Jennifer N. Stinson1,2,3, Kathryn A. Birnie4,5, & Petra Hroch Tiessen6 1 Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada 2 Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada 3 Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Ontario, Canada 4 Department of Anesthesiology, Perioperative, and Pain Medicine, University of Calgary, Calgary, Alberta, Canada 5 Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada 6 Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada This chapter provides an overview of the assessment of pain in children from neonates to adolescents. The difference between pain assessment and pain monitoring is highlighted and the key steps in pain assessment identified. Self‐report, observer‐report, behavioral and physiological indicators of pain in children are reviewed. Information about commonly used pain tools is provided and the factors that need to be considered when choosing a pain assessment tool are outlined. Finally, the need for clear documentation about pain assessment and how regularly pain assessment should be undertaken are also discussed. Pain in children occurs across a spectrum of conditions including everyday pains, acute injuries and medical events, recurrent or chronic pain and pain related to chronic disease. Pain assessment is the first step in the management of pain. Accurate assessment of children’s pain is needed to diagnose medical conditions and to guide pain management interventions [1,2]. To treat pain effectively, ongoing monitoring of the presence and severity of pain and the child’s response to treatment is essential. Pain assessment poses many challenges in infants and children because of: (a) the subjective and complex nature of pain; (b) developmental and language limitations that preclude comprehension and self‐report; and (c) dependence on others to infer pain from behavioral and physiological indicators. The important steps in assessing pain in children include: Assessment should be followed by ongoing monitoring of pain, having allowed time for pain‐relieving interventions to work. Parents and significant family members know their child best and can often recognize subtle changes in manner or behavior. They have a particularly important role in pain assessment [1]. Pain measurement generally describes the quantification of pain intensity (e.g. “How much does it hurt?”). The emphasis is on the quantity, extent or degree of pain. Pain assessment is a broader concept than measurement and involves clinical judgment based on observation of the nature, significance and context of the child’s pain experience [4]. Comprehensive pain assessment involves exploring the intensity of pain, location of pain, its duration, frequency, the sensory qualities (e.g. word descriptors), cognitive (e.g. perceived impact of pain on aspects of everyday life) and affective (e.g. pain unpleasantness) aspects of the pain experience [3]. Furthermore, contextual and situational factors that may influence children’s perception of pain should also be explored. This exploration helps healthcare professionals to make decisions regarding the most likely cause of the pain (nociceptive, neuropathic or mixed) and to choose the most appropriate intervention(s). Conducting a thorough history of the child’s prior pain experiences and current pain complaints is the first step in pain assessment. Standardized pain history forms have been developed for talking with children and parents/caregivers about the pain [5]. To assess pain of relatively brief duration, instruments measuring pain intensity, location and affect are typically used. For a child with chronic pain, a more detailed pain history needs to be taken that measures the frequency, duration, time course and activity interference due to pain (Table 9.1) [2,3]. The three approaches to measuring pain are self‐report (what the child says), behavioral (how the child behaves) and physiological indicators (how the child’s body reacts) [3]. These measures are used separately (unidimensional) or in combination (multidimensional or composite) in a range of pain assessment tools that are available to use in practice. The ideal would be a composite measure including self‐report and one or more of these other approaches [6,7]. Children’s self‐report of their pain is the preferred approach and should be used with children who are able to understand and use self‐report scales (e.g. 4–6 years of age and older) and are not overtly distressed [8,9]. With infants, toddlers, preverbal, non‐verbal, cognitively impaired and sedated children who are unable to self‐report, an appropriate behavioral or composite pain assessment tool should be used. Observer‐report of the child’s pain by a parent/caregiver or health professional can be used; however, it should not be considered equivalent to the child’s own report as observers tend to over or underestimate the child’s pain [10]. If the child is overtly distressed, no meaningful self‐report can be obtained at that point in time. The child’s pain can be estimated using a behavioral pain assessment tool until the child is less distressed [6]. More than 60 tools have been developed for self‐report of pain intensity by school‐aged children and adolescents; however, only those outlined below are considered well‐established with sufficient measurement properties for consideration in at least some children [8]. For a more in‐depth review of self‐report measures and their psychometric properties see the two reviews by Cohen et al. [2] and Birnie et al. [8]. A numerical rating scale (NRS) consists of a range of numbers (e.g. 0–10 or 0–100) which can be represented in verbal or graphic format. Children are told that the lowest number represents no pain/hurt and the highest number represents the worst pain or hurt you could ever imagine. The child is instructed to state, circle, or record the number that best represents their level of pain intensity. Verbal 11‐point NRS are the most frequently used pain intensity measure with children and are recommended for use for acute, postoperative, or chronic pain with children aged 6 or older who dis play numeracy skills [8]. Verbal NRS have the advantage that they can be verbally administered without a print copy and are easy to score. A high degree of agreement is shown between verbal NRS and those presented electronically [11]. Verbal NRS now have the most evidence examining their validity and reliability of all self‐report pain intensity scales with children [8]. Table 9.1 Pain history questions for children with chronic pain and their parents/caregivers Source: Stinson J. (2009) [3]. Reproduced with permission. Faces pain scales present the child with drawings or photographs of facial expressions representing increasing levels of pain intensity. The child is asked to select the picture of a face that best represents their pain intensity and their score is the number of the expression chosen. The Faces Pain Scale‐Revised [12]) uses line drawings and is strongly recommended for use with children aged 7 years and older [8]. The Wong‐Baker FACES Pain Rating Scale also uses line drawings. Its use is only weakly recommended as it is limited by the use of a face with tears to demonstrate the worst pain possible. This design is problematic as faces pain scales with a happy and smiling no pain face or faces with tears for most pain possible have been found to affect the pain scores recorded [13]. Therefore, faces pain scales with neutral expressions for no pain are generally recommended [13]. Other faces scales use photographs, such as the Oucher photographic, which is no longer a generally recommended tool [8]. In addition to faces scales for pain intensity, the Children’s Fear Scale is a faces scale with demonstrated measurement properties that asks children to self‐report their fear from not at all scared to the most scared possible [14]. The most commonly used graphic rating scale is the Pieces of Hurt Tool (also referred to as the Poker Chip Tool). This tool consists of four red poker chips, representing a little bit of hurt (one chip) to the most hurt you could ever have (four chips). The child is asked to select the number of chips that represents his/her pain intensity and the tool is scored from 0 to 4. Although, the Pieces of Hurt Tool was originally developed for use with young preschool children, its measurement properties suggest it is weakly recommended for use with children 6 years and older [8]. It should not be used for self‐report of postoperative or chronic pain. Additional drawbacks to its use include sanitizing the chips between patient use and the potential for losing chips [15].
Chapter 9
Measurement and assessment of pain in pediatric patients
Introduction
Comprehensive pain assessment in children
Obtaining a pain history
Approaches to measuring pain in children
Tools for assessing pain in children
Self‐report tools
Numerical pain scales
Description of pain
Type of pain Is the pain acute (e.g. postoperative pain), recurrent (e.g. headaches) or chronic (e.g. arthritis)?
Onset of pain When did the pain begin? What were you doing before the pain began? Was there any initiating injury, trauma or stressors?
Duration How long has the pain been present (e.g. hours/days/weeks/months)?
Frequency How often is pain present? Is the pain always there or is it intermittent? Does it come and go?
Location
Where is the pain located? Can you point to the part of the body that hurts? (Body outlines can be used to help children indicate where they hurt).
Does the pain go anywhere else (e.g. radiates up or down from the site that hurts)? Pain radiation can also be indicated on body diagrams.
Intensity
What is your pain intensity at rest? What is your pain intensity with activity?
Over the past week what is the least pain you have had? What is the worst pain you have had? What is your usual level of pain?
Quality of pain
School‐aged children can communicate about pain in more abstract terms.
Describe the quality of your pain (e.g. word descriptors such as sharp, dull, stabbing, burning, throbbing).
Word descriptors can provide information on whether the pain is nociceptive, nociplastic, or neuropathic in nature or a combination.
Associated symptoms
Are there any other symptoms that go along with or occur just before or immediately after the pain (e.g. nausea, vomiting, tiredness or difficulty ambulating)?
Are there any changes in the color or temperature of the affected extremity or painful area? (These changes most often occur in children with conditions such as complex regional pain syndromes).
Temporal or seasonal variations Impact on daily living
Is the pain affected by changes in seasons or weather?
Does the pain occur at certain times of the day?
Has the pain led to changes in daily activities and/or behaviors (e.g. sleep disturbances, change in appetite or mood, decreased physical activity, social interactions or school attendance)?
What level would the pain need to be so that you could do all your normal activities (e.g. tolerability)? What level would the pain need to be so that you won’t be bothered by it? (Rated on similar scale as pain intensity.)
What brings on the pain or makes the pain worse (e.g. movement, stress, etc.)?
Pain relief measures
What has helped to make the pain better?
What medication have you taken to relieve your pain? If so what was the medication and did it help? Were there any side effects?
It is important to also ask about the use of physical, psychological and complementary and alternative treatments tried and how effective these methods were in relieving pain (Chapter 28).
The degree of pain relief or intensity of pain after a pain‐relieving treatment/intervention should be determined.
Faces pain scales
Graphic rating scales
Visual analog scales
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