This resource serves as an introduction to understanding the sensation and expression of pain as well as how to assess pain in children. Although the manifestation and expression of pain are visible, the cause is often not readily apparent and multifactorial. The total pain of a patient may include psychological, mental health, nociceptive, deconditioning, nerve pain, social or contextual elements of life experience, spiritual, visceral pain, school attendance, racial disparities, delirium, and withdrawal. There are a multitude of tools and scales to assess the quality, intensity, and functional components of pediatric pain depending on age, developmental stage, and functional ability.

Expression of pain
Pediatric pain expression is a manifestation of social communication. Total pain (physical, emotional, spiritual, and social factors) can affect a child’s experience and expression of pain.

Assessment tools
Examples of pain scoring scales are Numeric, FACES, Simplified Rating Scale, R-FLACC, and Individualized Numeric Rating Scales.

Treatment
Bundled treatment strategies may inform treatment decisions and improve success in relieving acute or chronic pain. See Pain Management for different types of treatment.

There are no practice guidelines for the assessment of pediatric pain.

Pain occurs when an injury is inflicted, and the sensation is sent from the injury site to the brain. Pain due to an injury is transmitted through neuronal tracts in the spinal cord and travels to the brain’s thalamus and periaqueductal gray, leading to the feeling of pain. Facilitatory ascending inputs, such as stress, anxiety, depression, and poor sleep hygiene, can increase the perception of inhibitory ascending inputs, such as distractions, proper sleep, school attendance, and exercise, can decrease the perception of pain. In addition, there are neurothalamic tracts that can attenuate or reduce the source of pain.

Although pharmacotherapy is one tool to mitigate physical pain, depending on the development and strength of other neurologic tracts, there may be important adjuncts for treatment. Utilizing facilitatory ascending input strategies such as stress reduction, sleep management, and optimization of school attendance may help with pain. In addition, optimizing inhibitory influence through distraction, medical hypnosis, exercise, and rehabilitation may be important components of a treatment strategy.

Pain as a concept is informed by the person who experiences and expresses it, the features of the pain they are experiencing, and the person’s caregivers. Expression of pain is a form of social communication for pediatric patients and their caregivers. Contextual components of pain include the cause, the psychosocial environment, and an individual’s biology and chronic conditions. The context of the patient and the caregiver can sometimes be different and worth exploring. [Hamill: 2014] In addition, clinicians should be aware of the reactions and experiences that may influence our interpretation of expressed pain. Researchers have developed a concept known as total pain. Total pain includes physical and tissue injury causing pain, psychological components (anxiety, hopelessness, lack of control), social aspects of pain (fear of dependency, wheelchair), and spiritual feelings (despair, existential distress, disconnection). [Mehta: 2008]

Assessment can help differentiate nociceptive (tissue injury), visceral pain (midline organ injury), neuropathic (nerve injury), or psychological distress causing pain. These different types of pain can lead to significantly different treatment plans, outlooks, and outcomes. It is important to look at more than just a number rating scale, which is less informative than an assessment of severity, location, quality of pain, and social and psychological factors. Some scoring systems attempt to objectively and reliably rate pain based on behavioral observations. Behavioral cues, such as crying/vocalization, facial expressions, and engagement, may help a provider assess the overall situation. As clinicians work to address pain, continued assessment is required to optimize treatment.

Studies have shown that when evaluating pain in children, kids can be reliable at pointing to an anatomic location. When using a body map, kids can identify locations about 75% of the time, though they may confuse anatomic left and right. When assessing the degree and intensity of pain, self-reporting is most helpful. [Hamill: 2014]

Behavioral Cues
In addition to scales, behavioral cues should also be observed as an indicator of pain. Examples of informative behavior cues are calmness, agitation, alertness, and facial tension or grimacing. However, behavioral cues are also distress indicators and can indicate other negative emotions or symptoms, such as psychological distress.

Domains of Assessment
Evaluation of pain includes an assessment of the location, severity, quality, and impact of pain. Assessment of pain quality can help create a goal of treatment. The location of pain may be visible, occult, or psychological, thus it is important to ask about the location of pain. Appropriate questions regarding quality of pain include descriptors such as numbness, hypersensitive, burning sensation, boiling, warm, cold, snow, shooting or needles poking while being mindful of a child’s developmental level in use of descriptors. Assessment of the impact of pain on function and life can be an indicator of the severity of pain. PROMIS Pediatric Pain Interference study developed a scaled tool to assess physical function as an element of pain experience. The PROMIS Pediatric Pain Interference Scale includes questions regarding concentration, standing, sleeping, and enjoyment, with answers such as never, almost never, sometimes, often, and almost always.

Numeric and Faces Rating Scales
The most used pain rating scales are the Numeric and FACES Pain Rating Scale (Wong-Baker Foundation) rating systems. They are most helpful in assessing treatment effectiveness; however, they are less useful for assessing the severity of pain. The FACES scale is validated in children ages 8 years old and older. Younger children may struggle to think of pain this way and may do better with the Simplified Rating Scale (below). Numeric scales are most helpful for patients who have used them in the past and those who struggle with chronic pain.

Simplified Rating Scales
The Simplified Rating Scale is a 2-point scale that is most helpful to assess treatment effectiveness or severity of pain in children ages 4 and older. Questioning may begin with a simple question, “Is the pain present, yes or no?” If yes, follow up with a much-abbreviated version of the scales, such as “Is your pain a little? A bit more? Or a lot?” along with gestures describing the size of the pain if helpful to the child. It should be noted that the expression of the pain in the situation is important data that may give a clinician more information than a simple scale. [von: 2013] [von: 2017]

R-FLACC
The Revised Face, Legs, Activity, Cry and Consolability (R-FLACC) is a behaviorally based scoring system to assess pain in children with cognitive impairment. [Malviya: 2006] Consolability refers to the ability of an intervention to impact the child’s perceived pain.

• Face: Stern face, eyes wide open, look surprised
• Legs: Drawn to center, clonus in left leg, legs tremble, stillness
• Activity: Grabs site, nods head, clenches fist, head shaking
• Cry: “I’m ok,” “All done,” “No,” grunting, shouting
• Consolability: responds to stroking - but distant and unresponsive.

R-FLACC is a helpful tool but is not always sensitive to the unique manifestations seen in the diverse groups of children with cognitive impairment. About 40% of children with cognitive impairment have unique behaviors such as picking, clonus, dystonia, or biting that are difficult to capture in a standardized system.

Individualized Numeric Rating Scale (INRS)
The INRS was developed as a pain assessment and treatment guide for caregivers of children with severe illness, cognitive impairment, or intellectual disabilities. INRS is a personalized and individualized scale based on potential signs and symptoms of discomfort that is reviewed by the family along with a clinician familiar with INRS. [Solodiuk: 2010] [Solodiuk: 2003] The Individualized Numeric Rating Scale (INRS) is free tool available online.

Abdomen pain, R10.-

Back pain, M54.9

Breast pain, N64.4

Chest pain, R07.1-R07.9

Ear Pain, H92.0-

Eye pain, H57.1

Headache, R51

Joint pain, M25.5-

Limb pain, M79.6-

Lumbar region pain, M54.5

Pelvic and perineal pain, R10.2

Shoulder pain, M25.51-

Spine pain, M54.-

Throat pain, R07.0

Tongue pain, K14.6

Tooth pain, K08.8

Renal colic, N23

Pain disorders exclusively related to psychological factors, F45.41