How to Properly Assess Pediatric Pain
Welcome to this video on pediatric pain assessment. Children pose particular challenges in pain assessment, especially when they are too young to verbalize a description of their pain or have developmental delays.
Dozens of pediatric pain assessment tools are available, and choosing an appropriate age-based assessment tool is important, as is ensuring that staff members are well trained in utilizing the tools so that there is consistency in assessing and reporting pain. It’s also important to remember that many pain scales were developed to assess reactions to acute pain, and reactions to chronic pain may be more subtle.
First, let’s consider neonates and infants. Neonates and young infants lack cognitive understanding of pain, but experience pain and the stress associated with it. Uncontrolled pain in the neonate and young infant may have lasting psychological and physiological effects, including increased sensitivity to pain.
Neonates and infants often experience pain resulting from painful procedures, such as heel sticks and endotracheal tube suctioning. While crying is the most common indication of pain, other characteristics can indicate pain as well.
Pain assessment for neonates and children is based solely on behavioral observation. A commonly used assessment tool for neonates and infants of less than one year is the Neonate/Infant Pain Scale, commonly referred to as NIPS.
With this tool, the 5 characteristics that are scored include:
- the expression on the infant’s face
- respiratory patterns
- movements of the upper and lower extremities
- the arousal state
Five characteristics are scored 0 to 1 and crying is scored on a scale of 0 to 2.
Another pain assessment tool specifically designed for postoperative neonates and infants up to 6 months for whom oxygenation and changes in vital signs are especially concerning is CRIES, which assesses crying, required oxygen, increase in heart rate and blood pressure, expression, and sleeplessness on a scale of 0 to 2.
As children begin to talk and have a better understanding of pain, they are still rarely able to verbalize the extent of their pain, and the most common expression of pain is still crying. If a child is frightened, the child’s reaction to and perception of pain may be more intense. Even at 1 year of age, infants who have experienced pain may exhibit signs of anticipatory fears.
Alterations in vital signs, such as increased pulse and respirations, may occur with pain but also with stress alone.
The FLACC tool, which is also based on behavioral observation, is often used for children who are 1 to 3 years old and sometimes up to 7 years or even older for children who are nonverbal or developmentally delayed.
FLACC includes an assessment of the face, legs, activity, cry, and consolability with each characteristic scored from 0 to 2.
Starting at about age 3 through 7, children are usually able to self-report pain and say, “It hurts” or “OWW!” and can begin to quantify pain as well by saying, “It hurts a little,” or “It hurts a lot.” At this point, an assessment tool such as the Wong-Baker FACES tool is often utilized. The child is asked to point to the face that best describes the pain the child is experiencing.
However, children at these ages, especially at 3 and 4, are not always reliable reporters. They may not completely understand the directions and may just pick a face arbitrarily. They may be too frightened to respond accurately or, if crying, just pick the crying face. If they have been told to be “brave” and not to cry, they may pick a neutral face even if their pain is severe.
Thus, it’s important to observe children’s behavior and demeanor as well and to ask follow-up questions, such as “Can you tell me what you think this face is feeling?”
By age 7 or 8, most children are able to self-report pain and can respond to more probing questions, such as “When did the pain start?”, “Does it hurt more when you move?”, or “What does the pain feel like?” Providing a list of possible descriptors may be helpful, such as sharp, burning, or aching.
The most commonly used pain assessment tool is the 0 to 10 numeric scale. However, FACES or FLACC may be more appropriate for some children, especially if they are developmentally delayed or severely frightened. And remember, at any age, self-reporting by numbers on a scale is not always an accurate reflection of pain, so physical indications, such as increased pulse, respirations, and blood pressure should be assessed as well.
It’s common to consider scores of 4 or greater as indicating the need for analgesia. However, each child should be considered carefully rather than simply basing treatment on self-reported scores that may not be accurate.
Adolescents are almost always able to self-report the level of their pain and can usually differentiate physical pain from emotional distress. Pain assessment for adolescents should be done in private if possible because they are often self-conscious and may minimize—or exaggerate—pain if peers or family members are present.
Gender expressions of pain may also vary as girls are more often encouraged to express pain than boys, and adolescents may also be affected by cultural expectations about expressions of pain. Additionally, adolescents may exhibit behavioral signs of pain, such as increased irritability, mood changes, and social withdrawal, especially with chronic pain.
It is important to remember that children and adolescents’ perceptions of pain may be exacerbated by internal and external factors.
- Internal factors may include fear, anxiety, memories of previous pain, and associated symptoms, such as nausea or shortness of breath.
- External factors may include parental fear, invasive treatments, poorly managed pain, and a negative environment. Children may be unduly influenced by parental reactions, including both parents who remain stoic and parents who overreact.
Thanks for watching and happy studying.