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Scales for assessment of pain in infants, neonates and children

Article  in  Advances in Human Biology · January 2021

DOI: 10.4103/aihb.aihb_109_21

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Shibu Sasidharan Gurpreet Kaur Dhillon

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Short Communication

Scales for Assessment of Pain in Infants, Neonates and

Children
It is a humanitarian and ethical imperative for doctors to revealed that half the postoperative patients who were operated
provide pain relief to a patient in pain. In clinical practice, on were not asked about their pain status in the first 24 h post-
pain is considered the 5th vital sign.[1] Assessment of pain is operative period.[5]
the cornerstone for effective pain management. Some studies
have reported that doctors and nurses underestimated the Pain is an unpleasant, subjective, sensory and emotional
pain intensity of their patients.[2] Another study found that the experience originating from actual or potential tissue damage.
pain intensity scores between doctors and nurses had a weak The objective assessment of pain is difficult in the adult
correlation.[3] A French study stated that there are systematic population and more so in the paediatric population. However,
differences in the assessment of the intensity of pain between as per recommendations regarding the treatment of pain, it
patients themselves and physicians.[4] In Germany, a study must be precisely detected, located, quantified and reevaluated;

Table 1: Pain assessment scales for new‑borns and infants

Scales Age Type of pain Scale components Remarks
PIPP[8] New‑born (term Acute and 3 items on facial expression (brow bulge, eye Prolonged observation time and
and preterm) procedural squeeze, nasolabial furrow), and 2 physiological requires knowledge of the infant’s
variations (HR, oxygen saturation) usual behaviour
NFCS[9] New‑borns Acute pain 4 facial expression items (eyes squeeze, brow bulge, Reliable, easy to use, fast and
open lips and naso‑labial furrow) reproducible
EVENDOL[10] Age 0–7 years Acute and 4 behavioral items and 1 environment related Easy to use, reliable can be used
procedural item (verbal/vocal expression, facial expression, in emergency setting, and in
movements, postures, and relationship with post‑operative care
entourage)
Neonatal Till one year Acute pain Six item scale (cry, facial expression, breathing Excellent intra‑class correlation
infant pain of age patterns, leg movement, arm movement and state of
scale[11] arousal)
Cry has three response categories (0, 1, 2); all other
behaviours have two (0, 1)
NPDS[12] New‑borns Prolonged pain, Uses 5 behavioural indicators of Prolonged Requires knowledge about the
stress, and pain (facial activity, body movements, quality baseline behavior of new‑borns 1–4
discomfort of sleep, quality of contact with nurses, and h before applying the scale
consolability)
COMFORT New‑borns and Prolonged acute 8 items (alertness, calmness‑agitation, respiratory Sedated, unconscious, intubated
behavior infants pain, discomfort, response, crying, physical movement, muscle tone, ventilated and in the postoperative
scale[13] and distress facial tension, VAS) setting
CHIPPS[14] 0–5 years Post‑operative Crying, facial expression, posture of the trunk, Based on only observational system
pain posture of the legs, motor restlessness for these 5 behaviours
CRIES[15] New‑borns Post‑operative If no cry=0 Valid, reliable, acceptable and easy
from 32 weeks pain High pitched cry but baby is easily consoled=1 to use tool
gestational age high‑pitched cry with inconsolable baby=2
to age 6 months Requires O2 for Sat>95, nil required=0, <30% O2
required=1 and if >30% O2 required=2
If HR and BP are both unchanged=0
If increased by <20% of baseline=1 If either one is
increased >20% over baseline=2
If no grimace is present=0
If grimace alone=1
If grimace and non cry vocalization grunt present=2
Continuously asleep=0
Frequent awakenings=1
Awake constantly=2
PIPP: Premature infant pain profile, NFCS: Neonatal facial coding system, EVENDOL: Evaluation enfant douleur, NPDS: The Neonatal Pain and
Discomfort Scale, CHIPPS: Children and Infants Post‑operative Pain Scale, CRIES: Crying, requires increased oxygen administration, increased vital
signs, expression, sleeplessness, VAS: Visual Analogue Scale, HR: Heart rate, BP: Blood pressure

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Sasidharan, et al: Scales for assessment of pain in pediatrics

Table 2: Behavior scales for children (>4 years of age)

Scales Age Type of pain Scale components Remarks
CHEOPS[16] 1-5 years Acute post‑operative Cry, facial expressions, child Easy to use, fast, reproducible. In addition
and procedural pain verbal, torso, touch and leg posture to post‑operative settings, it has been
used to assess pain during immunizations,
venipuncture fracture reduction, laceration
repair
FLACC[17] 6 months-5 Acute pain in different Faces, legs, activity, cry, and Can be used in critically ill and cognitively
years settings consolability impaired children
OPS[18] 1-13 years Post‑operative pain BP, crying, moving, agitation, body OPS correlates well with linear analogue
language scale in non‑verbal children
The Post‑operative pain 15 items regarding child’s Used by parents after children return home
post‑operative behavior (play, energetic, eating,
pain measure quite groan, whining, worried,
for parents[19] crying, etc.)
NCCPC[15] 3-18 years of Post‑operative 30 behavioral items Children who cannot communicate
age settings has verbally because of a cognitive handicap or
polyhandicap
CHEOPS: The Children’s Hospital of Eastern Ontario Pain Scale, FLACC: The Faces, Legs, Activity, Cry, and Consolability Scale, OPS: The Objective
Pain Scale, NCCPC: The Non‑Communicating Children’s Pain Checklist, BP: Blood pressure

categorised into acute or chronic along with an attempt to Pain Assessment Scales for Children
determine underlying pathophysiology.[6]
The standard self‑assessment scales are reliable after age
The assessment of pain in children is challenging as it 6 years after attaining appropriate cognitive and language
depends on age and cognitive development. The gold standard skills because they require. However, between 4 and 6 years,
for children older than 06  years of age is self‑reported children can locate and verbalise the painful site. The various
pain scales (provided normal cognitive development), scales available are the Visual analogue scale, Numerical rating
while behavioural pain scales are used for younger scale, verbal rating scale, face pain scale [Table 2]. All these
children (<06 years).[7] The different types of pain scales are scales require optimal communication skills, in the absence
validated as per specific context depending on the types of of which behaviour scales are utilised.
pain; acute, prolonged or chronic. New‑borns have anatomic
and physiologic substrates to perceive painful stimuli. The above tables will serve as a quick reference for practising
However, they cannot verbalise it, which shifts the onus of paediatricians, anesthesiologists and pain physicians to
the clinicians to decipher the same. The correlates of pain in objectively quantify pain.
newborns and younger children are mainly nonverbal facial Financial support and sponsorship
expressions and physiological variables (Facial expression, Nil.
crying, controllability, eye squeeze, body movements,
withdrawal movements, tachycardia, tachypnoea, reduced Conflicts of interest
oxygen saturation, intermittent moans, interrupted sleep and There are no conflicts of interest.
state of arousal) [Table 1].
Shibu Sasidharan, Gurpreet Kaur Dhillon1, Harpreet Singh Dhillon2,
Babitha Manalikuzhiyil3
Pain Assessment Scales for New‑Borns and Departments of Anaesthesia and Critical Care and 2Psychiatry, Level III
Infants IFH Hospital, Goma, Democratic Republic of the Congo, 3Department of
Radiodiagnosis and Imaging, Alchemist Ojas Hospital, Panchkula, Haryana,
The methods used for the assessment of painful events can be 1
Department of Paediatrics, Military Hospital Jammu, Jammu and Kashmir, India
divided into three categories: measurement of physiological
responses of pain, observations of behaviors related to pain, Address for correspondence: Dr. Shibu Sasidharan,
Department of Anaesthesia and Critical Care, Level III IFH Hospital, Goma,
and verbal or written descriptions of pain and/or associated Democratic Republic of the Congo.
variables. There are measures of pain intensity (one- E‑mail: [email protected]
dimensional) and measures of multiple dimensions of pain
(multidimensional). The one-dimensional tools are designed Submitted: 18‑Jul‑2021  Revised: 21-Jul-2021
Accepted: 23‑Jul‑2021   Published: 04-Sep-2021
to measure the presence or absence of pain and have been
frequently used in hospitals and/or clinics to obtain fast,
noninvasive, valid information on pain and analgesia. As for
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