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PAIN ASSESSMENT IN CHILDREN

PRADEEP

DEVELOPMENTAL MILESTONE

• Pain in infants and children can be difficult to assess which has led to the creation of numerous age-specific pain management tools and scores. • Health care workers need to be able to detect the symptoms and signs of pain in different age groups and determine whether these symptoms are caused by pain or other factors • Effective care in paediatrics requires special attention to the developmental stage of the child.

. • Three main methods are currently used to measure pain intensity: Self report Behavioural Physiological measures.• Accurate pain measurement in children is difficult to achieve.

.• Self measures: Pain is a subjective experience so assessment of children’s pain must emphasize the child’s perception of experience. When carefully taught pain measuring stimulus. children are able to describe the varying levels and characteristics of their discomfort. Self reports are the optimal and most valid indicators of child’s subjective experience of pain.

as they are usually valid for short duration acute pain and differ with the general health and maturational age of the infant or child • Behavioural measures: Behaviours associated with pain include facial expression. oxygen saturation. respiration. palmer sweating. posture and vocalization or verbalization . blood pressure.• Physiological measures: Physiological measures include assessment of heart rate. and sometimes neuroendocrine responses. They are however generally used in combination with behavioural and self-report measures.

and movements. facial expressions. • Recent studies also demonstrate that infants elicit certain behavioural responses to pain perception. and maturity .Neonates and Infants • Despite early studies. current research supports that infants possess the anatomical and functional requirements to perceive pain. body posture. • Pain in infants. These measures include crying. • The quality of these behaviours depends on the infant’s gestational age. • The most common pain measures used for infants are behavioural. despite this data. remains undertreated and often mismanaged.

Examples of these scales are -Premature Infant Pain Profile (PIPP). the most common being -Neonatal Facial Coding System (NFCS) and -Neonatal Infant Pain Scale (NIPS). • Some scales also take into consideration gestational age and the general behavioral state of the infant. Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES) -Maximally Discriminate Facial Movement Coding System(MAX) .• Numerous scales are currently available to measure behavioural indicators in infants.

nasolabial furrow. eye squeeze. lip purse. coded. and chin quiver . open lips. acute pain in infants and neonates.  The system looks at eight indicators to measure pain intensity: brow bulge. stretched mouth (horizontal or vertical).  The indicators are recorded on videotape. tout tongue.  The system is also difficult to assess in intubated neonates . It is used to monitor facial actions in newborns.• Neonatal Facial Coding System (NFCS). and scored.  It has been proven reliable for short duration.

Although it has been fully validated. The indicators include: face. arms. It is a good system to measure responses to acute painful stimuli. with a maximum score of 7. and 2 indicates pain). . Results are obtained by summing up the scores for the six indicators (where 0 indicates no pain. during and after a painful procedure. The scale takes into account pain measurement before. breathing pattern. it is time consuming and hard to interpret in intubated infants.• Neonatal Infant Pain Scale (NIPS) It was developed at the Children’s Hospital of Eastern Ontario. and state of arousal. scored in one-minute intervals. cry. legs.

and (7) nasolabial furrow during painful stimulus [14]. (2) behavioral state before painful stimulus. (4) change in oxygen saturation. • The score ranges from 0–21. (3) change in heart rate during stimulus. . Infants are then observed for 30 seconds during the procedure where physiological and facial changes are recorded and scored. • 7-indicator composite measure that was developed at the University of Toronto and McGill University to assess acute pain in preterm and term neonates.Premature Infant Pain Profile (PIPP) . • The indicators include (1)gestational age. (5) brow bulge during painful stimulus. with the higher score indicating more pain. • Scoring is initially done before the painful procedure. (6) eye squeeze during stimulus. The infant is observed for 15 seconds and vital signs recorded.

• The scale was developed at the University of Missouri and may be recorded over time to monitor the infant’s recovery or response to different interventions . • It is an acronym of five physiological and behavioural variables proven to indicate neonatal pain. • It is commonly used in neonates in the first month of life.Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES).

> 30% O2 Inc vital signs HR & BP ≤ preop Inc in HR or BP < 20% preop Inc in HR or BP > 20% Expression None Grimace Grimace/grunt Sleepless No Wakes at freq intervals Constantly awake .CRIES SCALE 0 Crying No 1 High pitched 2 Inconsolable Requires O2 for saturation >95% No <30% O2.

verbal skills remain limited and quite inconsistent.Toddlers • In toddlers. • Pain-related behaviours are still the main indicator for assessments in this age group .

The maximum score obtained is 7. • In order to observe verbal. and bodily movement.Toddler-Preschooler Postoperative Pain Scale (TPPPS) • It is most commonly used for children aged 1–5 years. brow bulging and furrowed forehead) and bodily pain expression (restlessness. • If a behaviour is present during a 5-minute observation period. squinted eyes. (verbal complaint. rubbing touching painful area). moan) facial pain expression (open mouth. facial. • The TPPPS includes seven indicators divided into three pain behavior groups: vocal pain expression. . a score if 1 is given whereas a score of 0 is given if the behaviour was not present. cry. which indicates a high pain intensity. . the child needs to be awake.

and legs. touch. • Each is scored separately (ranging from 0–2 or 1–3) and calculated for a pain score ranging from 4–13. child verbal.Children’s Hospital of Eastern Ontario Pain Scales (CHEOPS) • It is one of the earliest tools used to assess and document pain behaviours in young children • It is used to assess the efficacy of interventions used in alleviating pain. facial. • It includes six categories of behaviour: cry. . torso.

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activity. • It includes five indicators (face. • FLACC is an easy and practical scale to use in evaluating and measuring pain especially in preverbal children from 2 months to 7 years. cry. and consolability) with each item ranking on a three point scale (0–2) for severity by behavioural descriptions resulting in a total score between 0–10. • It is a behavioural scale for measuring the intensity of postprocedural pain in young children.Faces Legs Activity Cry Consolability Scale (FLACC). legs. .

content. disinterested 2 Frequent to constant frown. clenched jaw. normal position. Distractible Each of the five categories (F) Face. withdrawn. (A) Activity. shifting back and forth. quivering chin Face Legs Normal position or relaxed Uneasy. (C) Cry. which results in a total score between zero and ten. moves easily tense Arched. does not require consoling . (L) Legs. (C) Consolability is scored from 0-2. frequent complaints Consolability Reassured by occasional touching. restless.FLACC PAIN SCALE Categories 0 No particular expression or smile Scoring 1 Occasional grimace or frown. or ‘talking to’. Difficult to console or comfort hugging. or jerking Cry No cry (awake or asleep) Moans or whimpers. rigid. occasional complaint Crying steadily. screams. tense Kicking or legs drawn up Activity Lying quietly. Squirming. sobs. relaxed.

calmness/agitation.The COMFORT Scale. and facial tension. • The COMFORT scale has been proven to be clinically useful to determine if a child is adequately sedated . • Each indicator is given a score between 1 and 5 depending on behaviours displayed by the child and the total score is gathered by adding all indicators (range from 8–40). muscle tone. respiratory response. physical movement. heart rate. • This scale is composed of 8 indicators: alertness. blood pressure. Patients are monitored for two minutes.

.Observational Scale of Behavioural Distress (OSBD) • It remains the most frequently used measurement in procedure-related distress studies. • It consists of 11 distress behaviours identified by specialists to be associated with paediatric procedure-related distress. anxiety. and pain. • Scores are calculated from summing up all 11 distress behaviours.

arms and fingers. cry. and is used to assess pain of short or long duration. where the higher score indicates greater discomfort . • The scale measures 7 parameters: facial expression. legs and toes. and states of arousal. • The indicators are rated from 0-1 with a maximum score of 7. • The OPS has a simple scoring system which makes it easy to use by all healthcare professionals to obtain valid and reliable results. torso. breathing.Observational Pain Scale (OPS) • It is intended to measure pain in children aged 1 to 4 years.

• These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing .Preschoolers • By the age of four years. • Facial expression scales are most commonly used with this age group to obtain self-reports of pain. • Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain. most children are usually able to use 4-5 item pain discrimination scales.

vertical mouth stretch. lip corner puller. and horizontal mouth stretch. nose wrinkle. open lips.Child Facial Coding System (CFCS) • It is adapted from the neonatal facial coding system and developed for use with preschool children (aged 2–5 years). flared nostril. • It consists of 13 facial actions: brow lower. upper lip raise. cheek raiser. • The CFCS has been useful with acute short-duration procedural pain . squint. blink. nasolabial furrow. eye squeeze.

• The tool is used to assess pain intensity • Targets 4-13 years .Poker Chip Tool • It was developed for preschoolers to assess “pieces of hurt ”. • The tool uses four or five poker chips. where one chip symbolizes “a little hurt” and four/five chips “the most hurt you could experience”.

Faces Pain Scale. • The scale requires health care professionals to point to each face and describe the pain intensity associated with it. • It was developed by Wong and Baker and is recommended for children ages 3 and older. and then ask the child to choose the face that most accurately describes his or her pain level .

. and Hispanic. • The photographic scale entails six different pictures of one child. females are not represented. • Even though it covers a wide array of patients. portraying expressions of “no hurt” to “the biggest hurt you can ever have” • Children are asked to choose the picture or number that closely corresponds to the amount of pain they feel . • It was developed by Beyer in 1980. • It is used for children older than 5 years • The tool has two separate scales: the numeric scale (i. • It is an ethnically based self-report scale. For example. which has three versions: Caucasian. AfricanAmerican. it still has limits. as well as other cultures.The OUCHER Scale.e.0–100) and the photographic scale usually used for younger children.

then they colour their hurt on a body outline. Eland’s Colour scale .Eland’s Colour scale Children select colours to indicate: ‘’Worst Hurt’’ ‘’Hurt not as much as’’ ‘’just a little Hurt’’ ‘’no Hurt at all’’.

Children select the level of pain from drawing of a ladder with higher rungs indicating greater pain.clinically relevant scoring system..It provides:   allowance for thirst and hunger and includes H. Pain discomfort scale(AIIMS).It is a good.Ladder scale.R.respiration. .

PAIN DISCOMFORT SCALE (AIIMS) Respiratory rate + 20% + 20-50% + 50% + 10% + 20% + 30% Calm Restless Agitated Pre op Pre op Pre op Pre op Pre op Pre op 0 1 2 0 1 2 0 1 2 Heart rate Discomfort Cry No cry Cry respond to water food Cry respond to tender loving care Cry not responding to tender love No pain States pain vague Can localize pain 0 0 1 2 Pain at operative site 0 1 2 .

101 VRS FLACC Scale Physiological HR BP RR Sweating Pre Schoolers CHEOPS Objective pain scale Pain behaviour rating scale Pain behaviour checklist Schoolers .Pain Assessment Method Age Group Pre Verbal (Neonate & Infants) Self Report Behavioural Cry characteristics Cry time Facial expression Visual tracking Response time to stimulus Behavioural state FACES pain scale Oucher scale Poker chip tool Ladder scale Eland colour scale VAS NRS – 11 .

• A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool . their use of language to report it is different from adults. • Self-report visual analogue and numerical scales are effective in this age group.School Aged Children • Although children at this age understand pain. begin to understand the quality of pain. • At roughly 7 to 8 years of age children.

“not hurting ” or “no pain” to “hurting a whole lot” or “severe pain”.. red) represent more pain .Visual Analog Scale(VAS) • It is a horizontal line. 100mm in length. • The children are asked to mark on the line the point that they feel represents their pain at this moment. where darker more intense colors (i. • A color analogue scale can also be used.e. attached to word descriptions at each end.

or think” certain items when they hurt or in pain. cognitive distraction.Paediatric Pain Questionnaire • It is a self-report measure to assess children and adolescents coping abilities using 8 subscales “information seeking. positive self-statements. behavioural distraction. with scores ranging from 1 (“never”) to 5 (“very often”). • The questionnaire usually takes about 10–15 minutes to complete . seeking social support. • It contains 39 items in total. do. • Children or adolescents are requested to state how often they “say. problem solving. and emotionfocused avoidance). externalizing and internalizing as well as three more complex scales (approach. distraction.

” “large. • It consists of a body map drawing to allow children to point to the location of pain on their body and a word graphic scale to measure pain intensity. • The APPT is most useful with children and adolescents who are experiencing complex. and quality of pain in children older than 8 years of age.” “little. • 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. location.Adolescent Pediatric Pain Tool (APPT) • It is a valid all encompassing pain assessment tool used for individual pain assessments and measures intensity.” “medium.” to “worst” possible pain . difficult to manage pain.

• Some adolescents regress in behavior under stress. the adolescent pediatric pain tool or the McGill pain questionnaire are helpful. so it is important to provide them with privacy and choice. especially in front of friends. specifically chronic pain. . • They expect developmentally appropriate information about procedures and accompanying sensations.Adolescents • Adolescents tend to minimize or deny pain. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable. • To assess pain and.

CONCLUSION • The score itself is not all important. • The goal of pain assessment is to improve objective component (function) and manage the subjective component (pain). . • Reducing the score is only one measure available to reduce overall pain and suffering.

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