PAIN ASSESSMENT TOOL FOR
CHILDREN
Pain is defined as an unpleasant feeling that is
conveyed to the brain by sensory neurons. The
discomfort signals actual or potential injury to
the body.
It tells you something may be wrong. It
can be steady, throbbing, stabbing, aching,
pinching, or described in many other ways.
Sometimes, it's just a nuisance, like a mild
headache. Other times it can be debilitating.
Factors to Consider When Assessing
Pain pain in certain special populations can be challenging and
Assessing
requires multiple considerations such as:
• Age
• Level of development
• Communication skills/language
• Cognitive skills
• Prior pain experiences
• Associated beliefs
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Examples of Pain
Scales
Pain Scales* Verbal, Alert and Oriented Non-verbal, GCS <15 or Cognitive Impairment
Pediatric 3 yo and older Birth – 6 mos
1. Wong Baker Faces 1. Neonatal Infant Pain Scale (NIPS)
2. Oucher (3-12yrs) 2. Neonatal Pain Assessment and Sedation Scale (N-PASS)
3. Numerical Rating Scale (NRS) 3. Neonatal Facial Coding System (NFCS)
(7-11yrs) 4. CRIES
8 yo and older Infant and older
4. Visual Analogue Scale (VAS) 5. Revised Faces, Legs, Activity, Cry, and Consolability
5. Verbal Numeric Scale (VNS)/ (r-FLACC)
Numeric Rating Scale (NRS) 6. Non Communicating Children’s Pain Checklist
(NCCPC-R)
7. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
*This is a short list of pain scales. Determine which pain assessment tools are used by your agency or facility.
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To learn more about the different scales, visit PAMI
Pediatric Pain Scale
Descriptions
Measurement Scale Age Range Description
Birth - 6 months
Neonatal Infant Pain Scale (NIPS) Preterm and full term neonates Behavioral scale.
Neonatal Pain Assessment and Preterm and full term neonates Behavioral and physiologic scale.
Sedation Scale (N-PASS)
Facial muscle group movement, brow budge, eye squeeze, nasolabial
Neonatal Facial Coding System (NFCS) 32 weeks gestation to 6months furrow, open lips, stretch mouth lip purse, taut tongue, and chin
quiver
CRIES 32 weeks gestation to 6 months Behavioral and physiologic scale.
Infant and older (non-verbal children)
Faces, Legs, Activity, Cry, and 2 months to 7 years, critically ill, cognitively Behavioral scale. Scored in a range of 0–10 with 0 representing no
Consolability (FLACC) impaired, and older than three years of age pain. The scale has five criteria, which are each assigned a score of 0, 1
unable to utilize a self-report scale. or 2.
Non Communicating Children’s Pain 3-19 years (with cognitive impairment) 30 items that assess seven dimensions: vocal, eating/sleeping, social,
Checklist (NCCPC-R) facial, activity, body/limb, and physiologic signs
3 years and older
Wong Baker Faces 3 years and older Self-report scale. Please refer to specific references for those
alternative face scales.
Oucher 3 -12 years Self-report tool consisting of a vertical numerical scale and a photo
scale with expressions of “hurt” to “no hurt.”
8 years and older
8 years and older Self-report scale. Consists of pre-measured vertical or horizontal line,
Visual Analogue Scale (VAS) where the ends of the line represent extreme limits of pain intensity.
Requires understanding of numbers, addition and subtraction.
Verbal Numeric Scale (VNS)/ Numeric Self-report scale. Eleven point scale that requires understanding of
Neonatal Infant Pain Scale (NIPS)
Birth - 6 months
Behavioral scale for Preterm and full term neonates
The NIPS (Lawrence et al., 1993) was developed at Children’s Hospital of Eastern Ontario. The NIPS assesses six behavioral indicators in response to
painful procedures in preterm newborns (gestational age < 37 weeks) and full-term newborns (gestational age > 37 weeks to 6 weeks after de6li9very).
How to use NIPS:
• Observe the baby for one minute before selecting a score for each behavior.
• Select only one numeric value per behavior.
Scoring/Documentation:
• Add the scores from the 6 individual behavior areas to generate a total NIPS score.
• NIPS has a range from 0 to 7 possible.
• Document the total NIPS score in the medical record.
Interpretation:
• Does not provide pain intensity rating
• Any score greater than 2 indicates the possibility of the presence of pain in the
patient:
• Continue evaluation to identify the potential source of pain and implement
appropriate nonpharmacologic and/or pharmacologic interventions.
• Re-assess patient per frequency of local pain policy.
• If upon reassessment the total NIPS score remains >2 consider pharmacologic
intervention.
Neonatal Pain Assessment and Sedation Scale
(N-PASS)
Birth - 6 months a behavioral & physiologic scale for Preterm and full term neonates
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SEDATION PAIN/AGITATION
How to Use • Sedation does not need to be assessed/ Observe the infant for a minute before selecting
scored with every pain assessment score for each behavior.
• Observe the infant for a minute before • Select only one numeric value per behavior.
selecting a score for each behavior
.• Select only one numeric value per
behavior.
Scoring/ • Sedation scores are negative scores only Pain/Agitation scores are positive scores only
• Add the scores from the 5 individual • Determine if scoring needs to be adjusted based
Documentation behavior areas to generate a total NPASS on the patient’s gestational age. See Premature
Sedation score. (Do not add points for Pain Assessment criteria.
correcting gestational age) • Add the scores from the 5 individual behavior
• NPASS Sedation total score has a range areas and for corrected gestational age (if
from 0 to -10 possible. indicated) to generate a total NPASS
• Document total NPASS Sedation score in Pain/Agitation score.
the medical record. • NPASS Pain/Agitation total score has a range
from 0 to 13 possible.
• Document the total NPASS Pain/Agitation score
in the medical record
SEDATION PAIN/AGITATION
Interpretation • Desired levels of sedation vary according Does not provide pain intensity rating.
to the situation. • Any score greater than 3 indicates the
• Discuss and determine sedation goal with possibility of the presence of pain in the
provider. infant
• “Deep sedation”: goal score of -10 to -5 • Continue evaluation to determine
• Deep sedation is not recommended unless individualized patient interventions
an infant is receiving ventilator support, (non-pharmacological and
related to the high potential for pharmacological).
hypoventilation and apnea • Reassess patient per frequency of local
• “Light sedation”: goal score of -5 to –2 pain policy.
• Reassess patient per frequency in local • If upon reassessment, the NPASS
sedation policy pain/agitation total score remains
• A negative score without the consistent or higher, consider
administration of opioids/ sedatives may pharmacologic intervention.
indicate:
• The premature infant’s response to
prolonged or persistent pain/stress
• Neurologic depression, sepsis, or other
pathology
N- PASS
Paralysis/Neuromuscular blockade
• It is impossible to evaluate behaviorally a paralyzed infant for pain.
• Infants will usually have a sedation score of -10.
• Increases in heart rate and blood pressure at rest or
stimulation may be the only indicator for a need of more analgesia.
Faces, Legs, Activity, Cry,
(FLACC) and Consolability
(Non Verbal) 2 months to 7 years, critically ill, cognitively
impaired, and older than three years of age unable to utilize a self-report scale.
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How to use:
• Observe the patient for a minute before selecting a score for each
behavior.
• Select only one numeric value per behavior.
Scoring/Documentation:
• Add the scores from the 5 individual behavior areas to generate a total
FLACC score.
• FLACC has a range from 0 to 10 possible.
• Document total FLACC in the medical record.
Interpretation:
• Does not provide pain intensity rating
• Any score between 1 and 10 can indicate the possibility of the presence of
pain in the patient:
• Continue evaluation to identify the potential source of pain and implement
appropriate non-pharmacologic and/or pharmacologic interventions.
• Re-assess patient per frequency of local pain policy.
• If upon reassessment the total FLACC score remains consistent or higher
consider pharmacologic intervention.
R-FLACC:
Revised face, legs, activity, cry and consolability
Behavior observation pain assessment tool indicated for use with infants 2 months to 18 years of age with a cognitive disability and is unable to self-report
their pain. Used primarily in pediatric non-ICU areas, ED, pediatric pre-op and post-op surgery, PICU and home care
BEHAVIOR SCORING DESCRIPTION Score
INDICATORS
0 1 2
FACE No particular expression or Occasional grimace or frown, Frequent to constant quivering chin,
smile withdrawn, disinterested, sad appears clenched jaw, distressed looking face,
worried expression of fright/panic
LEGS Normal position or relaxed, Uneasy, restless, tense, occasional Kicking, or legs drawn up, marked
usual tone & motion to tremors increase in spasticity, constant
limbs tremors, jerking
ACTIVITY Lying quietly, normal Squirming, shifting back and forth, Arched, rigid or jerking, severe
positions moves easily, tense, tense/guarded movements, agitation, head banging, shivering,
regular, rhythmic mildly agitated, shallow/splinting breath holding, gasping, severe
respirations respirations, intermittent sighs splinting
CRY No cry, (awake or asleep) Moans or whimpers; occasional Crying steadily, screams or sobs,
complaint, occasional verbal outbursts, frequent complaints, repeated
and/or grunting outbursts, constant grunting
CONSOLABILITY Content, relaxed Reassured by occasional touching Difficulty to console or comfort,
hugging or being talked to, distractable pushing caregiver away, resisting care
or comfort measures TOTAL R-FLACC S
How to use:
• Observe the patient for a minute before selecting a score for each
behavior
• Select only one numeric value per behavior.
Scoring/Documentation:
• Add the scores from the 5 individual behavior areas to generate a total
R-FLACC score.
• R-FLACC has a range from 0 to 10 possible.
• Document the total R-FLACC in the medical record
Interpretation:
• Does not provide pain intensity rating
• Any score between 1 and 10 can indicate the possibility of the presence
pain in the patient:
• Continue evaluation to identify the potential source of pain and
implement appropriate non-pharmacologic and/or pharmacologic
interventions. Partner with patient’s caregivers to identify appropriate
interventions.
• Re-assess patient per frequency of local pain policy.
• If upon reassessment the total R-FLACC score remains consistent or higher
consider pharmacologic intervention
Wong–Baker Faces Pain Rating Scale (3 years and older )
- is a pain scale that was developed by
Donna Wong and Connie Baker. The scale shows a
series of faces ranging from a happy face at 0, or
"no hurt", to a crying face at 10, which represents
"hurts like the worst pain imaginable".
- It is most preferred by physicians, parents
and children. It proves to be an inexpensive, yet
easy to use, pain scale, these factors are important,
as measuring pain in children who can be extremely
difficult
Children rating their pain on the Wong-Baker Faces Pain Rating Scale
are better able to communicate their level of pain, than in other pain
scales. A concern arises with children who do not cry with pain or are
embarrassed to choose a face with tears. Although no pain-rating scale is
efficient for all children, the Wong-Baker Faces Pain Rating Scale seems to
work best.
Adults with language barriers also benefit
from this type of pain scale. The Wong-Baker
Faces Pain Rating Scale has proven to be a valid
and reliable pain scale.
The scale consists of six faces that
range from no pain at all to the
worst pain imaginable. The
emotional faces range from smiling
to grimacing..
How to use:
• Show patient faces scale.
• Explain the tool, “These faces show how much something can hurt.” Point to zero picture
and state, “This one shows no pain.” Point to ten picture and state, “This one shows worst
pain experienced”.
• Ask patient, “What face best represents your pain level right now?”
Scoring/Documentation:
• Faces Pain Scale-Revised has a range from 0 to 10 possible.
• Document score in medical record; this includes 0 for no pain.
Interpretation:
• 0 to 3 mild pain
• 4 to 6 moderate pain
• 7 to 10 severe pain
• Compare the patients acceptable level of pain to the patients current self-report of pain to
determine level of intervention. This may include non-pharmacologic and pharmacologic
interventions.
• Reassess patient per frequency of local pain policy
Visual Analogue Scale Self-report scale for 8 years and older
. Consists of pre-measured vertical or horizontal line, where the ends of the line represent extreme limits of pain intensity. Requires understanding of
numbers, addition and subtraction.
Verbal Numeric Scale (VNS)/ Numeric Rating
Scale (NRS)
This is the gold standard for obtaining a self-reported pain
level. This scale may be used in any care setting for patients
8 years old and older who are able to self-report their pain
and understand the numeric scale.
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How to use:
Ask the patient, “On a scale from 0 to 10 where 0 is no pain and 10 is the worst pain you’ve
experienced, at this moment, what number represents your overall pain level?”
• Patient to select one whole value Scoring/Documentation:
• Numeric has a range from 0 to 10 possible.
• Document score in medical record (this includes 0 for no pain).
Interpretation:
• 0 to 3 mild pain
• 4 to 6 moderate pain
• 7 to 10 severe pain
• Compare the patient’s acceptable level of pain to the
patient’s current self-report of pain to determine level of
intervention. This may include non-pharmacologic and
pharmacologic interventions.
• Reassess patient per frequency of local pain policy
