#322 – Neonatal Pain and Stress: What We See, What We Miss, and What We Can Do

Hello friends 👋

In this episode, we speak with neonatal nurse scientists Dr. Marliese Nist and Dr. Kathy Dudding to explore the evolving understanding of neonatal pain and stress in the NICU. Together, we look at how outdated assumptions about infant pain still influence clinical care, and what providers can do to better recognize and respond to the signs of stress in fragile newborns.

Our guests discuss how even routine care can be a source of stress for preterm infants, and why thoughtful, individualized approaches—such as comfort touch and parental involvement—can make a meaningful difference. They also highlight the lack of standardization in pain protocols across NICUs and the limitations of existing assessment tools.

This conversation offers practical takeaways for clinicians at the bedside and makes the case for system-wide change in how we approach pain management and developmental care. The episode is part of our collaboration with the National Association of Neonatal Nurses (NANN), and underscores the vital role of interdisciplinary teamwork in improving neonatal outcomes.

Link to episode on youtube: https://youtu.be/hvGWwEK7WSE

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Short Bios: 

Dr. Katherine Dudding: Dr. Katherine Dudding is an expert in neonatal nursing with a 27-year career as a nurse, educator, and researcher. Her unwavering commitment to the health and well-being of neonates, coupled with her innovative approach to nursing informatics, earned her widespread recognition. Dr. Dudding began her academic journey by earning her Bachelor of Science in Nursing from East Carolina University in 1997. Fueled by her passion for advancing the nursing body of knowledge, she pursued her PhD in Nursing at the University of Arizona, which she completed in 2018. Her doctoral research centered on Informatics, and she further expanded her expertise by obtaining a minor in cognitive science with a focus on artificial intelligence and machine learning. In 2019, Dr. Dudding embarked on her tenure-track appointment, first at the University of Alabama at Birmingham and then at the University of Alabama, where she has made significant contributions as an Assistant Professor. Her dedication to both teaching and research has led to several national and international publications, presentations, and book chapters. Dr. Dudding's research is at the forefront of improving outcomes for neonates experiencing pain. Her work focuses on enhancing communication between neonates and nurses to facilitate quicker pain relief through technology-based interventions. This innovative research aims to bridge the gap in understanding neonatal pain and promote better clinical outcomes.

Dr. Marliese Nist: Dr. Marliese Nist's research focuses on improving the neurodevelopment of preterm infants with an emphasis on decreasing the negative effects of stress exposure in the neonatal intensive care unit (NICU). Dr. Nist's work incorporates laboratory science with clinical research methods to understand the biological and physiological effects of stress on immature infants and to develop and test interventions to improve long-term outcomes.

After graduating with her undergraduate degree in biology, Dr. Nist worked for several years as a laboratory technician before shifting her career to nursing. Following a decade of clinical nursing caring for the smallest and most critically ill infants in the NICU, Dr. Nist returned to The Ohio State University, where she completed her coursework to become a registered nurse, to earn her Master's and Doctoral degrees and to conduct rigorous research to improve outcomes for all preterm infants.

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The transcript of today's episode can be found below 👇

Ben: Hello, everybody. Welcome back to the Incubator Podcast. We’re back today for a special episode of the Incubator, and Daphna is in the studio with us. Daphna, good morning. How are you?

Daphna: I'm doing really well. I was telling you offline—this is kind of a personal area of interest and professional passion for me. So I’m really excited about today’s topic and our special collaboration with NAN.

Ben: Absolutely. I’ll talk about the collaboration in just a second, but first I’m going to introduce our guest. Let’s start with Kathy Dudding. Kathy, good morning, and thank you for being on the show. You’re an assistant professor at the University of Alabama and a neonatal nurse scientist for over 20 years. You’ve dedicated your career to improving how nurses understand and respond to neonatal pain. You use technology and informatics in your research to enhance communication between babies and caregivers, leading to faster and more effective pain relief. We’re really excited to talk with you about that today. You’re joined by Marliese Nist. Marliese, you’re an assistant professor and neonatal neuroscientist at The Ohio State University College of Nursing—we’re told not to skip “the”! Your research focuses on improving the neurodevelopment of preterm infants by reducing the harmful effects of stress in the NICU. You have a background in biology, a decade of NICU nursing experience, and you combine lab science and clinical research to develop interventions that support better long-term outcomes for fragile newborns.

We also want to mention that this episode is brought to you in partnership with the National Association of Neonatal Nurses, or NAN, for those familiar with the organization. For over 30 years, NANN has led the way in supporting and empowering neonatal nurses who care for our tiniest and most vulnerable patients. Through education, advocacy, and a strong professional community, NANN is dedicated to advancing neonatal care and improving outcomes for babies and families everywhere. As part of this collaboration, we also want to feature NANNcast, the official podcast of NANN, hosted by Jill Beck. NANNcast brings expert insights, the latest research, and real stories from the world of neonatal nursing. Whether you’re a healthcare professional or a family member with any connection to the NICU, there’s something for everyone to learn and share. Be sure to check out NANNcast wherever you get your podcasts, and join us in celebrating the incredible work of neonatal nurses and the families they serve. Daphna, take it away.

Daphna: Thank you for that. We’re really excited about this collaboration. For us to provide the best care for babies in the NICU, it truly requires multidisciplinary collaboration. And you both are the perfect guests to have on today as we talk about neonatal pain and stress.

Ben hates it when I say I “love” this topic, because the topics aren’t always positive—but I believe something positive can come from us talking about this. And I really feel that addressing neonatal pain and stress is everyone’s responsibility, not just the bedside nurse. Hopefully, you’ll help empower our listeners and explain why this is a shared duty.

To set the stage, Kathy, can you start by telling us a little about the history of neonatal pain in the NICU? I’m not sure everyone realizes that it wasn’t that long ago when people believed babies—especially preterm babies—didn’t even feel pain or stress. We've come a long way, though there's still a lot of work ahead. Tell us about that evolution.

Kathy Dudding: Yes, that’s a great question and a good place to start. Just like you said, neonatal pain was only formally recognized around 1985–1987—about 38 years ago. That’s younger than I am! To me, that’s astounding. Back in the late 1980s, there was a seminal study by Anand et al. that finally proved neonates do, in fact, experience pain. Before that, people believed neonates didn’t feel pain because they were neurologically immature—they thought their pain receptors weren’t fully developed, or that babies lacked consciousness of pain. Some also believed that neonates couldn’t tolerate pain medication. And we now know that simply wasn’t true.

In my dissertation work, I interviewed experienced neonatal nurses who worked at the bedside in the 1980s. They were adamant that babies were in pain, despite the prevailing belief and education at the time. It was fascinating—and humbling—to hear how bedside nurses recognized the signs of pain, even when others, perhaps the ones making decisions about whether to administer pain meds, did not.

Once neonatal pain was acknowledged in the late ’80s, it led to a major shift—textbooks changed, both in medicine and nursing, to reflect that neonates do experience pain. Since then, pain management has evolved significantly. We’ve developed non-pharmacological methods like developmental care and neuroprotective touch, and we've also explored pharmacologic strategies.

However, concerns over medication use—especially with the opioid crisis and increased awareness of NOWS/NAS—have made people more cautious. Some worry about giving medications for fear of causing dependency. So, we’ve kind of come full circle. And it’s still difficult because babies don’t express pain like adults do—the signs are subtle, and if providers aren’t trained to recognize them, they might go unnoticed.

Daphna: That’s a great recap. Along those lines, we often say “neonatal pain and stress” together, as if they’re always linked. But in these neurologically immature babies, stress itself can feel like a painful experience. Even when we’re trying to avoid painful procedures, our routine interactions can still be very stressful. Marliese, I know you’ve done a lot of work in this area. Can you talk about how routine care impacts infant stress?

Marliese Nist: Absolutely. I’m very focused on routine nursing care because it happens so frequently. Babies get diaper changes every 3 to 4 hours. They get fed every few hours. And those seemingly simple tasks can actually be quite stressful for a developing neurological system that isn’t ready for that stimulation. Yes, painful things are also stressful—but not all stress is pain. And I think we often forget that. One of the challenges in our work is even defining stress. Kathy and I met recently to plan a collaborative project, and even between the two of us—people who have dedicated our professional lives to this topic—we had different opinions on how to define pain and stress. So, it’s no wonder bedside nurses struggle to distinguish between the two.

Another challenge is the belief that infants won’t remember stress. That idea really bothers me. Sure, they won’t remember it cognitively the way adults do, but their bodies remember. Babies who experience frequent, prolonged stress have lasting changes in the way their physiological stress response systems function. The thresholds and parameters of those systems are altered—possibly forever. So, even if they can’t describe the experience, the impact shows up later in how they function. Their bodies remember.

Ben: That’s so interesting. There’s a real paradigm shift here compared to how pain is approached elsewhere in the hospital. Adult patients can advocate for themselves—they can say “ow,” or ask to be premedicated. But babies can’t do that. So it falls entirely on the provider to anticipate the pain they’ll experience and proactively manage it.

What I’m hearing from both of you is that we now fully understand that babies do feel pain—it’s no longer a myth. But what does that mean for care today? How do the best centers address pain consistently? I think many of our listeners—and I’ll include myself—may have a protocol for a specific scenario, like post-operative pain. But I rarely see pain management as a continuous philosophy throughout a unit. It often defaults to medications, but we know there’s more to it than that. With your expertise, what does a comprehensive, modern neonatal pain management guideline look like? Kathy, why don’t you start?

Kathy Dudding: Sure. The American Academy of Pediatrics' had a great policy from 2017 about how we can address pain in the NICU. One of the main points was education: having a pain protocol, always using non-pharmacological measures before pharmacological ones. We need pain scales with sound psychometric properties, and we need more research. Unfortunately, in my career, I've seen a lot of inconsistencies in observing those guidelines, which is disheartening. From talking to nurses and nurse practitioners at conferences, I’ve often asked: does your hospital have a pain policy? The responses are inconsistent. One person told me that at their hospital, there was no pain protocol—they didn’t give meds for anything, not even sucrose. Then she said she went to another hospital with a huge pain protocol, and it was like the pendulum had swung too far—babies were just flat-out sedated.

So, while we have guidelines, there's no standard, which is interesting. The standard we should be following involves an interdisciplinary team—from medicine to NPs to nurses, OT, RT—everyone. It's a little disheartening that we're not consistently coming together to get the best outcomes for our babies.

Ben: Marliese, any thoughts?

Marliese Nist: Yeah, I agree with Kathy a lot. I think there are some things we can create policies around. For example, an infant coming back from the OR—we can probably create protocols for that. But a lot of what we do is so individualized, and infants have such unique responses that it’s difficult to proactively develop policies, say, for a heel stick. Not every infant experiences a heel stick the same way. It depends on the context, the infant’s prior experiences, and how it’s done. I’ve seen a lot of variation in nursing care. As nurses, we need to consider what we should do at the bedside at that moment.

Are there stressful procedures we can eliminate without affecting the infant's wellbeing or long-term outcomes? If the diaper is dry, do we really need to change it? If the baby’s sleeping, can we wait until they naturally wake up? We need to use subtle signs—though not every baby will exhibit them—and involve parents, who are often present and know their baby well. Listening to them is key to understanding the baby’s experience because they’re the best proxy.

It’s great when there’s consistency in care among nurses and physicians. They get to know individual babies and can better manage their stress. We also often forget that these infants are babies first, patients second. Babies are naturally comforted by nurturing touch, and they rarely get that in the NICU. I did a study a few years ago and found that less than 2% of touch during routine nursing care was exclusively for comfort. That’s not natural for an infant. We found that just one minute of intentional, exclusive comforting touch at the beginning of care reduced the infant’s stress response. So we need to be intentional in how we provide care.

Ben: You’re both bringing up such interesting points. What I’m jotting down is, first, there doesn’t seem to be a gold standard to emulate. There’s an opportunity here to innovate and define a pain philosophy or protocol that fits each unit’s needs and resources. Kathy, you mentioned it has to be multidisciplinary—absolutely key. Marliese, you emphasized that we need to get better at recognizing pain and not just knowing something causes pain, but actually having a mechanism to assess it objectively. And I really appreciated the point about non-painful touch. What an opportunity for families who want to help at the bedside, especially when nurses and doctors are stretched thin. Maybe that can be a key role for families.

Now, going back to assessment—there are so many scales out there for pain. It can be overwhelming. Are there any tools you’d recommend that are particularly valid or practical? Marliese, do you want to start?

Marliese Nist: I’ll let Kathy speak to the pain scales—she knows them far better than I do. As for stress, there really aren’t any good tools. In research, people often use checklists of invasive or skin-breaking procedures. We did a study using the Neonatal Infant Stressor Scale, which includes many different procedures that happen in the NICU. We found it was highly correlated with invasive procedures. But again, it doesn’t account for the context, the infant’s prior experiences, gestational age, or genetic predispositions to stress. So there's no really good measure of stress—it’s highly individualized. I think this is where clinical providers can help researchers. What are you seeing at the bedside that hasn’t been reported? What should we be looking for? These tools don’t yet exist—for stress, at least.

Kathy Dudding: I’ll add on pain scales—the bane of my existence! We do the best we can.

Ben: Pain scales are causing you pain?

Kathy Dudding: They are! There are over 40 neonatal pain scales used worldwide. But many lack solid psychometric properties—validity and reliability are questionable. There’s no standard benchmark. What happens is that one scale claims to be valid and reliable, and then new scales get compared to that one. If they get the same result, they say, “Okay, we’re valid too.” It’s a bit flawed.

So, if a NICU is looking at a new pain scale, you have to consider gestational age. Most pain scales are validated only for certain gestational ages. Also consider the type of pain—post-surgical pain is very different from procedural pain or acute pain like a heel stick. You have to individualize based on the baby's age and the type of pain. We also need to remember that pain and stress are part of routine NICU care. I just looked this up—on average, neonates experience 7 to 17 painful events per day in the NICU.

Think about what that does to their immature neurological systems, the rewiring that’s happening because of that. These babies shouldn’t even be here yet—they should still be in the womb. Everything we do should be intentional. These are first experiences that shape the body’s response.

Over time, we’ve all seen it—a baby that’s been in the NICU for a few weeks jerks away at touch, shows signs of stress, hemodynamic changes. We need to be so intentional with our touch and care. But the reality is, we’re task-oriented, spread thin. We do what we need to do and move on. The system doesn’t support increased nurse-to-patient ratios, even though it should. And because we don’t see these babies long-term, we often don’t know the full impact of their NICU experience.

Daphna: Yeah, I always tell my team—when you approach a baby’s bedside, pretend this is your own baby in a crib at home. How would you do this procedure? We’ve become desensitized. These babies are small and sick, and they don’t put up a big fight. But think—would you do this to a toddler this way? To an adult? To a newborn in the well-baby nursery? Probably not. Parents really notice. They see us approach their baby, and if they grimace, that speaks volumes. That reaction helps realign us with what the baby and the family need.

Marliese, I want to ask about individualization. You mentioned it before—recognizing infant behavioral cues. Most NICU professionals have little to no training in this. But it’s something someone listening can start working on right now.

Can you talk about what signs to look for? And after we identify that a baby is stressed, what are the signs they’ve recovered and we can move on?

Marliese Nist: That’s a great question—and a tough one. There are obvious signs—if a baby’s heart rate drops from 130 to 50, we know something is wrong.

Daphna: We recognize it but often ignore it, right? “The baby always desats. Let’s go faster.”

Marliese Nist: True! You're right. That’s exactly what happens.

We want to avoid those extreme reactions. But there are subtle signs, too. We’re trained to look for the salute, the stop sign, splayed fingers, arching, grimacing. But even a 10 bpm heart rate change may just indicate stimulation—not necessarily distress.

Often, the monitor is behind us. We can’t look at the baby and the monitor. Maybe we need to rethink our workflows or NICU design to help us integrate all that information.

Ask the parents: “What does your baby do when they’re stressed? Have you seen good or bad reactions?” That helps us—and it empowers parents. They’re not just bystanders. They’re essential members of the care team.

But just because a baby doesn’t show behavioral cues doesn’t mean they’re not stressed. I once observed a baby undergoing an arterial stick—and the baby didn’t move. The nurse said, “He did great.” That’s terrifying. The baby should respond. Stress responses are protective, babies should have stress responses to stressful procedures. It’s a problem when they’re repeated, overwhelming, and prolonged—without support. We can help babies cope. If we provide comforting touch, give them a rest period, and end or begin care with something soothing, we can shift that experience. Maybe it’s as simple as a parent providing containment during a gavage feed. The baby learns: my tummy is full, and I feel safe. My colleague Rita Pickler has done a lot of work on this “patterned experience” and why it’s crucial—especially around feeding.

Daphna: I love that. Medical professionals often connect with the idea of neuronal development. We forget that these babies are not just critically ill patients—their brains are growing, wiring, connecting. Are they learning that the world is scary and painful? Or are they learning it’s full of love and bonding? People are catching on—containment holds, swaddled bathing, doing labs during kangaroo care. But we need to take that next leap: what if NICU babies could wire their brains to see the world as a place of bonding and attachment?

Parents are often encouraged to bond, but they might only visit once or twice a day. We, the caregivers, interact with the baby much more often. I love the idea of bedside professionals seeing themselves as stand-ins for parents. Not replacing them—but stepping in. Babies won’t bond with us per se, but they will learn about bonding through how we respond to their cues, how we talk to them, how we touch them. So what can people take away from this conversation and start doing at the bedside right now?

Kathy Dudding: Well, I mean, I love what you're saying about family-centered care, which I know a lot of NICUs across the country have adopted. I really think it's important for both physicians and nurses to really pull parents in as part of the team caring for the baby. That might look different for individual parents—we have to treat them individually. Some parents can be there all the time, but others are working or can only come once a day or a couple of times a week. We are an extension of that family, providing those firsts and wiring the brain. In the NICU, we're in the business of growing brains—that's what we do. And we just need to make it a positive experience.

Parents are part of this, and they need to be part of this. They’re absolutely part of decision-making. There are so many things they can do even if they can't be physically present. We have moms who can provide breast milk—I mean, what is more loving and caring than a mom being able to feed her baby even when she’s not there?

As nurses, we often know a lot about the parents' social situations. So if you have time, give a little extra care—some extra attention or cuddling when you're holding them during a gavage feeding. Talk to them. We need to make that time. Sometimes it's not as much as we’d like, but I've never met a neonatal nurse who didn’t want to spend more time with a baby when providing care.

Ben: Yeah, and it seems that beyond just the time we can allocate, it's about reshaping every interaction—having a metamorphosis of our approach as clinicians, nurses, providers, and parents. We should ask: how do we turn this experience into the least painful one possible? How do we maximize comfort? And how do we do that consistently as a team?

You’ve given us such great insights into the opportunities this topic presents—not just the challenges of measurement, but also creating consistency. The interventions around comfort touch, nursing, policy, parental involvement, and intentional care are exciting.

As people listening get inspired—thinking, “This is it, I’m going to take this on, this will be my quality initiative!”—what are your words of wisdom regarding the systemic barriers they might face, and the opportunities to overcome them?

Marliese Nist: This is going to be challenging. We need a paradigm shift in how we approach infant care—it's going to require a system-wide change. I can speak to nursing: we have a task list we feel we must complete—A, B, C, D—before we leave for the day, plus audits one, two, and three. We need to examine which tasks are high-value and which are low-value. What can be eliminated? Where should we focus our attention? We have limited hours and a limited number of providers and nurses. So how do we maximize efficiency, provide high-quality care, and eliminate things that don’t improve outcomes? That takes research and buy-in—from administration, management, nursing, medicine, and all disciplines.

Ben: Can I just plug a Harvard Business Review article that calls exactly what you're talking about the “GROSS” system—Get Rid Of Stupid Stuff. I love that analogy.

Marliese Nist: Love it. If it doesn’t improve outcomes, why are we doing it?

We’ve been talking about intentional care. I’d love if nurses approached their shift by looking at everything they need to do and asking: which things are low-value? Are they all necessary? Do they all need to be done every three hours? Have some flexibility. Incorporate the parents. Make a plan, but be flexible based on what the baby is telling you.

Ben: Love that. Kathy, any thoughts?

Kathy Dudding: Yes. This shift really has to be system-wide, and we need the interdisciplinary team—including parents—to come together with open minds and hearts about what’s best for the baby when minimizing pain and stress.

One thing that comes to mind is Magnet status. Research is a key component of that. I’ve worked at hospitals with an evidence-based council—it was nurses only. Looking back, I wonder why we didn’t include physicians. To make effective change, we need the most up-to-date literature. But many bedside nurses don’t have access to library resources. Why not? They absolutely should. That’s small potatoes—just provide continuing education. Nurses are lifelong learners. Everyone needs to be open and respectful. If a stakeholder says no, ask why and request a rationale. If we can approach each other with mutual respect, we can move mountains for these babies.

Marliese Nist: Kathy made a great point. As researchers, we need to do better. As a student, I was told to skip the methods section. But we need to create white papers for clinical providers—summarizing what our research means and how it can be implemented. Our professional organizations could help make that happen. I'm working with NANN right now to improve communication between researchers and clinicians—so researchers know what to ask and clinicians know how to apply the findings. There’s real opportunity there.

Kathy Dudding: I completely agree. We need to include the interdisciplinary team in all discussions. Everyone should have a say in the pros, cons, and evidence. Why can’t we all just work together like that?

Ben: You're bringing up such interesting points. The breakdown in hospital discussions often stems from different incentives—nurses, doctors, administrators. But in this case, our incentives are aligned. From an administrative point of view, it's a win if your hospital can say it has a comprehensive plan for neonatal pain in the NICU. That sets you apart. Nurses and doctors, even when stretched thin, still prioritize the baby—and neonatal pain is not something people shrug off anymore. If we had better communication, we could really make progress. It’s all about the baby and their experience.

Kathy Dudding: Exactly. From a research perspective, we fund studies on cancer, high blood pressure—we search for cures. But for babies in pain and stress? There’s a disconnect. The experiences they have in the NICU can affect their whole lifespan, not just those few weeks or months. We need to do a better job—researchers, nurses, physicians, and all stakeholders.

Daphna: As we wrap up, I hope for some this was preaching to the choir, and for others it sparked new curiosity. I’d love if each of you could recommend some resources. One of my favorites is from a multidisciplinary committee through the Gravens Conference. It’s called the Infant and Family Developmental Care Standards, available at nicudesign.nd.edu. It’s easy to digest, split into clear sections, and very comprehensive.

Marliese Nist: There’s a great book endorsed by NANN on Developmental Care of the NICU Infant. It’s lengthy but helpful. Also, there are great reviews on infant stress and pain if you don’t have time for all the primary literature.

Kathy Dudding: I love the Handbook of Neonatal Pain—you can get it on Amazon. And there was a fascinating article on fetal pain, discussing fetuses undergoing surgery in utero. It explored how their neurological systems develop and how pain is processed. Mind-blowing. I haven’t been the same since reading it.

Marliese Nist: Thinking more broadly, not necessarily practical, but for a philosophical foundation—look at the work of Dr. Jack Shonkoff. He’s a pediatrician who writes about early life toxic stress and its impact on long-term health. It applies beautifully to NICU infants. The NICU can be a toxically stressful environment. His work has deeply influenced how I think about my research and infant care.

Ben: It’s the most exciting—and most terrifying—part of our work. Every little interaction in the NICU likely has a long-term impact. Thank you, Kathy and Marliese, for this fantastic conversation. Marliese, would you like to give a quick plug for your upcoming article?

Marliese Nist: Yes! We were invited to submit a paper on NICU stress for Seminars in Perinatology. We discuss the developmental context for stressors and how they can be mitigated. It should be submitted soon.

Ben: We’ll be looking out for it—and might even review it on an upcoming Journal Club episode. Kathy, any final plugs?

Kathy Dudding: Yes! Marliese and I were co-editors for a recent Advances in Neonatal Care series on stress and pain in the neonate. The third issue was just released. We were really excited to be part of that and want to highlight those articles as well.

Ben: Thank you both. We’ll link to those resources in the show notes so people can explore further. You’re really pushing this topic forward—thank you both again for your time and dedication.