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Created on - 10 Jul, 2016

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.


Assessing pain


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




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




Cry and


The five scores are added and the severity of pain is determined based on the 0-10 pain scale.

Face -

0 - No particular expression or smile

1 - Occasional grimace or frown, withdrawn, disinterested

2 - Frequent to constant frown, clenched jaw, quivering chin

Legs -

0 - Normal position or relaxed

1-Uneasy,restless, tense

2-Kicking, or legs drawn up

Activity -

0 - Lying quietly, normal position, moves easily

1 - Squirming, shifting back and forth, tense

2 - Arched, rigid, or jerking

Cry -

0- No cry (awake or asleep)

1 - Moans or whimpers, occasional complaints

2 - Crying steadily, screams or sobs, frequent complaints

Consolability -

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 0-Normal

Score 1-Short grimace < 50% of time

Score 2-Long grimace > 50% of time


3. Posture

Score 0 -Normal

Score 1 -Touching/rubbing/sparing

Score 2 - Defensive/tense


4. Movement

Score 0- Normal

Score 1- Reduced or restless

Score 2 - Immobile or thrashing


5. Colour

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




Observer rated measure for use in intensive care environments.

It assesses eight domains :



respiratory response,

physical movement,

mean arterial blood pressure,

heart rate,

muscle tone and

facial tension.

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

32–60 weeks


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

1–4 years


Toddler-Preschooler Postoperative Pain Scale (TPPPS) - 


Vocal pain expression, facial pain expression, bodily pain expression

1–5 years


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.

1–6 years


The Observational Scale of behavioral Distress (OSBD) -


Eleven behaviors related to pain and/or anxiety

3–13 years  


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

8–17 years


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.

8–17 years            


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,

(3) evaluative

(4) miscellaneous.

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




Pain History


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)



References –


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. | Dr Amarja

- by Dr Amarja

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