Pain assessment in children

Abstract

Causes of childhood pain include peri-procedural, injury and disease. Systematic reviews have shown that pain can lead to anxiety, sleep disturbance, and have deleterious effects on daily life.

Experienced pain is influenced by biological, psychological and social factors. Pain assessment in children is particularly challenging due to the wide variation in physiological responses, communication abilities and developmental stages of this group of patients. For example, their limited verbal repertoire can lead to an under-recognition of pain as compared to adults who may be better able to articulate their pain.

Childhood pain has an effect in the short-term not only on the child but their carers. Long-term effects of unrecognized, undertreated or poorly managed pain can lead to important cognitive and behavioural consequences. This can lead to anticipatory anxiety and can lead to more difficulty in management of pain during future episodes of illness or future treatments.

Well-managed pain is associated with faster recovery, fewer complications and decreased health care resources. Regular assessment and documentation of pain, using appropriate tools for development age and ability, is essential in order to assess efficacy of pain treatments.

Learning objectives

After reading this chapter you should be able to:

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discuss different methods used to assess pain in children
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select the appropriate method to assess pain for age group and developmental stage
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list biological, psychological and social factors predisposing to pain perception

Pain assessment in children

Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness and medical procedures. Pain assessments in this group of patients can be challenging due to some children not being able to verbalize the quality and severity of pain.

Mechanisms and perceptions leading to pain can be affected by age and developmental stage as well as previous exposure. To fully evaluate pain, biological drivers for pain should be sought as well as psychological and social elements.

The gold standard for measuring pain is self-report, whereby the child directly describes their experience. Depending on the age of the child, different measures of self-report can be used.

However, this is not always possible and other indirect measures, including biological observations, physiological responses and facial expression are used.

Effective pain management in children requires a nuanced understanding of these assessment tools and methods, tailored to each child’s individual needs and developmental stage.

History-taking

Predisposition to pain occurs with depressive symptoms, anxiety and adverse life events: asking about these factors can help to highlight those more likely to experience more significant pain. Social and developmental contexts are also important in the perception of pain and thus should be asked about and considered.

Asking about how the pain affects daily life and activities and general mood, what improves/worsens pain, and understanding the impact of pain on every day activity helps to contextualize pain and its effect on the patient in front of you.

Recognizing, understanding and eliminating inequity

By recognizing that perception of pain is influenced by social and cultural factors and understanding previous misconceptions, we can help to reduce inequity in recognition and treatment of pain.

For example, patients with sickle cell disease are mostly of African heritage. It is well recognized that their pain treatment can be under recognized and undertreated.

Children and adolescents with disabilities have been found to have their postoperative pain assessed less often and receive fewer opioids and fewer days of opioid pain management than children and adolescents without disability.

Assessing pain

The assessment should be tailored to the individual paediatric patient, to their developmental stage and to their communication abilities. Communication should also include their care-givers responses as they may be best able to understand the child.

Assessing pain in children involves a few key approaches tailored to their developmental stage and communication abilities.

The gold standard for pain reporting for children is self-report using the following self-report tools.

Self-report tools

In order to use a numerical rating scale, children need to have developed the cognitive ability to assign a number to an experience and express this.

Tools like the Wong–Baker FACES Pain Rating Scale or the Numerical Rating Scale (1–10) let children indicate their pain level using faces or numbers.

A systematic review looking into recommendations for selection of self-report pain intensity measures in children and adolescents identified 60 separate pain intensity assessments.

It is important to be able to standardize pain rating scales. This work is ongoing.

For children >6 years with acute pain, they strongly recommended use of the Numerical Rating Scale .

a)

Numerical Rating Scale (NRS) (see Figure 1 )
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  Description : Children rate their pain on a scale from 0 to 10, with 0 meaning no pain and 10 representing the worst pain imaginable.
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  Age range : Suitable for children aged 6 and older, or younger if they understand the concept of numbers.
b)

Wong–Baker FACES scale (see Figure 2 )
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  Description : This tool uses a series of faces with expressions ranging from happy (no pain) to crying (worst pain). Children point to the face that best represents their pain.
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  Age range : Typically used for children aged 3 and older
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  Research show validation for Caucasian, African-American, Hispanic, Thai, Chinese, and Japanese children
c)

FACES Pain Scale-Revised (FPS-R)
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  Description : This scale is similar to the Wong–Baker FACES but includes more detailed facial expressions and is used for children who can understand and differentiate expressions better.
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  Age range : Often used for children aged 4 and older
d)

Colour Analogue Scale (see Figure 3 )
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  Description: There are several versions of this. This scale uses traffic light colours to indicate level of pain, with red being severe pain and green being none.
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  Age range : children >8 years