69 1.22
8.33 1.53
0.89 (NS)
5.50 3.12
7.50 1.83
6.67 7.76
0.31 (NS)
4.42 3.10
4.19 1.77
4.00 1.50
0.96 (NS)
4.67 3.14
5.63 1.16
5.83 1.04
0.63 (NS)
7.08 2.44
8.56 1.12
8.00 1.80
0.34 (NS)
FLACC Over-all
6.40 1.72
6.95 1.23
6.58 0.96
0.76 (NS)
Table 3 shows the agreement among observers on FLACC score. The results
showed, based from the comparison of the mean scores of observers, that there was no
significant difference noted as proven by all p values >0.05. This means that all three
observers were comparable in their observation of FLACC. Both individual FLACC and
over-all scores for FLACC were not significantly different (p>0.05).
to
CRIES
0
0
18 (100%)
NIPS
16 (88.9%)
2 (11.1%)
0
FLACC
2 (11.1%)
15 (88.9%)
0
16 (88.9%)
2 (11.1%)
16 (88.9%)
2 (11.1%)
The NIPS was selected by 16 participants (88.9%) as the easiest-to-use tool for
pain assessment followed by the FLACC Scale (11.1%), chosen by 2 participants in the
Pain Scale Training Seminar. The NIPS was also chosen as the easiest to understand
and deemed most useful at the NICU (88.9%) by the residents, nurses and midwives.
The CRIES Scale was unanimously chosen as the most difficult pain scale to
understand and implement at the NICU.
12
PHASE II
Interpretation
CRIES
0.441
Moderate agreement
NIPS
0.469
Moderate agreement
FLACC
0.221
Fair agreement
Comparing the agreement of pain scales, the CRIES scale and NIPS showed
Kappa values of 0.441 and 0.467, respectively, interpreted as moderate agreement. The
FLACC scale showed fair agreement with a Kappa of 0.221.
Table 6. Scoring on CRIES
CRIES1
Score of 8
Score of 9
Score of 10
Total
CRIES 2
Score of 7
2
2
0
4
Score of 8
2
4
0
6
Total
Score of 9
1
9
3
13
Score of 10
0
3
4
7
5
18
7
30
Agreement = 50%
Disagreement = 50%
Table 7. Scoring on NIPS
NIPS1
Score of 5
Score of 5
Score of 6
Score of 7
Total
0
2
0
2
NIPS 2
Score of 6
1
8
3
12
Total
Score of 7
0
5
11
16
1
15
14
30
Agreement = 63.3%
Disagreement = 36.7%
Table 8. Scoring on FLACC
FLACC1
FLACC 2
Total
13
Score of 8
Score of 9
Score of 10
Score of 8
Score of 9
Score of 10
Total
1
1
0
2
3
7
8
18
1
5
4
10
5
13
12
30
Agreement = 40.0%
Disagreement = 60.0%
Tables 6, 7 and 8 show the rate of agreement of the score given by 2 observers.
The NIPS had the highest rate of agreement at 63.3% while the FLACC scale showed
40% rate of agreement.
VI. DISCUSSION
The study had two phases: Pain Scale Training Seminar (Phase I) and Bedside
Observation (Phase II). The Pain Scale Training Seminar was participated by the
Neonatal Intensive Care Unit Staff composed of six (6) Resident Pediatricians, eight (8)
Neonatal Nurses, and four (4) Midwives. The participants viewed eight (8) neonatal
subjects undergoing heel-prick on video and assessed the intensity of acute pain using
the three (3) pain scales: CRIES scale, NIPS and FLACC scale.
The participants were grouped according to their medical background. The
scores given by the residents, nurses and midwives were comparable indicating that
standard education enables the NICU staff to use the pain scales. In addition, the scores
assessed by the pain scales were consistent.
However, the video provided the participants with only an audiovisual depiction of
the subjects pain experience. The video format denied them use of palpation to assess
the subjects muscle tone. The participants were also unable to console the video
subjects. These factors definitely affected the accuracy of pain assessment, usually
underestimating the degree of pain. Despite the limitation of assessing videotaped
subjects, the scores given by the different observers were comparable.
The participants of the seminar were also asked to evaluate the pain scales after
applying them on the videotaped subjects. The Neonatal Infant Pain Scale was chosen
as the tool easiest to use and understand. It was deemed most useful in the NICU
setting. The participants preferred the NIPS.
On the other hand, the CRIES scale failed in this aspect. The participants took
more time to understand the variables and answer the pain scale. It was noted that the
preparations needed to use the CRIES scale was time-consuming and taxing. The14
participants specified the use of the pulse oximeter and the monitoring of blood pressure
as obstacles in the completion of the pain assessment. In order to hook and secure the
two equipment (blood pressure cuff and pulse oximeter probe), physical manipulations of
the neonates extremities are needed. This would subject the neonate to undue stress
and cause inaccuracies in the determination of physiologic variables such as oxygen
saturation, heart rate and blood pressure. Based on their observations, even if the pulse
oximeter probe was secured properly, the slightest movement of extremities caused
fluctuations in the readings of the heart rate and pulse oximeter, more so, with the
introduction of the painful stimulus (heel prick). Another participant also commented that
difficulty in the completion of the assessment was due to the need to calculate the
percent (%) change in the heart rate and blood pressure. All the participants identified
the CRIES scale as impractical in the actual setting. Taking into account the limited
number of resources (equipment and manpower) and the increasing number of
admissions at the NICU, the successful implementation of the CRIES scale is highly
improbable.
The Neonatal Infant Pain Scale is the tool-of-choice of the NICU staff. In an open
forum, the staff is amenable in implementing the pain scale. Pain, being the fifth vital
sign, should be included in the routine monitoring of neonates at the NICU. An easy-touse tool such as this will encourage compliance among NICU staff. This would facilitate
consistency in pain assessment which is the building block of a successful pain
management program.
In Phase II of the study, NIPS had the best rate of agreement at 63.3% as
compared to the CRIES and FLACC scale with 50% and 40%, respectively. The NIPS
and CRIES scale scores given by two residents who observed the neonates at bedside
showed moderate agreement with a Kappa of 0.469 and 0.441 respectively. Scores
using the FLACC scale showed only fair agreement with a Kappa of 0.221.
Various research and information on neonatal pain are available but it is not
universally applied. The causes may be due to the additional work load it imposes on the
neonatal staff, misconceptions on the topic of neonatal pain, and fear from deviating
from the status quo. This is the reason why continuous education on pain assessment
and management should be advocated.
The Medical City is in need of standardizing a pain assessment tool for the15
NICU.
A valid, reliable and easy-to-use tool is ideal. In this study, the Neonatal Infant
Pain Scale is highly recommended based on its interobserver reliability and feasibility.
However, further studies supporting the validity and reliability of the NIPS involving a
larger group of observer and neonate at TMC-NICU are highly recommended.
Neonatal
pain
assessment
and
management
is
continuous
quality
improvement measure for international health care facilities such as The Medical City.
There is a need to formulate an effective pain assessment and management strategy to
move a notch higher not just for accreditation purposes but in terms of quality patient
care.
VII. CONCLUSION
The three pain scales had comparable inter-observer reliability among residents,
nurses and midwives. Regarding feasibility, the Neonatal Infant Pain Scale was chosen
as the easiest-to-use pain assessment tool at the NICU. Bedside assessment done by
two residents using the NIPS and CRIES scale showed moderate agreement. The NIPS
had the best rate of agreement at 63.3%.
16
BIBLIOGRAPHY
1. Franck LS, Cox S, Allen A, Winter I. Parental Concern and Distress About Infant
Pain. Arch Dis Child Fetal Neonatal Ed 2004; 89:F71-F75
2. PubMed Morelius E, Hellstrom-Westas L, Carlen C, Norman E, Nelson N. Early
Hum Dev. 2006 Oct; 82[10]669-76.EPUB 2006 FEB 28.
3. Joint Commission on the Accreditation of Healthcare Organizations. (2002). Hospital
accreditation standards: Accreditation policies, standards, intent statements.
Oakbook Terrace, IL: Author
4.
Prevention
Pediatrics.2000; 105:454-461
assessment
2464-69.
Prevention
18
APPENDIX 1
Pain-Assessment Tools
19
Assessment Tool
Physiologic
Indicators
Behavioral
Indicators
Gestational
Age Tested
Assesses
Sedation
Scoring
Adjusts for
Gestational
Age
Nature of Pain
Assessed
PIPP: Premature
Infant Pain Profile
Heart rate,
oxygen
saturation
2840 wk
No
Yes
Procedural
and
postoperative
pain
CRIES: Crying,
Requires Oxygen
Saturation,
Increased Vital
Signs,
Expression,
Sleeplessness
Heart rate,
oxygen
saturation
Crying, facial
expression,
sleeplessness
3236 wk
No
No
Postoperative
pain
NIPS: Neonatal
Infant Pain Scale
Respiratory
patterns
Facial
expression, cry,
movements of
arms and legs,
state arousal
2838 wk
No
No
Procedural
pain
N-PASS:
Neonatal Pain
Agitation and
Sedation Scale
Heart rate,
respiratory rate,
blood pressure,
oxygen
saturation
Crying, irritability,
behavior state,
extremities tone
0100 d of
age and
adjusts score
on the basis
of gestational
age
Yes
Yes
Ongoing and
acute pain and
sedation
NFCS: Neonatal
Facing Coding
System
None
Facial muscle
group movement
Preterm and
term
neonates,
infants at 4
mo of age
No
No
Procedural
pain
PAT: Pain
Assessment Tool
Respirations,
heart rate,
oxygen
saturation,
blood pressure
Posture, tone,
sleep pattern,
expression, color,
cry
Neonates
No
No
Acute pain
Central nervous
system state,
breathing, heart
rate, mean
blood pressure
Movement, tone,
face
Neonates
No
No
Acute pain
EDIN: Echelle de
la Douleur
Inconfort
Nouveau-Ne'
(Neonatal Pain
and Discomfort
Scale)
None
Facial activity,
body movements,
quality of sleep,
quality of contact
with nurses,
consolability
2536 wk
(preterm
infants)
No
No
Prolonged
pain
BPSN: Bernese
Pain Scale for
Neonates
Heart rate,
respiratory rate,
blood pressure,
oxygen
saturation
Facial
expression, body
posture,
movements,
vigilance
Term and
preterm
neonates
No
No
Acute pain
20
APPENDIX 2
CONSENT FORM
(Heel Prick Procedure)
APPENDIX 3
21
PAHINTULOT
(Heel Prick Procedure)
_________________________
Pangalan at Lagda
22
APPENDIX 4
PAIN SCALES
Date:__________________________________________
Evaluator:______________________________________
Age/Sex:________________________________________
Position:
23
APPENDIX 5
Score
Score
Requires O2 for SaO2 < 95% - Babies experiencing pain manifest decreased oxygenation.
Consider other causes of hypoxemia, e.g., oversedation, atelectasis, pneumothorax)
0
No oxygen required
Increased vital signs (BP* and HR*) - Take BP last as this may awaken child making other
assessments difficult
0
Expression - The facial expression most often associated with pain is a grimace. A grimace may
be characterized by brow lowering, eyes squeezed shut, deepening naso-labial furrow, or open
lips and mouth.
0
No grimace present
Sleepless - Scored based upon the infants state during the hour preceding this recorded score.
0
TOTAL
24
APPENDIX 6
Score
Score
Facial Expression
0 Relaxed
muscles
1 Grimace
Cry
0 No Cry
1 Whimper
2 Vigorous Cry
Breathing Patterns
0 Relaxed
1 Change in
Breathing
Arms
0
Relaxed/Restrained
1
Flexed/Extended
Legs
0
Relaxed/Restrained
1
Flexed/Extended
State of Arousal
0
Sleeping/Awake
1 Fussy
TOTAL
25
APPENDIX 7
Pain Assessment
Score
Score
Face
0
Legs
0
Activity
0
Cry
0
Consolability
0
Content, relaxed
2
TOTAL
26
APPENDIX 8
APPENDIX 9
27
Videotaped Babies
Baby
1
2
3
4
5
6
7
8
Sex
M
M
M
M
F
F
F
F
BW
3525
3505
3645
3285
2605
3230
2510
2645
Del
NSD
CS
CS
NSD
CS
NSD
CS
CS
AOG
39
38
39
39
38
39
37
39
DOB
9/18
9/18
9/17
9/18
9/18
9/22
9/18
9/21
DOC
9/20
9/20
9/20
9/20
9/20
9/23
9/20
9/23
Age (HR)
48
48
72
48
48
24
48
48
DOC
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/30
9/29
9/29
9/29
9/29
9/29
9/29
9/29
9/29
9/29
9/28
9/28
9/28
9/28
Age (HR)
48
24
24
48
48
48
72
72
72
24
48
24
48
72
24
48
72
48
24
48
48
48
48
48
72
48
48
48
48
72
Observed Babies
Baby
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Sex
M
F
M
F
F
M
M
M
F
F
F
F
F
M
F
M
F
M
F
F
F
F
M
M
M
M
F
F
M
F
BW
3265
2535
3940
2950
3220
3565
2755
3165
3300
3350
2835
3010
2980
2925
3205
3145
2305
2835
3280
2725
3020
2455
4180
3210
2915
3105
2980
2780
3485
2595
Del
NSD
NSD
CS
CS
NSD
NSD
CS
CS
NSD
NSD
NSD
NSD
NSD
CS
NSD
CS
CS
NSD
CS
NSD
CS
NSD
CS
CS
CS
NSD
CS
NSD
CS
NSD
AOG
38
40
39
39
38
40
38
39
39
39
38
39
38
37
40
38
37
38
39
40
40
37
40
39
38
41
38
40
38
40
DOB
9/28
9/29
9/29
9/28
9/28
9/28
9/27
9/27
9/27
9/29
9/28
9/29
9/28
9/27
9/29
9/28
9/27
9/27
9/28
9/27
9/27
9/27
9/27
9/27
9/26
9/27
9/26
9/26
9/26
9/25
28
APPENDIX 10
CRIES
NIPS
FLACC
OBS
BB1
10
BB2
BB3
10
BB4
10
BB5
BB6
BB7
BB8
BB9
BB10
10
BB11
10
BB12
10
10
BB13
10
10
10
10
BB14
10
10
BB15
10
10
BB16
10
10
BB17
10
BB18
BB19
BB20
10
BB21
10
10
BB22
10
10
10
10
BB23
10
10
10
BB24
10
10
10
BB25
10
10
BB26
10
10
BB27
10
BB28
BB29
BB30
18 OBSERVERS
CRIES
NIPS
FLACC
16
FAIRLY EASY
16
DIFFICULT
17
16
16
EASIEST TO UNDERSTAND
MOST USEFUL
29
30