In young patients, no single measure can provide all the information needed to properly assess pain. Yet if we use too many tools and approaches, we can create confusion and inefficiency. Here are some steps you can take to simplify and standardize your pediatric pain-assessment program.

Use numbers, FACES, then fingers
Since pain is subjective, the self-report is the best measure of pain, and practitioners should use it whenever possible. Pediatric patients can self-report pain in different levels of detail, depending on age. Young children, for example, typically don't have the life experiences needed to quantify pain, nor do they have the cognitive skills needed to understand the concept of magnitude. As a result, these patients will often assign extremes of either 0 or 10 to their pain. To effectively solicit a self-report from young patients, then, consider these guidelines:

• Numeric scale for older patients. For capable, older pediatric patients, numeric scales elicit the best, most detailed measure of pain intensity. One good numeric scale is the 0-to-10 pain scale positioned vertically, rather than horizontally, to illustrate the concept of escalating pain (Fig. 1). To be able to use the scale, patients must:
  
  >> Be at least 7 to 9 years old. The ability to describe pain intensity and the nature or type of pain typically begins around 8 years of age. Younger children typically don't have the life experiences needed One study showed that just 26 percent of 5-year-olds have the cognitive skills needed to use numeric pain scales.1
  
  >> Understand rank order. You can quickly evaluate a patient's understanding of numeric relationships by asking the patient which of two numbers (7 or 4, for example) is bigger and which of two numbers (3 or 8, for example) is smaller.
  
  >> Understand magnitude. To determine a child's understanding of magnitude, ask the patient to place three blocks in ascending order of size (small, medium and large, for example).
• Wong-Baker FACES scale for younger patients. If patients are unable, reluctant or too young to use a numeric scale, consider FACES (Fig. 2). This tool is simple, easy to reproduce and, according to one study, preferred by most children 3 to 18 years old.2 Patients must be at least 3 years old to use this tool; most children of this age have the ability to classify, match and estimate.

• Finger Span Scale. For pediatric patients who find it hard to use these other self-reporting tools, or when language barriers inhibit communication, try the Finger Span Scale (Fig. 3). This tool is simple, visual and always in your pocket. Simply ask the child or parent(s) before surgery what word they use to express pain (such as "hurt" or "ache"). During the pain assessment, show the child how the span between your thumb and forefinger represents the amount of pain or "hurt," and ask the patient to use his fingers to show "how big his hurt is now." Children may not know numbers, but they do know who gets the bigger piece of cake.

Many factors can determine a child's ability to self-report pain - including cognitive development, illness, therapeutic restrictions like sedation, language barriers and overall reluctance or anxiety. When using a self-report, consider all these factors, and use the tool that best suits the patient at the time. In addition, it helps to review all assessment tools with patients and their families pre-operatively.

Define site/type of pain
Children as young as 2 or 3 years of age can indicate pain and point to it, and this is important because the location of pain indicates the source (incisional pain versus bladder spasms, for example). At about 8 years of age, children usually have a sufficient vocabulary and enough life experience to describe their type of pain, as well as the location. For example, words such as "stabbing" or "cutting" typically describe incisional pain, and words like "cramping" can describe spasms or pressure in a casted arm or leg. These older pediatric patients can also tell you how long their pain lasts. For these patients, it's important to determine which words the child uses for pain, anxiety and distress before surgery. This is key to uncovering how the child is feeling post-operatively.

Evaluate behavior
It's important to evaluate behavior in all children; they tend to have barriers to communication just as adults do. Sometimes, children are expected to be brave; other times, they fear an injection or they complain. When children are unable to report pain, whether due to young age or disability, behavioral observation becomes the primary approach to pain assessment. The Face, Legs, Activity, Cry and Consolability (FLACC) scale is an established, reliable, easy-to-use tool for evaluating behaviors in patients from 2 months to 16 years of age (Fig. 4).

There are two keys to a good behavioral assessment. First, it's critical to consider the context. A child may be screaming not because he is in pain but because he is very hungry or anxious. Alternately, sleeping and withdrawal can indicate that the child is attempting to control pain by limiting movement and interaction. In these cases, reconsider the child's consolability. If, for example, he remains inconsolable after eating and your attempts to soothe him fail, a trial of medication is warranted. Second, don't be judgmental. That is, don't let the magnitude of the procedure influence your interpretation of the child's behavior. Minor surgeries can produce major pain in some children. Pain is a very individual experience, and situational factors like fear, anxiety and PONV can increase the physiologic response to pain. Let your assessment, not your beliefs, guide your decisions.

Get parents involved
Parental input is helpful before surgery, for identifying how a child describes and responds to pain, and after surgery, for identifying the presence of pain. But parents tend to underestimate the degree of pain because their own beliefs and anxiety factor into their assessment. Solicit parental input, but rely on your tools for defining the intensity of pain.

Simple and standardized
It's possible that, even after a thorough assessment using all these tools, you'll still be uncertain if pain exists. In this case, it's reasonable to begin an analgesic trial if you have a good reason to suspect pain.

Taken together, however, these few tools and an understanding of how to use them will help you better assess pain in pediatric patients. You're left with a simple and effective pain-assessment program.

References

1. Fanurik D, et al. Pain assessment in children with cognitive impairment: An exploration of self-report skills. Clin Nurs Res. 1998;7(2):103-19. 2. Keck JF, et al. Reliability and validity of the FACES and word descriptor scales to measure procedural pain. J Pediatr Nurs. 1996;11:363-74.