Pain assessment and tools (Paediatric)

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There are many things that can influence a child’s perception of pain and how they behave when experiencing pain. These include age, culture, level of cognitive development, family learning, any previous experiences of pain, the child’s temperament and personality. Fear can play a large part on a child’s perception of pain therefore it is important to deal with potentially painful experiences effectively. During childhood , a positive experience may prevent anxiety and fear associated with pain being carried over into adult life.

If optimal pain management in children is to be achieved, accurate pain assessment is fundamental. This should involve a physical assessment and a clinical interview with the child and their parent/carer. The use of an age and context appropriate pain intensity measurement tool is essential.

Tools used for assessment

Children should be assessed using these tools and if appropriate, the child should be asked how they rate their pain since their last assessment. Pain should be assessed at rest and on movement such as:

  • Deep breathing and coughing exercises
  • Movement of affected limb, if allowed to mobilise
  • Sitting up in bed or mobilising out into a chair
  • Any other activity that is required for the child’s recovery.

Children with communication difficulties will need individual assessment. This should be done along with the child’s parent/ carer. The child’s normal response to pain and any usual interventions that are used to relieve pain should be documented.

A pain score of 4 or above must be addressed urgently. Ensure the child has received the maximum prescribed dose of analgesia, both regular and any as required analgesic medications prescribed and that basic comforting measures have been taken. If the pain score remains 4 or above despite this, a review of their analgesia is required, contact the ward doctor and follow the analgesia guidelines.

Pain assessment tools used for children unable to communicate
  • Use the FLACC (Face, Legs, Activity, Cry and Consolability) Scale Scoring tool for children from 2 months to 7 years or children that are unable to communicate.
  • Pain tools have been adapted for different languages; please contact The Acute Pain Nurse for further advice.
  • Explain the tool to a parent or carer who understands the English Language, in turn they can explain it to the child.

Remember that a child’s facial expression and vital observations can also be used:

  • A child lying still may be withdrawn and quiet due to pain, also consider any changes in normal behaviour.
  • If vital observations have changed from the child’s normal, this could be due to pain, but remember it may be due to other factors e.g. full bladder. Physiological indicators alone do not form a valid clinical pain measure for children. A multidimensional measure including physiological and behavioural indicators (as well as self-report) is therefore preferred whenever possible.

It is very important to educate and encourage the child to inform the nursing staff if they are in pain. Many children do not inform the nurse, for many different reasons, they may be frightened of: speaking to nurses or doctors, finding out they are sick, disappointing or bothering their parents or others, receiving an injection or medication, delaying their discharge home or having more invasive procedures.

Considerations when choosing/ introducing an appropriate pain assessment tool
  • the child’s age and developmental stage.
  • Involvement of parent/carer whenever possible or appropriate
  • Identify the child’s past painful experiences and which words they use for absence or extreme of pain
  • Identify what settles the child and their coping measures

If possible ensure a quiet environment for pain assessment with few distractions and decide with the child (as far as possible) which assessment tool is to be used. Explain the tool to the child, and then ask the child to explain their understanding of the assessment tool. Allow the child to score independently. Avoid the use of influential words, gestures.

Flacc Scale Children between 2 months and 7 years or individuals who are unable to communicate their pain.
Criteria Score 0 Score 1 Score 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, uninterested Frequent to constant quivering chin, clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up
Activity Lying quietly, normal position or relaxed Squirming, shifting, back and forth, tense Arched, rigid or jerking
Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadily, screams or sobs, frequent complaints
 Consolability Content, relaxed Reassured by occasional touching, hugging or, talking distractible Difficult to console or comfort

The scale is scored in a range of 0–10 with 0 representing no pain.
The scale has five criteria, which are each assigned a score of 0, 1 or 2.
The score generated correlates well with scoring from other assessment scales so 0-2 little/no pain; 3-4 mild pain; 5-7 moderate pain; 8-10 severe pain likely.

Extracted from The FLACC: A behavioural scale for scoring postoperative pain in young children, by S Merkel and others, 1997, Paediatric Nurse 23(3), p. 293–297)

Wong-Baker Faces Pain Rating Scale Children over 4 years


Editorial Information

Last reviewed: 30 September 2021

Next review: 30 September 2024

Author(s): Acute Pain Team

Version: 2

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Acute Pain Nurse Specialist

Document Id: TAM318