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The Use of the Faces, Legs, Activity, Cry and Consolability Scale to Assess Procedural Pain and Distress in Young Children

Babl, Franz E. MD, MPH, FRACP, FAAP, FACEP*†‡; Crellin, Dianne RN, BN, MN, NP*†‡; Cheng, Joyce BSc*; Sullivan, Thomas P. MBBS, BSc*; O’Sullivan, Ronan MB, FRCSI, FCEM, MBA*; Hutchinson, Adrian RN, RM*

doi: 10.1097/PEC.0b013e3182767d66
Original Articles

Introduction Young children frequently undergo diagnostic and therapeutic procedures in the emergency department (ED). Although developed and validated for postoperative pain, Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scores have been recommended and used for the assessment of procedural pain as well. We set out to assess if FLACC scores can differentiate pain and distress and establish a hierarchy of FLACC scores experienced during common ED procedures.

Methods Prospective observational study at an urban tertiary children’s hospital ED. We aimed to recruit 30 children each aged 6 to 42 months undergoing intravenous cannula (IV) insertion, nasogastric tube (NGT) insertion, metered dose inhaler (MDI) use and oxygen saturation (SpO2) measurement. Based on videotapes, 2 independent observers assessed pain and distress using FLACC scores during all procedural phases.

Results A total of 125 patients were recruited and filmed for IV (33), NGT (30), MDI (34), and SpO2 (28). Median FLACC scores were as follows: NGT, 10 (interquartile range [IQR] 8.75–10); IV, 6.5 (IQR, 4.5–9.75); MDI, 6.5 (IQR, 0–9); and SpO2, 0 (IQR, 0–0.5). The FLACC scores increased during each of the 3 phases, before the procedure, during restraint, and during the procedure. Procedural distress decreased with age except for NGT insertions, which remained very high irrespective of age.

Conclusions FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children. This study identified substantial levels of pain and distress in young children by FLACC during commonly performed ED procedures, with nasogastric tube insertion having very high and intravenous cannulation/venepuncture and MDI having high FLACC scores.

From the *Emergency Department, Royal Children’s Hospital; †Murdoch Children’s Research Institute, Victoria; and ‡The University of Melbourne, Melbourne, Australia.

Disclosure: The authors declare no conflict of interest.

Reprints: Dianne Crellin, RN, BN, MN, NP, Emergency Department, Royal Children’s Hospital, Parkville, Vic 3055, Australia (e-mail:

The authors received grant support from the Murdoch Children’s Research Institute, Melbourne, Australia and the Victorian Government’s Operational Infrastructure Support Program.

© 2012 Lippincott Williams & Wilkins, Inc.