A 6 year old boy is brought to the Emergency Department after a fall from a tree. The boy ambulates into triage, but is holding his arm and grimacing with discomfort. Immediately, you conduct a focused physical exam of his arm and rule out other injuries. It is obvious to you that this patient is in pain, and you would like to assess his experience of pain in more depth. How do you proceed?
Over the last decade, self-reported scales have become the globally accepted gold standard of pediatric pain assessment. They are a measure of pain intensity along a continuum of ‘no pain’ to ‘worst pain’, with the continuum being comprised of either numbers, faces, or graduated lines of colour. The success of self-reported scales lies with research, which has found these tools really accurate in measuring both acute and chronic paediatric pain at different ages in childhood. They are relatively easy to use, and healthcare professionals require little training before implementing them into clinical practice.
Unfortunately, ease of use has not excluded paediatric pain self-reported scales from being improperly implemented or under-utilised in the clinical setting. Past quality and educational audits show self-reported scales are often used inconsistently, and misunderstood by healthcare professionals. To bring more clarity of such scales to the end user, this post will discuss six evidence-based strategies to help improve upon both the accuracy and efficiency of the paediatric pain assessments made in the clinical setting.
Age directs selection of a self-reported scale
Self-reported scales have been found to accurately measure the a child’s pain from as early as the age of three, and beyond into adulthood. This does not mean that all paediatric pain self-reported scales are suitable for every age group. In fact, the most common self-reported scales used to assess paediatric pain are only recommended for certain ages, and carry the warning that falsely high pain assessments can be made when the scale is used on a younger age group than recommended. As such, all healthcare professionals should take time to pick a scale based on the age of the child.*
This table summarises guidelines from the World Health Organization (WHO). It outlines several age group appropriate pain scales.
|Self-Report Scale||Applicable age range||Comments|
|Faces Pain Scale - Revised (FPS-R)||4 to 12 years||Requires minimal instruction.nnQuick to administer.|
|Pieces of Hurt Tool/ Poker Chip||3 to 12 years||Requires confirmation that size-sorting task is developed in the child. nnModest evidence of reliability and validity in preschool children between 3 and 4 years.|
|The Oucher (Photographic)||3 to 12 years||Requires minimal instruction.nnQuick to Administer.nnThere are four versions of the photographic scale, all depicting children of different ethnicities.|
|Visual Analogue Scale (VAS)||Above 8 years||Requires a high degree of abstraction from the child to indicate varying pain intensity on a graded line.|
|0-10 Numerical Rating Scale (NRS)||Above 8 years||Can be administered verbally.nnRequires child to have an understanding of numbers and counting.|
For more information and tips to guide your assessments of paediatric pain check out the WHO document Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. 
Behavioural scales should not be substituted for self-report
Paediatric pain behavioural scales are not the same as paediatric pain self-reported pain scales, but are often confused and used interchangeably by healthcare professionals. To improve the accuracy of pain assessments, you must have a clear understanding of how these scales are different, and when to apply one over the other.
Like self-reported scales, behavioural scales often provide a numerical ranking of pain intensity. However, unlike self-reported scales, behavioural ones measure pediatric pain based on the child’s observable movements and expressions. As a result, the intensity of pain measured by behavioural scales is almost solely based on the perceptions of the healthcare professional using the scale. A well-known example of a behavioural scale that measures infant and toddler pain is FLACC, which stands for Faces, Legs, Activity, Cry, and Consolabilty, but a variety of behavioral scales can be found in practice.
Comparing the two paediatric pain scales clinically, behavioural scales are still considered ‘second-best’ to self-reported scales. Research recommends behavioural scales should only be routinely utilised for pain assessment among children who are either preverbal or not yet able to comprehend self-reported scale instructions. Behavioural scales should also be avoided in the assessment of children with chronic pain , as outward signs of pain diminish with time, physical disability, as healthcare professionals frequently mistake disability for pain, and children with anxiety, as their fear can falsely appear as a sign of pain.
Consider contraindications and factors that limit assessment
Use of a self-reported scale to assess pediatric pain is contraindicated in the presence of any of the following clinical findings (which make engagement of the patient in assessment difficult):
- Age less than three years.
- Unable to demonstrate cognitive skills like estimation of quantities, seriation, or classification.
- Patient is experiencing excessive fear or anxiety.
- Altered level of consciousness due to either head trauma, disease processes, or sedating pharmaceuticals.
Note: Though being able to verbalise pain is essential to the use of some paediatric pain self-reported scales, this does not rule out their use. For example, visual scales, like Faces and The Oucherm may still be used if cognitive function is adequate, but the patient is unable to speak.
Beyond direct contraindications for the use of self-reported scales, there are several factors that can limit their accuracy.
- Eastern culture: culture can hinder the administration of self-reported scales in numerous ways. Patients who are from an Eastern culture may find self-reported scales particularly confusing and difficult to read. This is because most visual paediatric pain self-report scales are oriented in a horizontal manner, which is common in Western culture, but unfamiliar in the east (which tends to prefer vertical layouts). As well, few translated versions of self-reported scales in eastern languages exist, which increases the difficulty of giving instructions for healthcare professionals.
- Malnourishment: children who have limited access to food have poor cognition, and therefore, may lack the cognitive skills required to self-report their pain.
- Beliefs of the healthcare professional: research shows that if healthcare professionals feel self-reported scales are ineffective at assessing paediatric pain, than administration of the scale is less likely to be successful, and unable to accurately capture the patient’s pain.
Don’t leave out parents who can provide important context
Without a doubt, each assessment of paediatric pain done with a self-reported scale should result directly from the child verbally sharing their experience of pain. Parents, who may interject or try to rate their child’s pain for them, can detract from this portion of the assessment, but should not be discredited or ignored overall. After a child has successfully rated their pain, the parent’s knowledge of the child’s personality, habits, and behaviours could give important context to the assessment. This may include pointing out that a child may have reported their pain based on a favourite colour or number. A parent can also provide important clarification when explaining the instructions for using a self-reported scale to a child. Parents can rephrase the steps to reporting pain in terms the patient knows and will understand.
Minimize recall bias on reassessment
It’s no surprise that good pain management requires healthcare professionals to regularly return to their patient and reassess their pain with the same scale. Though you may not know that if reassessment is occurring over longer periods of time, recall bias can occur and impact the accuracy of your reassessments. Recall bias is a memory related problem, in which a patient forgets or incorrectly remembers their past experience. With paediatric pain specifically, children and adolescents lose the original frame of reference in which they experienced pain, and then are unable to accurately tell healthcare professionals if their pain is better or worse after being treated. As such, some children may over-estimate, under-estimate, or refuse to rate the effect of the treatment entirely. Minimising recall bias can be difficult, but there are two strategies you can use to help your patient remember their pain more accurately.
- Remind the patient of their original self-report ranking before reassessment.
“When you first arrived in the ED your pain was 8 out of 10, what would it be now?”
- Shorten the length of time between pain assessments or assess the patients pain on a frequent, regular basis.
Assess other attributes of pain
Self-reporting scales are only a measure of pain intensity, and cannot be used as the sole assessment of their pain. This may be an obvious tip to you, but in my clinical experience, I find seasoned healthcare professionals often fall short of making paediatric pain assessments beyond the self-reporting scale. To carry out a complete paediatric pain assessment following the well-known pain acronym PQRST (Provocation, Quality, Region, Severity, Temporality) is sufficient for most clinical situations. Depending on the child there may also be value in noting affective changes, ability to carry out activities of daily living, and cultural background.
Reflect on the use of paediatric pain self-reporting scales in your own practice. With the consequences of untreated pain being detrimental to children, it is especially prudent that we examine our roles in the under-assessment, or inaccurate assessment of paediatric pain. If a clinical setting is not conducive to pain assessment, we must also share our thoughts openly to create change, and help confront the misconceptions that currently surround self-reporting scales.
* With the exception of children whose cognitive development does not align with their chronological age.
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