The child's pain history not only provides context but may also shed light on circumstances that could influence the child's report of pain. Ideally, the history is gathered from both the child and the parent or caregiver either before or during a painful event (see Table 217 for questions to ask when conducting a pain history). For children with a chronic pain condition, nurses need to conduct a more detailed pain history (see Table 38).
PAIN ASSESSMENT TOOLS
After obtaining and documenting the child's pain history, it's necessary to quantify the presence and level of pain, document the need for intervention, and determine the effectiveness of any pain management interventions used.
The following three types of assessment are used to measure pain intensity in children, and a number of tools or scales employ one or more of the three (see Table 41, 16, 17, 19-31):
Physiological measures of pain include heart rate, respiratory rate, blood pressure, and oxygen saturation. Although embedded in some observational pain assessment tools, physiological measures alone do not discriminate between responses to pain and stress. Additionally, responses to pain measured by these indices wane over time, making their exclusive use an invalid measure of pain.
Behavioral–observational tools allow nurses to monitor observable behaviors that are indicative of pain. They may be used to assess pain in children who are
- too young to self-report.
- restricted by bandages or sedating drugs.
- altering (exaggerating or minimizing) their self-report ratings because of fear.
Pain assessment should be considered for sleeping children, because children often use distraction (play) to cope with pain but can then become exhausted, fall asleep, and experience persistent pain while sleeping.10, 32 When assessing pain in a sleeping child, use a validated behavioral–observational scale, as these scales are least likely to disrupt the child's sleep. Behavioral–observational scales include the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)26; the COMFORT Scale1; the Face, Legs, Activity, Cry, Consolability (FLACC) scale27; and the revised FLACC scale.25
Documentation in an established section of the electronic health record should follow each assessment, preferably with a drop-down menu to guide the nurse in scoring.
Self-report measurements of pain are preferred because they provide the most valid measurement of a patient's subjective pain experience and are convenient to use. Their clinical utility is limited, however, by the communication skills of the patient. That being said, children as young as four years of age can often provide a self-report of their pain if provided with a tool appropriate for their age and developmental level. There are several self-report tools that can be used in children of varying ages.
Numeric rating scales require patients to gauge their pain severity using numbers, with 0 representing “no pain” and 10 representing “the most pain possible.” These scales may be used to assess pain in children ages eight years and older, provided they understand numbers, have the ability to express pain in quantitative terms, and can communicate verbally.16
Faces scales present children with drawings or photographs of facial expressions representing different levels of pain intensity. Children are asked to select the picture that best represents their pain. These easily reproduced scales require no quantitative reasoning on the part of the child.16 Examples include the Wong–Baker FACES Pain Rating Scale, for use by children ages three to 18 years31; the Faces Pain Scale–Revised (FPS-R), for use by children ages four years and older21; and the Oucher Scale, for use by children ages three to 12 years.19
Visual analog scales (VAS) present children with a horizontal or vertical line, most commonly 100 mm in length, with anchors at each end indicating either “no pain” or “worst possible pain.” The child makes a perpendicular mark on the line to indicate pain severity.29 VAS scores demonstrate good interrater reliability and are sensitive to changes in pain following analgesic interventions.33 These tools are appropriate for children eight years or older29 and are easily reproduced, though photocopying may distort the line length.
Adjective scales require patients to select a word out of a list of adjectives that describe pain severity. These scales can be used to assess pain in patients with at least a high school level of verbal fluency, but their use in children is not recommended as it has not been widely studied.16
Graphic rating scales, such as the Pieces of Hurt tool, which is also known as the Poker Chip Tool, invite children to measure their pain intensity using four colored chips, each of which represents a “piece of hurt.”16, 17 One chip indicates “a little hurt” and four chips indicate “the most hurt” the child could have. This clinical assessment tool is most useful in determining the presence or absence of pain in young children. It was developed for use in children ages four through seven years, but has been used for acute procedural pain in patients as young as three years and as old as 18.29
Children who are cognitively impaired, sedated, or receiving mechanical ventilation, as well as premature infants and neonates, pose additional pain assessment challenges. On the assumption that pain induces alterations in the autonomic nervous system, physiological indicators are often embedded in the scales used to assess pain in these patients.
Cognitively or developmentally delayed children. These children are at elevated risk for undertreated pain owing to their neurologic impairments and limited ability to self-report pain. In addition to physiological cues, behavioral cues—such as facial expressions, vocalizations, changes in posture or movement, alterations in sleeping or eating patterns, feeding intolerance, and changes in mood or sociability, including irritability or reports of “not acting like themselves”—may be used to identify pain in these children.34 For this reason, it's important for nurses to work in partnership with children's caregivers when conducting the initial baseline pain history and subsequent pain assessments. Well-validated tools for this patient population include the Noncommunicating Children's Pain Checklist–Revised (NCCPC–R)20 and the revised FLACC.25
Infants and children who are sedated or receiving mechanical ventilation. Numerous factors influence the expression of pain in these children, making it difficult for caregivers to differentiate pain from distress, anxiety, or agitation. The COMFORT Scale, however, is the only tool validated for assessing pain in mechanically ventilated patients ages zero to 18 years and is particularly useful in pediatric ICUs.1, 35
Premature infants and neonates. These infants may be assessed with tools that combine behavioral and physiological indicators and are specific to such contextual factors as gestational age and sleep–wake state. These tools include the Premature Infant Pain Profile (PIPP),28 Neonatal Infant Pain Score (NIPS),24 Crying, Requires Increased Oxygen Administration, Increased Vital Signs, Expression, Sleeplessness (CRIES) tool,23 and Neonatal Pain, Agitation, and Sedation Scale (N-PASS).22
PAIN ASSESSMENT FREQUENCY AND DOCUMENTATION
When a child is treated in a health care setting, pain should be assessed and documented at all of the following points36, 37:
- with any ED or ambulatory clinic visit
- on admission to the hospital or surgical center
- before, during, and after any procedure
- before and after any pain management intervention
- once per shift in an acute care setting, coinciding with routine assessments and patient care
PARTNERING WITH CAREGIVERS
Involving a child's parents or consistent caregivers is an important aspect of pain assessment and management. Since parents and caregivers are most familiar with a child's typical behavioral response to pain, they can often identify behaviors unique to the child and provide valuable “proxy reports” of the child's pain, though such proxy assessments should be combined with other types of assessment when possible.38 Authors of a small qualitative study that investigated how parents of children with Down syndrome assess pain in their children and intervene to relieve it suggest that it may be even more important to involve parents of children who have difficulties with self-report in interpreting their child's behavior and identifying comfort strategies.39
Researchers studying parents’ use of the FLACC scale and a 0 to 10 numeric scale to assess pain in their cognitively impaired children made the following observations, which support both construct and criterion validity of parental proxy pain ratings40:
- Parental ratings using the FLACC scale correlated well with parental ratings using the numeric scale.
- Parental ratings decreased significantly after analgesics had been given to the children.
- There was a high correlation between parents’ and nurses’ ratings using both tools, though there was slightly more agreement between parents’ and nurses’ FLACC ratings.
The Royal College of Nursing's clinical practice guideline, The Recognition and Assessment of Acute Pain in Children, defines parental (caregiver) involvement as a principle of practice.41 It states that children and their families should be viewed as partners in care, involved in shared decision making for individualized pain assessments, and provided with training regarding the use of pain assessment tools.
The effectiveness of educating parents or caregivers in pain assessment and management was demonstrated in a 2003 study that included the parents of 51 children undergoing cardiac surgery.42 Parents who were exposed preoperatively to educational material on pain assessment and management significantly increased their knowledge in these areas, as measured by improved pretest to posttest scores. By introducing educational materials that promote advocacy for the child and encouraging optimal communication between health care providers and the family, nurses can better involve parents and caregivers in the pain assessment and management processes.
1. Ambuel B, et al Assessing distress in pediatric intensive care environments: the COMFORT scale J Pediatr Psychol 1992 17 1 95–109
2. Fortier MA, et al Acute to chronic postoperative pain in children
: preliminary findings J Pediatr Surg 2011 46 9 1700–5
4. Rennick JE, et al Children
's psychological responses after critical illness and exposure to invasive technology J Dev Behav Pediatr 2002 23 3 133–44
5. Taddio A, et al Conditioning and hyperalgesia in newborns exposed to repeated heel lances JAMA 2002 288 7 857–61
6. Young KD Pediatric procedural pain Ann Emerg Med 2005 45 2 160–71
7. Meyerson DA, et al Posttraumatic growth among children
and adolescents: a systematic review Clin Psychol Rev 2011 31 6 949–64
8. Ismail A The challenges of providing effective pain management for children
in the pediatric intensive care unit Pain Manag Nurs 2016 17 6 372–83
9. Engel GL The need for a new medical model: a challenge for biomedicine Science 1977 196 4286 129–36
10. Ball JW, Bindler R Ball JW Pain assessment
and management Principles of pediatric nursing: caring for children
2012 5th ed. Boston Pearson 370–91
11. Hurley A, Whelan EG Cognitive development and children
's perception of pain Pediatr Nurs 1988 14 1 21–4
12. Huguet A, et al Development and preliminary testing of a scale to assess pain-related fear in children
and adolescents J Pain 2011 12 8 840–8
13. Wilson AC, et al Fear-avoidance beliefs and parental responses to pain in adolescents with chronic pain Pain Res Manag 2011 16 3 178–82
14. Evans S, et al Parent-child pain relationships from a psychosocial perspective: a review of the literature J Pain Manag 2008 1 3 237–46
15. Chambers CT, Craig KD An intrusive impact of anchors in children
's faces pain scales Pain 1998 78 1 27–37
16. von Baeyer CL Children
's self-reports of pain intensity: scale selection, limitations and interpretation Pain Res Manag 2006 11 3 157–62
17. Hester NO, et al Putting pain measurement
into clinical practice Prog Pain Res Manag 1998 10 179–98
19. Beyer JE, et al The alternate forms reliability of the Oucher pain scale Pain Manag Nurs 2005 6 1 10–7
20. Breau LM, et al Psychometric properties of the non-communicating children
's pain checklist-revised Pain 2002 99 1-2 349–57
21. Hicks CL, et al The Faces Pain Scale–Revised: toward a common metric in pediatric pain
measurement Pain 2001 93 2 173–83
22. Hummel P Psychometric evaluation of the Neonatal Pain, Agitation, and Sedation (N-PASS) Scale in infants and children
up to age 36 months Pediatr Nurs 2017 43 4 175–84
23. Krechel SW, Bildner J CRIES: a new neonatal postoperative pain measurement
score. Initial testing of validity and reliability Paediatr Anaesth 1995 5 1 53–61
24. Lawrence J, et al The development of a tool to assess neonatal pain Neonatal Netw 1993 12 6 59–66
25. Malviya S, et al The revised FLACC observational pain tool: improved reliability and validity for pain assessment
with cognitive impairment Paediatr Anaesth 2006 16 3 258–65
26. McGrath PJ, et al CHEOPS: a behavioral scale for rating postoperative pain in children
Adv Pain Res Ther 1985 9 395–402
27. Merkel SI, et al The FLACC: a behavioral scale for scoring postoperative pain in young children
Pediatr Nurs 1997 23 3 293–7
28. Stevens B, et al Premature Infant Pain Profile: development and initial validation Clin J Pain 1996 12 1 13–22
29. Stinson JN, et al Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children
and adolescents Pain 2006 125 1-2 143–57
30. von Baeyer CL, Spagrud LJ Systematic review of observational (behavioral) measures of pain for children
and adolescents aged 3 to 18 years Pain 2007 127 1-2 140–50
31. Wong DL, Baker CM Pain in children
: comparison of assessment scales Pediatr Nurs 1988 14 1 9–17
32. Hawley DD Postoperative pain in children
: misconceptions, descriptions and interventions Pediatr Nurs 1984 10 1 20–3
33. Cohen LL, et al Evidence-based assessment of pediatric pain
. J Pediatr Psychol
2008;33(9):939-55; discussion 956-7.
34. Quinn BL, et al Pain in nonverbal children
with medical complexity: a two-year retrospective study Am J Nurs 2018 118 8 28–37
35. Twycross A Managing pain in children
: a clinical guide for nurses and healthcare professionals 2014 2nd ed. Chichester, West Sussex, UK John Wiley and Sons
36. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children
, and Adolescents. The assessment and management of acute pain in infants, children
, and adolescents. Pediatrics
38. Herr K, et al Pain assessment
in the patient unable to self-report: position statement with clinical practice recommendations Pain Manag Nurs 2011 12 4 230–50
39. Davies RB Pain in children
with Down syndrome: assessment and intervention by parents Pain Manag Nurs 2010 11 4 259–67
40. Voepel-Lewis T, et al Validity of parent ratings as proxy measures of pain in children
with cognitive impairment Pain Manag Nurs 2005 6 4 168–74
42. Huth MM, et al A study of the effectiveness of a pain management education booklet for parents of children
having cardiac surgery Pain Manag Nurs 2003 4 1 31–9
For 11 additional continuing nursing education activities on the topic of pediatric pain, go to www.nursingcenter.com/ce.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
assessment tools; children; pain assessment; pain measurement; pediatric pain