Pediatric Pain Measurement

Pediatric Pain Assessment

By Erin Sweet, RN, CFNP and Jean Solodiuk, RN, PhD

Many clinicians have questioned whether routine pain assessments are beneficial to medical care.1 Some have suggested that pain assessment contributes to patients’ expectations of receiving opioids when seeing a provider for pain.2 We are not aware of any studies that describe the benefits or risks of assessing pain. We maintain that especially while caring for children or people that have difficulty communicating, routine pain assessment is a necessary part of compassionate medical care.

Pain management is a crucial component of compassionate care. The first step in pain management is communicating (verbally or nonverbally) the pain experience to someone who can help with pain management. Not everyone has the ability to communicate pain, an abstract physical and emotional experience. For those who are preverbal, nonverbal, have a limited vocabulary, a communication disorder or those who are simply shy when talking to health care professionals, routine pain assessment improves the chance of communicating the pain experience to someone who can help. 

Trying to understand a child’s pain experience can be challenging. Pain is a multidimensional experience. Pain assessment in children is confounded by the child’s: 1) developmental stage; 2) ability to comprehend and; 3) communicate (verbally and nonverbally) his/her pain experience. The experience of pain is influenced by mood, environment and the meaning of the pain to the individual.  For simplicity, most pain assessment tools measure one dimension of pain: Pain intensity. Since pain is a subjective experience, some children may consistently report higher (or lower) than expected for the source of pain. For this reason, when using a pain assessment tool, it is important to compare the child’s responses to previous responses of that child NOT between different children. Pain assessment tools (like all measurement tools) are not precise. No pain tool is ideal for every clinical situation, but a pain assessment tool that has been psychometrically tested for a certain patient subgroup has the best chance of measuring pain intensity well within that subgroup.

The gold standard of measuring pain intensity remains self-report whenever possible. Examples of self-reported pain assessment tools are the Wong-Baker FACES scale,3 or Numeric Rating Scale (NRS).4 The FACES scale can be used in children older than three years. The FACES tool is comprised of six black and white cartoon faces that portray increasing levels of pain. The scale is consisted of faces that score 0 (smiling face), 2, 4, 6, 8 and 10 (crying face). The NRS scale is scored from 0 (no pain) to 10 (worst pain imaginable) and is typically reported verbally. The NRS is used for children seven years and older.

For children unable to self-report, behavioral pain assessment tools can be used. For example, for infants and children up to age seven years old, the FLACC (Face, Legs, Activity, Cry and Consolability) is a commonly used behavioral pain assessment tool. The FLACC scale is composed of five items, face, legs, activity, cry and consolability. Each item is scored from 0 to 2. Items are added together to result in a total score from 0 to 10.5

Pain assessment is comprised of a thorough assessment of a child’s facial expression of pain, pain behaviors, emotional response to pain, physical function and physiological measures of pain. When assessing pain using self-report, observe the child to ensure that other aspects of pain are consistent with the self-reported pain intensity. For example, a child may report a score of 0/10 if he believes that it will get him discharged from the hospital. 

Certainly, there is a need for health care professionals to reeducate the public on the use of opioids to manage pain.  Not all pain requires an opioid for treatment. In order for the pain treatment plan to be safe, effective and appropriate, the treatment plan must be based on the source and intensity of pain and how the pain affects the patient.

Pain assessment and development of a safe and effective pain treatment plan can be challenging for any population. There is no ideal pediatric pain assessment tool but rather many components that go into the development of a complete pain assessment. In doing these assessments routinely, conceivably the healthcare provider’s assessment may be more sensitive to each specific child. Furthermore, pain treatment plans may be optimized, as not all pain responds to opioid management. 

References

1. Voepel-Lewis, T. (2011). Pain assessment and decision making: Have we missed the mark? Pediatric Pain Letter, 13(1), 1-6.
2. Friedman, J. Remove Pain as 5th vital sign, AMA urged. June 13, 2016. Retrieved from www.medpagetoday.com
3. Morain-Baker, C., Wong, D. QUEST: A process of pain assessment in children. Orthopaedic Nursing. 1987;6:11–21.
4. von Baeyer CL, Spagrud LJ, McCormick JC, Choo E, Neville K, Connelly MA: Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children’s self-reports of pain intensity. Pain 143:223-227, 2009.
5. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23: 293–7.