Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : SC01 - SC05 Full Version

Agreement of Revised Premature Infant Pain Profile Scoring between Healthcare Providers and Laypersons: A Cross-sectional Study

Published: November 1, 2023 | DOI:
Dipen V Patel, Megha J Anant, Bhadra Y Trivedi, Ajay Gajanan Phatak, Mayur K Shinde, Reshma K Pujara, Somashekhar M Nimbalkar

1. Professor, Department of Neonatology, Bhaikaka University, Karamsad, Anand, Gujarat, India. 2. Junior Resident, Department of Paediatrics, Bhaikaka University, Karamsad, Anand, Gujarat, India. 3. Assistant Professor, Department of Paediatrics, Bhaikaka University, Karamsad, Anand, Gujarat, India. 4. Professor, Department of Central Research Services, Bhaikaka University, Karamsad, Anand, Gujarat, India. 5. Assistant Professor, Department of Central Research Services, Bhaikaka University, Karamsad, Anand, Gujarat, India. 6. Assistant Professor, Department of Neonatology, Bhaikaka University, Karamsad, Anand, Gujarat, India. 7. Professor, Department of Neonatology, Bhaikaka University, Karamsad, Anand, Gujarat, India.

Correspondence Address :
Mr. Ajay Gajanan Phatak,
Professor, Department of Central Research Services Academic Centre Bhaikaka University, Karamsad-388325, Anand, Gujarat, India.


Introduction: The experience of pain during the neonatal period has short and long-term consequences. The Revised Premature Infant Pain Profile (PIPP-R) is a globally accepted and validated tool for assessing pain in neonates. Adequate pain management measures can be implemented using the PIPP-R, even in the absence of consultants.

Aim: To assess the agreement among healthcare providers and laypersons in scoring the PIPP-R.

Materials and Methods: A cross-sectional study was conducted at Shree Krishna Hospital, a rural Tertiary Care Teaching Hospital in central Gujarat, India. The duration of the study was one year and six months, from January 2021 to June 2022. The study included 12 volunteers from various fields, such as consultant neonatologists, first year postgraduate students in Department of Paediatrics, neonatal nurses, social workers, Bachelor of Medicine, Bachelor of Surgery (MBBS) interns, and mothers of newborns. A neonatology consultant provided training on the PIPP-R scoring system using handouts and a presentation. The volunteers then evaluated 100 prerecorded videos of newborns undergoing painful procedures. Agreement between volunteers for the total PIPP-R score and its subcomponents was assessed using Bland-Altman analysis and Cohen’s Kappa statistics.

Results: A total of 100 videos of newborns (51 girls, 49 boys) undergoing painful procedures were evaluated for the PIPP-R score. The mean age, gestational age, and birth weight of the newborns were 2.21±1.55 days, 37±2.44 weeks, and 2.56±0.72 kg, respectively. The procedures included heel prick for Random Blood Sugar (RBS) (44%), intravenous sampling/insertion (34%), and intramuscular vitamin K injection (22%). The mean difference with 95% Confidence Limits (CL) of total PIPP-R scores between the two consultants (neonatologists) was -0.640 (-5.196, 3.916). The length of the CL was -9.112, which fell outside the defined CL of 4.2 (20% of the total score), indicating unacceptable agreement between the two consultants. Similarly, agreement between each consultant and any of the other participants, including residents, nurses, interns, mothers, and social workers, regarding the total PIPP-R score, as well as its subcomponents, was also deemed unacceptable.

Conclusion: The present study concluded that the inter-rater reliability of the PIPP-R score and its subcomponents was unacceptable between consultants and with any of the other participants.


Agreement, Neonates, Painful procedures, Pre-recorded video, Reliability

Preterm babies are delivered prematurely before their anatomy and physiology are capable of sustaining them in the extrauterine environment. In the Neonatal Intensive Care Unit (NICU), infants are subjected to a hostile environment and various tissue damaging procedures as part of their clinical care (1). Pain is a continuous or periodic unpleasant feeling that can be dull, acute, or piercing in nature. Newborns experience pain when they are sick or when they undergo diagnostic and therapeutic treatments (2),(3). On average, babies undergo 14 painful procedures in the first two weeks of life (4). These procedures elicit varying degrees of pain, which can have short-term, as well as long-term consequences (5),(6),(7),(8). Evaluating pain in newborns and young children is more complex and challenging than in adults. There are several techniques and approaches for measuring pain in newborns like Neonatal Infant Pain Scale (NIPS), Neonatal Facial Coding System (NFCS), Neonatal Pain Agitation and Sedation Scale (N-PASS), and PIPP-R, among others (2),(9).

The PIPP-R is a feasible and validated tool for pain assessment in preterm and term neonates. Although the name is “PIPP-R,” it is validated for neonates with a gestational age of 26-40 weeks. PIPP-R consists of three behavioural, two physiological, and two contextual indicators. Each indicator is assessed on a 4-point scale. The instrument requires physicians to evaluate the neonate’s behavioural state and monitor physiological changes in Heart Rate (HR), oxygen saturation, and facial expression as potential markers of pain (10),(11),(12).

The primary objective of all caregivers should be to evaluate the newborn baby’s pain and take steps to minimise it in order to avoid these adverse effects (5). The mother (caretaker) and healthcare providers should be able to interpret the information expressed by the neonate to assess pain. Pain evaluation should be part of a holistic approach to the child’s care, and clinicians and other healthcare professionals must regularly measure pain in real-time. It was hypothesised that PIPP-R scoring has a low learning curve, allowing anyone (volunteer/participant) to master this skill with short training. However, the reliability of PIPP-R between investigators has not yet been examined. Therefore, the current study was carried out with the aim of studying the inter-rater reliability of the total PIPP-R score and its components among healthcare providers/laypersons.

Material and Methods

A cross-sectional study was conducted at Shree Krishna Hospital, a rural Tertiary Care Teaching Hospital in central Gujarat, India. The duration of the study was one year and six months, from January 2021 to June 2022. The study was approved by the Institutional Ethics Committee (IEC), registered with the Central Drugs Standard Control Organisation (CDSCO), on 19 November 2020 (IEC/HMPCMCE/2020/Ex.34/279/20). Informed written consent was taken from each volunteer for the study.

Inclusion criteria: Videos of 100 physiologically stable newborns were included for assessment. The study included two volunteers (participants) from different fields, namely consultant neonatologists, social workers, MBBS interns, 1st year postgraduate students from paediatrics, nurses, and mothers of newborns, to score the PIPP-R from the videos. Thus, a total of 12 volunteers were selected for the assessment of PIPP-R scoring.

Exclusion criteria: Neonates requiring any respiratory support, sedatives, or analgesics, having hypoxic ischaemic encephalopathy, or any congenital anomaly were excluded from the study.

Sample size calculation: Bland JM and Altman DG, suggested a minimum of 100 records to provide reasonably stable estimates of the 95% Confidence Interval (CI) for agreement studies (13). So, from the video collections of previous studies, a total of 100 videos of neonates undergoing a pain procedure were selected for the current study.

Study Procedure

A training session was conducted for the participants by two consultants from the Neonatology Department, who were co-investigators of the study. The participants were educated about the importance of identifying neonatal pain, the components of the PIPP-R scoring system, and the calculation of the total PIPP-R score using handouts for one hour. The participants then independently assessed 10 videos, and these videos were individually discussed with each participant by the consultant neonatologist to ensure accurate scoring. Any questions or difficulties raised by the participants were addressed. By the end of assessing the 10 videos, all participants were found competent in scoring the videos for PIPP-R. This process took approximately two hours for each participant.

Within 15 days after the completion of the training sessions, five tablets were arranged, each containing 100 pre-recorded videos of newborns who had undergone painful procedures at the Institute. Each participant group (social workers, interns, residents, nurses, and mothers) received one tablet each, except for the consultants. The scoring process of the 100 videos took each participant about three weeks before the tablet was transferred to the next participant in the group. This scoring process was completed in approximately two months. After the tablets were returned by the other participant groups, the consultants were provided with one tablet each. Due to their busy schedules, the consultants took about three months to perform the scoring.

The PIPP-R scoring system includes indicators viz., changes in heart rate, decreases in oxygen saturation, brow bulge, eye squeeze, nasolabial furrow, gestational age, and baseline behavioural state. Each indicator was scored on a scale of 0-3. Therefore, the total PIPP-R score ranges from 0-21 (11). The entire procedure of 2measuring the PIPP-R score was divided into four steps.

• Step 1: Observing an infant at first for 15 seconds just before the procedure to record the highest HR, lowest oxygen saturation, and behavioural state.
• Step 2: Observing an infant for 30 seconds immediately after the procedure to record changes in the form of the highest HR, lowest oxygen saturation, and duration of each facial action.
• Step 3: Scoring for contextual items based on the changes.
• Step 4: Calculating the total score by adding up the scores of all the items.

The total score represents the intensity of pain, with a higher score indicating a higher degree of pain. The agreement among assessors was evaluated for the total score. However, for clinical decision-making, the total PIPP-R score is categorised as follows: scores of 6 or less generally indicate minimal or no pain, scores between 6-12 are considered mild pain, and scores greater than 12 reflect moderate to severe pain (10). It is important to note that these categories were not used to classify the intensity of the pain.

Statistical Analysis

Bland-Altman analysis was used to assess agreement among different volunteers (13). It was decided that the mean difference in the total score should be between -1 and +1, and the length of the CL should be within 20% to 25% of the total PIPP-R score. The maximum total PIPP-R score for preterm newborns is 21, and for term newborns, it is 18. Thus, a range of CI below 4.2 (i.e., 20% for the preterm newborn’s PIPP-R score and 23.33% for the term newborn’s PIPP-R score) was considered as acceptable agreement. For facial expressions, the total score is 9, so 20% of that (i.e., 1.8) was considered an acceptable range for the CL. Cohen’s Kappa statistic measures the inter-rater reliability of categorical data (14). Cohen’s Kappa was used to assess agreement between different components of PIPP-R among consultants, as well as between consultants and other volunteers. It was interpreted as none, minimal, weak, moderate, strong, and almost perfect agreement if the Kappa was in the range of 0 to 0.20, 0.21 to 0.39, 0.40 to 0.59, 0.60 to 0.79, 0.80 to 0.90, and 0.91 to 1.00, respectively. STATA (14.2), Stata Corp LLC, Texas, United States of America (USA) was used to analyse the data.


A total of 100 recorded videos of newborns undergoing painful procedures were evaluated for PIPP-R scores. The videos included 51 girls and 49 boys. The mean age, gestational age, and birth weight of the newborns were 2.21±1.55 days, 37±2.44 weeks, and 2.56±0.72 kg, respectively. The procedures involved heel prick for RBS estimation (44%), intravenous sampling/line insertion (34%), and intramuscular vitamin K administration (22%). All the assessors were middle-aged (25-40 years). Both consultants had more than a decade of experience in paediatrics, while both nurses had 5+ years of experience. In all participant groups except for nurses, mothers, and interns, one male and one female assessor were included. The mean±SD oxygen saturation (SpO2) in percentage (%) and HR at baseline for the babies were 94.61±3.54 and 147.60±18.81 Beats Per Minute (BPM), respectively. The mean±SD values of all the components of PIPP-R, along with the total score, are provided in (Table/Fig 1). The mean difference (95% CI) in PIPP-R scores between the consultants was -0.640 (-5.196, 3.916). This means that the mean difference between consultants in PIPP-R scores of the 100 videos is -0.64 units, and about 95% of the differences are within -5.196 and +3.916 units (Table/Fig 2).

The length of the confidence interval is 9.112, which is outside the defined confidence limit of 4.2 (20% of the total score), suggesting unacceptable agreement. The mean difference for agreement between consultants and other assessors ranged from -2.75 to -0.14, indicating that other assessors probably underestimated the pain. Although unacceptable, nurses assessed PIPP-R better than others (Table/Fig 3).

The agreement of facial expression parameters (combined score of brow bulge, eye squeeze, and nasolabial furrow) of PIPP-R scores between consultants and the rest of the assessors was also found to be unacceptable with a similar trend. Most assessors underestimated the pain compared to consultants, and nurses had better agreement with consultants, though still unacceptable (Table/Fig 4).

Even after categorising behaviour state and changes in SpO2 and HR according to the PIPP-R scoring instructions, a weighted Kappa (with quadratic weights) showed poor inter-rater reliability, although nurses exhibited acceptable Kappa values with consultants (Table/Fig 5).

Subtle observations: During the process of assessing heart rate and SpO2, it was observed that in some newborns, after the procedure, the heart rate dropped (21%), and SpO2 increased (17%) according to the consultant’s assessment.


The present study was conducted to assess the agreement between consultants and other healthcare workers, as well as laypersons, for PIPP-R. In the present study, 100 prerecorded videos of newborns undergoing painful procedures were examined by study participants (volunteers). Overall, there was unacceptable agreement between the consultants and the rest of the participants. There are many one-dimensional and multidimensional pain evaluation measures for newborns (15). The PIPP-R, an upgraded version of the original PIPP, is a multidimensional pain assessment instrument. Since the item statements on the scale were altered to make them more comprehensible, pain evaluation in disadvantaged groups is considered more objective due to the improved scoring system and the broad range of gestational ages for which it may be used for pain assessment (16). Results and subtle observations from the current study indicate that recording PIPP-R is not easy, and it is not a straightforward process for everyone, as even the scores did not agree between the experienced consultants.

There have been a few attempts to assess the concordance between two assessors in the PIPP-R scoring. The reliability of PIPP-R scores, in terms of Intraclass Correlation (ICC), was found to be good when the scoring was performed by two competent nurses (16). Similar findings were reported when three specialists assessed the PIPP-R scores (17). Another validation study also reported very high ICC among three nurses for PIPP-R scores (18). These studies indicated that within a subspecialty, PIPP-R is a reliable tool in terms of ICC. In contrast, the agreement between two consultants was found to be unacceptable in the current study. This discrepancy might be due to the fact that ICC is mathematically equal to Kappa, which is a measure of agreement for categorical data. There have been a few attempts to check the concordance between different groups (nurses/parents/physicians, etc.) in assessing pain. A study conducted in the pediatric emergency department reported discordance between nurses and parents on the Face Legs Activity Cry Consolability (FLACC) scale in children below four years of age (19). Another study from the pediatric emergency department reported poor agreement between patients and caregivers in pain assessed through the Wong-Baker FACES (WBF) and Faces Pain Scale-Revised (FPS-R) scales (20). These findings corroborate with the results of the current study.

Perception of pain and pain scores may vary from person to person based on their previous experiences and their relationship with the patients (19),(21). Zhou H et al., conducted a meta-analysis of 12 studies investigating the association between self-reported pain ratings for dyads consisting of a child and parent, a child and nurse, and a parent and nurse. They concluded that assessments of children’s pain by nurses and parents provide rough estimates rather than an accurate reflection of what children are actually experiencing (21). The authors found that the assessment of changes in heart rate and SpO2 did not agree between the two individuals, even among the consultants. Although changes in physiological markers are detected in newborns undergoing painful procedures, it is doubtful if they accurately assess pain, as they are a result of sympathetic nervous system activation and may represent general discomfort rather than specific pain. These markers are also reported in response to non painful stimuli, making it challenging to interpret them solely as indicators of pain. Nevertheless, they are recognised as objective markers in composite pain measurements (22).

Participants observed that while assessing the PIPP-R score, the assessor has to simultaneously focus on multiple parameters, including behaviour, identifying maximum heart rate and minimum SpO2 before and immediately after the procedure, all within a strict time-bound manner. Placing the pulse oximetry probe is necessary to record pulse rate and SpO2. Due to the painful procedure, newborns often move their hands and legs, causing changes in the waveform and heart rate on all types of SpO2 monitors, including Masimo pulse oximeters. This reduces the accuracy of the PIPP-R score. The current study was based on video assessments, allowing the ability to replay the video to carefully evaluate the individual components, which might be very difficult in real-time assessments.

An alternative to PIPP-R could be the use of simpler scales that contain fewer components, have better inter-rater reliability, and are less time-bound (21). The Neonatal Infant Pain Scale (NIPS) is a multidimensional pain scale designed for use in newborns. It contains indications for facial expressions, crying, breathing patterns, arm and leg movements, level of arousal, as well as one physiological signal (23). The NIPS can be considered a reliable, valid, and clinically relevant instrument with high practical importance (24). Oliveira NRG et al., assessed the correlation, internal consistency, and reliability between two experts in physical therapy who have extensive technical experience in neonatology, in assessing pain using NIPS and PIPP-R. They found high internal consistency for NIPS (r=0.824) and moderate for PIPP-R (0.655) (25). Similarly, Bellieni CV et al., assessed the agreement of NIPS and PIPP between three nurses and found that NIPS had better interobserver reliability than PIPP (26).

Most neonatal pain assessment scales assess babies’ facial expressions, although some also include elements like crying, limb movement, and vital indicators. Real-time pain assessment requires dynamic nursing monitoring rather than an instantaneous operation. As a result, frequent pain assessment is time consuming and labour-intensive. The results can be influenced by various factors, including subjective differences in observers, interruptions from other clinical procedures, a lack of time, gender differences, neonatal activity interference, etc. [27, 28]. Therefore, another alternative could be to utilise Artificial Intelligence (AI) as a neonatal pain-expression-recognition technology. The automated detection of newborn pain expressions has progressed from static photos to dynamic films and from theoretical research to system implementation, making AI-based Neonatal Pain Assessment (AI-NPA) possible. On one hand, AI-NPA may compensate for the inadequacies of onsite NPA performed by medical staff, and it may offer the benefits of simplicity and efficiency. To create a model with strong anti-interference capabilities and great resilience for real-world data, AI-NPA requires a huge amount of precisely classified neonatal pain data. Cheng XC et al., developed an automated NPA system for NIPS and found highly consistent readings with onsite measurement (27).

The authors considered the total PIPP-R score, as well as its subcomponents to assess agreement. The sample size is reasonably good for the present study. Videos were assessed so that the evaluators had ample time to do the scoring. Different care professionals were involved in the present study.


The present study was a single-centre study. Purposive sampling of assessors was done to select the volunteers. Having only two participants from each profession may not be representative. The videos were evaluated for agreement rather than real-time bedside assessment.


The agreement between consultants and other healthcare workers, as well as lay persons, was deemed unacceptable in both the total PIPP-R score and facial expression score. Even after considering the subcomponents of the PIPP-R score, such as behaviour state, change in oxygen saturation, and change in HR, the Kappa value was not impressive, confirming poor agreement. Contrary to expectations, the learning curve for PIPP-R scoring appears to be steep, suggesting that persistent efforts and experience are required to master this skill, hence rejecting the hypothesis. This fact is supported by the better agreement observed between experienced nurses and consultants. Conducting multicentric agreement studies utilising different frontline healthcare workers will help strengthen the evidence.


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DOI and Others

DOI: 10.7860/JCDR/2023/63552.18652

Date of Submission: Feb 27, 2023
Date of Peer Review: Apr 22, 2023
Date of Acceptance: Sep 13, 2023
Date of Publishing: Nov 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Mar 02, 2023
• Manual Googling: May 12, 2023
• iThenticate Software: Sep 11, 2023 (5%)

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