Page 386 Acute Pain Management

A reduced scale with five items (brow bulge, eye squeeze, nasolabial furrow, horizontal mouth
stretch and taut tongue) has been found to be a sensitive and valid measure of postoperative
pain in infants ages 0 to 18 months (Peters, Koot, Grunau et al, 2003). In neonatal intensive care,
facial actions were found to be more reliable than physiological measures for evaluating pain
responses (Stevens, Franck et al, 2007), but may be dampened in preterm neonates (Holsti &
Grunau, 2007) in whom cortical responses to pain have been demonstrated in the absence of a
change in facial expression (Slater et al, 2008).
Many neonatal pain assessment tools have not been rigorously evaluated, but the following
are widely used (McNair et al, 2004; Howard et al, 2008) (see Table 10.1 and 10.2):
• acute procedural pain — PIPP, Cries, Requires oxygen, Increased vital signs, Expression,
Sleeplessness (CRIES), NFCS;
• postoperative pain — PIPP, CRIES; and
• intensive care — COMFORT.

10.3.2 Observational and behavioural measures in infants
and children

Many scales incorporate both physiological and behavioural parameters to determine an
overall pain score and may result in more comprehensive measurement (Franck et al, 2000).
Some examples are included in Table 10.2 but a wider range of measures, their strengths and
limitations, and issues of testing reliability and validity have been reviewed (Johnston et al, 2002;
von Baeyer & Spagrud, 2007; McGrath et al, 2008). In infants and young children, behavioural items
that predicted analgesic demand in the postoperative period were crying, facial expression,
posture of the trunk, posture of the legs and motor restlessness (Buttner & Finke, 2000).
There is still no single gold standard for pain assessment as requirements vary with the age
and developmental stage of the child, the type of pain (eg procedural vs postoperative), and
the context (eg clinical utility versus research reliability). Based on current data the following
observational / behavioural measurement tools were recommended for pain measurement in
infants 1 year and above (McGrath et al, 2008 Level I), children and adolescents (von Baeyer &
Spagrud, 2007 Level I) (see Table 10.2).
• acute procedural pain — Face Legs Activity Cry and Consolability (FLACC) and Children's
Hospital of Eastern Ontario Pain Scale (CHEOPS);
CHAPTER 10 • postoperative pain — FLACC;

• postoperative pain managed by parents at home — Parents Postoperative Pain Measure
(PPPM); and
• intensive care — COMFORT.

10.3.3 Self-report in children and adolescents
Self‐report of pain is preferred when feasible, and is usually possible by 4 years of age, but this
will depend on the cognitive and emotional maturity of the child. Scales for self‐report need to
consider the child’s age, ability to differentiate levels of intensity, and to separate the
emotional from the physical components of pain. It is important that a measurement tool be
used regularly and uniformly within each centre as staff familiarity and ease of use are major
factors in the successful implementation of a pain management strategy. At 4 to 5 years of
age, children can differentiate ‘more’, ‘less’ or ‘the same’, and can use a Faces Pain Scale
(Figure 10.1) if it is explained appropriately and is a relatively simple scale with a limited
number of options. At this age, children have some capacity to appraise current pain and
match it to previous experience but they are more likely to choose the extremes of the scale
338 Acute Pain Management: Scientific Evidence