If you’ve ever felt your face get hot with anger, or had a chill go down the back of your neck while watching a horror movie, then it won’t come as a surprise that emotional stress can cause changes in body temperature.

But can temperature changes also indicate physical pain?

That’s the question currently being investigated by Kim Francis, PhD, RN, PHCNS-BC, Nurse Director for the Newborn Family Units at Massachusetts General Hospital and her team; Karen Sharp, RN, Ellen Hutchinson, RN, Margaret Settle, PhD, RN, and Jaqueline McGrath, PhD, RN, FAAN.

Dr. Francis and team are investigating how changes in facial temperature could be connected to facial expressions associated with pain in premature infants. The goal is to find a more objective way to assess and relieve pain.

Untreated pain could affect neurological development and may have lifelong impacts on infants’ physiological function.

Francis was recently presented with the 2020 Excellence in Nursing Research Award from the American Nurses Association of Massachusetts in recognition of her efforts.

She has also received institutional support from the Yvonne L. Munn Center for Nursing Research as a Connell Research Scholar in 2015 and again from the Mass General Research Institute as the inaugural recipient of the Jeannette Ives Erickson Nursing Research Award in 2017.

The Need for Objective Pain Assessment

There are two rating scales that are mostly used to assess infant pain—N-Pass (the Neonatal Pain, Agitation and Sedation Scale) and NIPS (the Neonatal-Infant Pain Scale).

The challenge with both scales is they are subjective, Francis explains. “I could ask five different nurses to rate the same baby and get five different answers.” This is something she is also evaluating in her current study.

Part of the challenge in assessing preterm infant pain is that their nervous systems are often not developed enough to process pain the way a full-term infant does.

“If you give a full-term infant a heel stick to draw blood, for the most part they are going to scream, kick and try to push you away,” Francis explains.

“They can really localize that pain too. If I am doing a heel stick in the left foot, they know it’s in their left foot, and they’re going to be kicking their left foot.”

“Preterm infants—especially those at extremely low gestational age—will be aware that they are experiencing pain, but unable to localize it,” Francis says. “They feel it everywhere.”

To compound the problem, these infants typically undergo a higher amount of painful procedures, such as blood draws, as part of their neonatal care.  

Without interventions to relieve this pain—such as medications, swaddling, non-nutritive sucking and skin-to-skin contact with parents—infants can enter a constant pain loop that they can’t break out of.

They will eventually shut down, appearing to be slow or sluggish. “They may not look like they are still in pain, but they are,” Francis explains.

By looking at changes in facial temperature before, during and after painful and non-painful procedures, Francis hopes to find a more objective way to assess preterm pain.

“You’re never going to take the total clinical assessment out of it, but you need a tool that can catch things that otherwise might be missed,” she says.

To accomplish this, she equipped a rolling cart with three cameras on adjustable arms and a computer to collect data.

Two of the cameras record video footage—one to capture the infant’s facial expressions and the other to record the infant’s monitor readings. The third camera uses infrared technology to monitor facial temperature changes.

After spending the past few years collecting footage, Francis is now processing the data to see what connections can be made.

She is also interested in exploring machine learning or AI algorithms that could identify signs of pain that can be missed by the human eye.

Engaging Parents in the Process

One challenge that Francis had in gathering data was recruiting the parents of preterm infants to take part in the study.  This led her to evaluate the factors which influence parental participation in research.

A poster on the topic was presented at the Mass General Nursing Research Day 2020 and a paper is currently under development.

“I found that a lot of parents really do want to participate in research, but we don’t do a good job of telling them about it,” she explains. “We make it more complex than it needs to be.”

“Another thing I learned was that parents want information,” she adds. “They often want to be part of a study and want to know about research, so don’t be afraid to approach them. They may say no, but at least they have had the chance to say yes or no.”

About the Mass General Research Institute
Research at Massachusetts General Hospital is interwoven through more than 30 different departments, centers and institutes. Our research includes fundamental, lab-based science; clinical trials to test new drugs, devices and diagnostic tools; and community and population-based research to improve health outcomes across populations and eliminate disparities in care.
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