Paediatric Pain Assessment
ABCs of Pain Management
A – Ask about pain regularly. Assess pain systematically.
B – Believe the patient and family in their reports of pain and what relieves it.
C – Choose pain control options appropriate for the patient, family, and setting.
D - Deliver interventions in a timely, logical, coordinated fashion.
E – Empower patients and their families. Enable patients to control
their course to the greatest extent possible.
QUESTT (Wong et al, 1999) -
Q- Question the child
U- Use a pain rating scale
E- Evaluate the behaviour and physiological changes
S- Secure parents involvement
T- Take cause of pain into account
T- Take action and evaluate results
Wong-Baker Faces Pain Rating Scale -
Explain the child that each face is of a person who feels happy because of no pain (hurt) or sad because of having little or more pain.
Face 0 is very happy because it doesn't hurt at all
Face 2 hurts just a little bit.
Face 4 hurts a little more.
Face 6 hurts even more.
Face 8 hurts a lot.
Face 10 hurts as much as you can imagine.
Ask the child to choose the face that best describes how he is feeling.
This rating scale is recommended for people age 3 years and older.
Visual analogue scale (VAS) -
Self report visual analogue scales for pain intensity.
It is a horizontal line with “no pain” at one end to “worst possible pain” at the other. Patient draws a line that intersects to indicate intensity. For ages 3 - adult.
Faces Pain Scale - Revised(FPS-R) -
Self report faces scale for acute pain. Six cartoon faces range
from neutral to high pain expression. These faces can be numbered 0, 2, 4, 6, 8, and 10.
Age group 4-16 years.
Poker chip tool -
Self-report poker chips are used to represent pain intensity. Child chooses which chips represent the pain they experience with one chip indicating a little hurt and all four chips indicating the most hurt a child could have. Age group 4-7 years
Numeric Rating Scale -
0 1 2 3 4 5 6 7 8 9 10
0 -no pain
10 – worst pain
FLACC SCALE -
Is a behavioural scale
It is appropriate for use with children less than 3 years of age or those with cognitive impairments or any child who is unable to use the other scales.
FLACC is the acronym for
The five scores are added and the severity of pain is determined based on the 0-10 pain scale.
0 - No particular expression or smile
1 - Occasional grimace or frown, withdrawn, disinterested
2 - Frequent to constant frown, clenched jaw, quivering chin
0 - Normal position or relaxed
2-Kicking, or legs drawn up
0 - Lying quietly, normal position, moves easily
1 - Squirming, shifting back and forth, tense
2 - Arched, rigid, or jerking
0- No cry (awake or asleep)
1 - Moans or whimpers, occasional complaints
2 - Crying steadily, screams or sobs, frequent complaints
0- Content, relaxed
1- Reassured by occasional touching, hugging or “talking to”. Distractable
2- Difficult to console or comfort
Alder Hey Triage Pain Score
•Developed specifically for emergency setting
•Total score range 0 -10
1. Cry or voice
Score 0 - No complaint/cry Normal conversation
Score 1- Consolable Not talking negative
Score 2- Inconsolable Complaining of pain
2. Facial expression
Score 1-Short grimace < 50% of time
Score 2-Long grimace > 50% of time
Score 0 -Normal
Score 1 -Touching/rubbing/sparing
Score 2 - Defensive/tense
Score 0- Normal
Score 1- Reduced or restless
Score 2 - Immobile or thrashing
Score 0 - Normal
Score 1 - Pale
Score 2- Very pale/‘‘green’’
Procedure Behavior Checklist (PBCL) -
Observational measure of pain and anxiety during invasive medical procedures.
It assesses muscle tension, screaming, crying, restraint used, pain verbalized, anxiety verbalized, verbal stalling and physical resistance.
Behaviour is rated on occurrence and intensity (scale 1-5)
Age group 3-18 years
Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) -
It is an observational measure.
It assesses six behaviours that include cry, facial, child verbal, torso, touch and legs.
Each behaviour is coded on a scale of 0 to 3 based on intensity.
Age group 1-12 years
COMFORT Scale -
Observer rated measure for use in intensive care environments.
It assesses eight domains :
mean arterial blood pressure,
muscle tone and
Each dimension is scored between 1 and 5, and the scores are added to yield a measure of sedation.
Age group 0-18 years
Premature Infant Pain Profile (PIPP) -
Gestational age, behavioral state before painful stimulus, change in heart rate during stimulus, change in oxygen saturation, brow bulge, eye squeeze nasolabial furrow
Preterm to full-term infants
Neonatal Facial Coding System (NFCS) -
Brow bulge, eye squeeze, nasolabial furrow, open lips, stretched mouth (horizontal or vertical), lip purse, tout tongue, and chin quiver
Preterm to full-term infants
Neonatal Infant Pain scale (NIPS) -
Face, cry, breathing pattern, arms, legs, and state of arousal
Preterm to full-term infants
Crying Requires Increased vital signs Expression Sleeplessness (CRIES) -
Crying, increased oxygen requirements, expression, vitals signs, sleeping
Maximally discriminate facial movement coding system (MAX) -
Brow, eye, and mouth movement
Observational Pain Scale -
Facial expression, cry, breathing, torso, arms and fingers, legs and toes, and states of arousal
Toddler-Preschooler Postoperative Pain Scale (TPPPS) -
Vocal pain expression, facial pain expression, bodily pain expression
Child Facial Coding System (CFCS) -
Facial actions: brow lower, squint, eye squeeze, blink, flared nostril, nose wrinkle, nasolabial furrow, cheek raiser, open lips, upper lip raise, lip corner puller, vertical mouth stretch, and horizontal mouth stretch.
The Observational Scale of behavioral Distress (OSBD) -
Eleven behaviors related to pain and/or anxiety
Oucher Scale -
Pain intensity Faces correspond to pain intensity
>= 5 years
Pediatric Pain Questionnaire -
Information seeking, problem solving, seeking social support, positive self-statements, behavioral distraction, cognitive distraction, externalizing, internalizing
Adolescent Pediatric Pain Tool (APPT) -
Intensity, location, and quality of pain
The word graphic rating scale is a 67 word list describing the different dimension of pain and a horizontal line with words attached that range from “no,” “little,” “medium,” “large,” to “worst” possible pain.
McGill Pain Questionnaire -
Sensory and affective pain experience
The categories are
(1) sensory, which contains words describing pain in terms of time, space, pressure, heat, and brightness,
(2) affective category which describes pain in terms of tension, fear, and autonomic properties,
After the patient is done rating their pain words, the administrator allocates a numerical score, called the “Pain Rating Index”. Scores vary from 0–78 with the higher score indicating greater pain.
>= 12 years
O: Onset- When did it start
P-Provocation or Palliation -what makes it better or worse
Q-Quality -sharp, dull, crushing
R- Region and Radiation
S-Severity and scale-pain scales
T-Timing and type of onset -intermittent, constant.
(This is Mnemonic for history taking)
Paediatric pain: Physiology, Assessment and Pharmacology, 08/07/2013 Dr Saeda Nair
Pain in Children: Assessment and Nonpharmacological Management
Rasha Srouji et al International Journal of Pediatrics
Volume 2010 Article ID 474838
Stewert B;Lancaster G;Lawson J; Williams K; Daly J.(2004) Validation of the Alder Hey Triage Pain Score.Archive Disease in Childhood; 89:625-630
Pain management in children: Part 1 — Pain assessment tools and a brief review of nonpharmacological and pharmacological treatment options
Cecil Wong et al Can Pharm J (Ott). 2012 Sep; 145(5): 222–225.
www.cardiacanaesthesia.in | Dr Amarja