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The finding that nearly all participants reported no dedicated neonatal pain training deserves particular attention when considering the broader educational landscape in which these professionals operate. Formal curricula for nursing and medical training in many low- and middle-income countries have historically given limited space to pediatric pain medicine as a distinct topic, and neonatal pain specifically is often embedded within broader pediatrics or surgery rotations rather than taught as a structured competency. This means that even highly motivated clinicians may complete their training without ever having been introduced to a validated neonatal pain scale, let alone practiced applying one at the bedside. The near-universal absence of reported training in this survey therefore likely reflects a systemic gap in educational infrastructure rather than individual indifference, and it suggests that interventions targeting continuing professional development could reach an entire workforce that has never received this content in any form.

The distinction between recognizing that neonates feel pain and acting on that recognition through systematic assessment is a recurring theme in implementation research on pediatric pain. Knowledge alone has rarely proven sufficient to change clinical behavior; guidelines published in high-income settings have repeatedly documented similar gaps between awareness and practice, even where resources are comparatively abundant. What makes the Kinshasa findings notable is the magnitude of the discrepancy: recognition of neonatal pain was nearly universal among respondents, yet the reported use of standardized assessment tools was an order of magnitude lower. This pattern suggests that the barrier is not denial of neonatal pain capacity, which was a historical problem in twentieth-century practice, but rather the absence of practical tools, training, and institutional routines that translate belief into measurable action.

The statistical approach taken by the researchers merits some explanation for readers less familiar with survey methodology. Because participants were drawn from only ten hospitals, individuals within the same hospital share institutional characteristics such as staffing levels, available protocols, and local leadership priorities. Ignoring this clustering would artificially inflate the precision of the estimates, so the investigators used cluster-robust standard errors at the hospital level in their multivariable logistic regression. This technique adjusts the confidence intervals to account for the correlation of responses within each facility, producing more honest uncertainty estimates. The adjusted odds ratio of 4.90 for the association between higher knowledge and reported standardized tool use should therefore be interpreted with this design feature in mind, as should the sensitivity analysis, which demonstrated that the strength of the association depended partly on whether scale recognition was counted as a knowledge item.

That sensitivity analysis is methodologically informative in its own right. When the investigators removed the item asking whether participants could recognize a validated pain scale from the composite knowledge score, the association between knowledge and tool use weakened considerably, dropping from an adjusted odds ratio of 4.90 to 1.93. This attenuation suggests that a substantial portion of the observed relationship was driven by familiarity with the existence of such instruments rather than by deeper conceptual knowledge about neonatal pain physiology or assessment principles. In practical terms, this could mean that simply making clinicians aware that validated neonatal pain scales exist, and showing them what these tools look like, might move a meaningful fraction of the workforce toward adoption. It also underscores a caution for future research: composite knowledge scores are sensitive to which items are included, and findings built on such scores should be stress-tested in the way these investigators did.

The context of postoperative care specifically deserves emphasis. Neonates undergoing surgery represent a population in which pain is predictable, sustained, and amenable to planned management, in contrast to the episodic pain of routine procedures such as heel lances or venipuncture. International guidance on neonatal surgical care generally assumes that scheduled assessment of pain using a validated instrument is a basic component of postoperative nursing care, alongside monitoring of vital signs and wound inspection. The finding that only about one in seven respondents reported assessing postoperative pain at regular intervals indicates that this assumption cannot be made in the settings studied. Regular, scheduled assessment is the mechanism by which analgesic dosing is titrated and by which complications such as inadequate analgesia or excessive sedation are detected; without it, even medications that are physically available in the pharmacy may be underused or applied without a rational basis for dose adjustment.

The ten hospitals included in the survey spanned both tertiary and secondary levels of care, which strengthens the representativeness of the findings for the urban Kinshasa setting. Because the investigators approached the exhaustive set of hospitals providing pediatric surgical activity in the city during the study period, the sample is not subject to the selection biases that arise when only flagship institutions participate. At the same time, the findings describe one major African metropolis and should not be generalized automatically to rural facilities, to other countries, or to non-surgical neonatal units such as intensive care nurseries without surgical services. Neonatal care in district hospitals, mission facilities, and community health centers may face different constraints, including even scarcer access to analgesic formulations suitable for newborns and fewer staff per bed.

The high response rate achieved in the survey, with 536 of 580 approached professionals returning the questionnaire and only six excluded for excessive missing data, reduces concern about nonresponse bias, which is often the Achilles heel of cross-sectional surveys in busy clinical environments. However, the study measured self-reported practices rather than directly observed behavior, and a substantial literature has documented that clinicians tend to overestimate their adherence to recommended practices when asked retrospectively. Social desirability may also have influenced responses, particularly on questions touching on the adequacy of one’s own professional practice. The true prevalence of standardized tool use could therefore be even lower than the 10.0% figure reported, or the relationship between knowledge and practice could differ from what self-reports suggest. Studies combining direct observation, chart review, or audit of nursing records with questionnaire data would help triangulate the true state of practice.

The neurodevelopmental rationale for aggressive neonatal pain management has accumulated steadily over recent decades. Animal and human studies have shown that early nociceptive experience can shape the developing somatosensory system, with implications for subsequent pain sensitivity, stress regulation, and possibly long-term neurobehavioral outcomes. Repeated untreated painful exposure in preterm infants has been associated in some cohorts with altered brain development on imaging and with differences in developmental scores during follow-up. While the precise clinical significance of these associations continues to be investigated, the direction of the evidence supports the principle that preventing and treating neonatal pain is not merely a matter of immediate comfort but may influence trajectories that extend well beyond the hospital stay. This framing gives the gaps documented in Kinshasa a significance that reaches beyond the perioperative period itself.

Non-pharmacological comfort measures, which the source study situates within a broader assessment framework, occupy an interesting position in resource-limited settings. Interventions such as breastfeeding, skin-to-skin contact, swaddling, facilitated tucking, and oral glucose administration require little in the way of material resources and have demonstrated benefit primarily for procedural pain in neonates. Their accessibility makes them attractive options where opioid supplies are unreliable or where trained pediatric anesthesiologists are scarce. However, the evidence base for these measures is strongest for brief procedural pain, and they are not substitutes for systemic analgesia after major surgery. The study’s careful framing of these approaches as complementary rather than equivalent to postoperative analgesia reflects an important distinction that is sometimes blurred in discussions of pain management in low-resource contexts, where non-drug measures are occasionally presented as a full alternative when pharmacological options are constrained.

The choice of the DAN scale in earlier Congolese work on procedural neonatal pain illustrates that validated instruments have already been deployed in the country’s clinical research environment, which is a relevant precedent for implementation efforts. French-language instruments are particularly relevant in the DRC, where francophone medical education means that tools and training materials developed in French-speaking research communities can be adapted more readily than those available only in English. The EDIN scale, the NFNS, DAN, and other instruments each have different intended contexts, and the recent systematic evidence cited by the investigators emphasizes that no single scale suits every population and pain type. Selecting an instrument for widespread implementation in Kinshasa would therefore involve matching the tool to the predominant clinical scenarios, the literacy and staffing realities of the units, and the feasibility of routine scoring during busy postoperative care.

From a health systems perspective, the association between knowledge and reported tool use points toward educational interventions as one plausible lever, but the near-total absence of prior training also implies that such interventions would be starting from a very low baseline. Continuing education formats that have shown promise in other settings include structured in-service workshops, integration of pain scales into nursing documentation forms so that assessment becomes part of the routine charting workflow, and audit-and-feedback cycles in which units review their own assessment rates. Embedding a pain score in the vital signs chart is a particularly low-cost structural intervention, because it converts assessment from an optional cognitive task into a required documentation step. Whether such approaches are effective in the specific conditions of Congolese hospitals would need local evaluation, but the underlying logic of making the desired behavior the path of least resistance is well established in implementation science.

The cross-sectional design of the study, which the investigators themselves flag as precluding causal interpretation, leaves open the direction of the relationship between knowledge and tool use. It is plausible that clinicians who use standardized scales become more knowledgeable through practice, rather than the reverse, or that a third factor such as working in a hospital with an engaged leadership or access to continuing education drives both. Longitudinal designs, or before-and-after evaluations of training programs, would be needed to establish whether improving knowledge leads to increased tool adoption. Nevertheless, the consistency of the association after adjustment for professional characteristics, and its persistence in attenuated form through the sensitivity analysis, makes knowledge a credible target for intervention even in the absence of proof of causation.

Finally, the study contributes to a slowly growing literature on pediatric pain in sub-Saharan Africa, a field the investigators describe as limited and heterogeneous. Multicenter surveys of this kind provide the baseline data against which future interventions can be measured, and the exhaustive sampling of eligible hospitals in Kinshasa offers a model that could be replicated in other cities of the region. If subsequent efforts build on this foundation, whether through training initiatives, documentation reforms, or the local validation and adoption of specific neonatal pain scales, the present survey will serve as the reference point for judging whether practice has moved. The gap it documents between near-universal recognition of neonatal pain and minimal use of standardized assessment is a measurable starting line for that work.

Subject of Research: …

Article Title: Knowledge and practices regarding postoperative neonatal pain assessment among healthcare professionals in Kinshasa: a multicenter cross-sectional survey

Article References: Landu, E., Nsiala, J., Makembi Bunkete, A., Mbombo, W., Mutombo, S., Mukuna, P., Lemba, C., Nantulu, C., Kabuni, P., Mosolo, A., Ilunga, J.-P., Kabwe, B., Bulabula, M., & Barhayiga, B. (2026). Knowledge and practices regarding postoperative neonatal pain assessment among healthcare professionals in Kinshasa: a multicenter cross-sectional survey. Frontiers in Pain Research, 7, Article 1968968. https://doi.org/10.3389/fpain.2026.1968968

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1968968

Keywords: Knowledge, practices, regarding, postoperative, neonatal, pain, assessment, healthcare, professionals, Kinshasa, multicenter, cross-sectional