Children who present to hospital frequently encounter medical procedures that are painful, unexpected and frightening. These procedures are worsened by the stress and anxiety caused by unfamiliar surroundings and this leads to poor experiences of healthcare settings. 

The principles of pain management apply to all; however, infants and children pose unique challenges to nurses that require consideration of a number of factors, including: the child’s age, developmental level, communication skills, cognition, previous experience of pain and associated beliefs. 

Perception of pain in children is complex and involves physiological, psychological, behavioural and developmental factors.¹ Despite this, pain in infants and children is frequently under-estimated and under-treated. It has been found that infants and children who experience pain in early years, show long-term changes in terms of pain perception and related behaviours.² 

In 2007, a total of 144,703 children aged between 0-17 years were discharged from hospital in Ireland.³ Common procedures that children undergo while hospitalised include venepunctures, wound dressings, lumbar punctures and urinary catheterisation. Many pain assessment tools and child-friendly aids are available to nurses to assess and ease children’s experiences of what is frequently frightening and foreign in a child’s life. This article focuses on those used with neonates, infants and school-aged children.

Tool selection 

Selection of an appropriate pain assessment tool is influenced by a number of key factors that nurses need to be cognisant of. These include: age group; the clinical setting in which the tool is being used; the cultural appropriateness and language of the tool; whether the tool has been designed for use by the child, nurse or parent; and any training and educational requirements needed to deliver the tool.⁴

As a general rule, tools designed to be observer-rated should not be used as self-report tools and vice versa. A number of studies that compared children’s scores on a self-report scale to observer-rating with the same tool found that professionals consistently record lower pain than children. Meanwhile, parents’ scores correlated well with their children’s scores.^5-7

The accurate clinical assessment of pain relies on a multitude of formats, including self-reporting, behaviour observational pain scales and physiologic measures of pain. Self-reporting relies on the cognitive ability of the child to effectively convey their discomfort. Neonates express pain through crying and physical gestures. Toddlers begin to articulate words for pain by about 18 months of age, and by age three to four years they are more able to accurately report degrees of pain, which supports the use of a combination of physiologic and observational scales.

Self-reporting and physiological or observational scales are effective in older children (five to seven years-of-age) who exhibit improved understanding of pain and are more able to localise pain and cooperate with healthcare professionals. As a rule, school-aged children without any neurological deficits can start using the standard adult pain assessment scales around the age of seven to eight years.⁸

Pain assessment tools for neonates and infants

As neonates cannot self-report, pain assessment tools for use in this age category should ideally include a composite of measures. For example, the measurement of facial response to painful stimuli and physiological response. Tools in this category are observer-rated and will require the user to undergo training in their appropriate use and interpretation of neonate responses. 

The majority of pain assessment tools in this category have been validated in post-operative settings with some validated following procedures such as catheter insertion, routine heel stick and endotracheal intubation. Examples of scales include COMFORT, Cries, Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), Objective Pain Scale (OPS), Pain Assessment Tool (PAT) and Premature Infant Pain Profile (PIPP).⁴

Pain assessment tools for children

For verbal children, self-report is considered to be the most valid measure of pain intensity. Face scales such as OUCHER, Wong-Baker FACES (see Figure 1) and the FACES Pain Scale are cognitively appropriate for children aged between three and seven years and who have the ability to quantify abstract phenomena.⁹

 (click to enlarge)

Observer-rated tools enhance a child’s self-report, or may be useful for children who are unable or unwilling to report their pain. Examples of these tools include the Cardiac Analgesic Assessment Tool (CAAT), Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), COMFORT, Derbyshire Children’s Hospital Pain Tool (DCHPT), Face, Legs, Arms, Cry, Consolability (FLACC), Toddler Preschool Post-operative Pain Scale (TPPPS), and Visual Analogue Scale (VAS).⁴

The majority of these scales require user training in their application. OUCHER consist of two scales – one photographic and one numeric. The numerical scale should only be used in children who can count to 100. The choice of pain assessment tool must be used in the context in which the assessment takes place. 

Practical issues to consider when using the tools include:

• The equipment needed for tools that include physiological measures such as blood pressure and heart rate
• Consideration of the time required to complete the assessment, as lengthy ones may not be suited to emergency situations
• The cost of the tool
• The format the tool takes. 

Some tools may be in chart format, others in poster or poker chip format. This may raise concerns relating to storage, ease of use, durability and infection control. For triage and emergency departments, a tool has been developed called the Alder Hey Triage Pain Scale (AHTPS), which is deemed suitable for use in children aged between 0-15 years. 

Issues relating to culture and language also need to be considered given the increasing multicultural population using Irish healthcare services. For most tools, translingual validity is unclear, however COMFORT has been validated in Dutch, and CAS, CHEOPS, FLACC, Poker Chip Tool (PCT), Verbal Rating Scale (VRS) and Sheffield Facial Expression Scale have been validated in Thai. Three ethnic versions of the OUCHER tool have been validated: African-American, Caucasian and Hispanic.⁴

Other key factors to consider when choosing a pain assessment tool is the child’s clinical condition, which may preclude the use of certain tools. For example, tools that assess facial features are not appropriate if the face is fully or partially obscured by a face mask, or in the case of tools that rely on the assessment of body movements, if a child is heavily sedated or paralysed.

Assessment and documentation

Whatever pain assessment tool chosen to assess a child’s pain level, it is important to first gain a baseline assessment on admission and an accurate history of their past painful experiences, including what pain management strategies worked in previous admissions and what didn’t. Write down words that the child uses or behavioural signs to indicate that they have pain. This will also serve to inform others on the patient’s healthcare team.

Once the child’s pain has been assessed, a pain management plan can be made. It is important that pain is reassessed frequently to ensure that pain medication is working and that the child is pain-free. Pain assessment should be incorporated into routine nursing observations, becoming the fifth vital sign or ‘TPRP’ – temperature, pulse, respiration and pain. On discharge home, the child’s pain assessment tool and advice on pain assessment and treatment should be given to parents for continued use at home or in other care settings.^4,10

Conclusion

Numerous child-friendly pain assessment scales exist. Ideally, use one that is simple, inexpensive, reproducible, accurate in its assessment, and usable with both the verbal and non-verbal child. The tools are best chosen by nurses to suit their client population and the environment in which it is to be used. 

It is important that only tools appropriate to the age group of the paediatric client are chosen. The importance of proper identification and treatment of paediatric pain cannot be understated. Therefore, training requirements must also be considered when choosing an appropriate tool as all users will require a basic understanding of how to apply, interpret and document findings and results. 

Alternative techniques for the use of tools have been investigated recently and include the temporary tattooing of the FACES scale on children’s arms.¹¹ This was well accepted by children who indicated greater satisfaction and engagement with the pain assessment process. Similarly, the printing of the Wong-Baker FACES scale onto dolls for children to interact with was the preferred assessment tool for all children (n-45) aged four to 10 years, who were undergoing port-a-cath access when compared with the Wong-Baker FACES Pain Rating Scale.¹² 

Finally, nurses need to be familiar with the range of child-friendly aids in pain management and choose a tool that best meets the specific needs of their practice area and captures the true pain picture of their paediatric clients to ensure that objective assessment, documentation and treatment occurs.

References

1. Morton NS. Pain assessment in children. Paediatric Anaesthesia 1997; 7(4): 267-72
2. McGrath PJ, Frager G. Psychological barriers to optimal pain management in infants and children. Clini J Pain 1996;  12(2): 135-41
3. Department of Health. State of the Nation’s Children. Dublin: Office of the Minister for Children and Youth Affairs 2008
4. Royal College of Nursing. The Recognition and Assessment of Acute Pain in Children: Update of full guidelines. London: Royal College of Nursing, 2009
5. Schneider EM, LoBiondo-Wood G. Perceptions of procedural pain: parents, nurses and children. Children’s Health Care 1992; 21(3): 157-62
6. Maciocia PM, Strachan EM, Akram AR et al. Pain assessment in the paediatric emergency department: whose view counts? Eur J Emergency Medicine 2003; 10(4): 264-7
7. Kelly AM, Powell CV, Williams A. Parent visual analogue scale ratings of children’s pain do not reliably reflect pain reported by child. Pediatric Emergency Care 2002; 18(3): 159-62
8. Sohn VY, Zenger D, Steele SR. Pain management in the pediatric surgical patient. Surg Clin N Am 2012; (In Press) doi:10.1016/j.suc.2012.03.002
9. Loy FL. Literature review of the validity and reliability of three self-report tools to measure pain in young children aged three to eight years. Physiotherapy Singapore 2002; 5(4); 81-6
10. Jonas D, Muldowney Y, Byrne I, Southern H. Clinical Skills for Children’s Nursing: Ch. 6: Essential Care. Oxford: Oxford University Press 2010
11. Franck LS, Allen A, Oulton K. Making pain assessment more accessible to children and parents: can Greater involvement improve the quality of care? Clin J Pain 2007; 23(4): 331-8
12. Badr LK, Puzantian H, Abboud M et al. Assessing procedural pain in children with cancer in Beirut, Lebanon. J Pedi Oncol Nursing 2006; 23: 311-20