Page 272 Guide to Pain Management in Low-Resource Settings

260 Dilip Pawar and Lars Garten

or draw a picture illustrating their perception of pain. A pain, a combination of (1) questioning the child and
widely used and appropriate pain assessment scale is the parents, (2) using a pain rating scale, and (3) evaluating
Faces pain rating scale (recommended for children age 3 behavioral and physiological changes is recommended.
years and older) (Fig. 3).
How can you assess pain
Do children always tell you in infants and toddlers?
when they are in pain? Parents, caregivers, and health professionals are con-
Even when they have adequate communication skills, stantly challenged to interpret whether the distressed
there are some reasons children may not report pain. behaviors of infants and children, who cannot self-
Children may be frightened of (1) talking to doctors, report, represent pain, fear, hunger, or a range of other
(2) fi nding out they are sick, (3) disappointing or both- perceptions or emotions. A range of behavioral distress
ering their parents or others, (4) receiving an injection scales for infants and young children have been devised.
or medication, (5) returning to hospital or delaying dis- Facial expression measures appear to be the most useful
charge from hospital, (6) having more invasive diagnos- and specifi c in neonates. Typical facial signs of pain and
tic procedures, or (7) having medication side eff ects. physical distress in infants are: (1) eyebrows lowered
And after all, children just may not think it is necessary and drawn together; (2) a bulge between the eyebrows
to tell health professionals about their pain. Th us, par- and vertical furrows on the forehead; (3) eyes sightly
ents should always be asked for their observations re- closed; (4) cheeks raised, nose broadened and bulging,
garding the child’s situation. So even in children whose deepened nasolabial fold; and (5) open and squarish
cognitive development should allow them to report mouth (Fig. 4).

Fig. 4. Facial expression of physical distress and pain in the infant.
Fig. 3. Faces Pain Rating Scale. Original instructions: Explain to the (From: Wong DL, Hess CS. Wong and Whaley’s clinical manual
person that each face is for a person who feels happy because he has of pediatric nursing, 5th ed. St Louis: Mosby; 2000. Reprinted
no pain (hurt), or sad because he has some or a lot of pain. Face 0 with permission.)
is very happy because he doesn’t hurt at all. Face 1 hurts just a little
bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts
a whole lot. Face 5 hurts as much as you can imagine, although you Th e FLACC Scale (Fig. 6) is a behavioral pain
don’t have to be crying to feel this bad. Ask the person to choose
the face that best describes how he is feeling. Brief word instruc- assessment scale for use in nonverbal patients unable to
tions: Point to each face using the words to describe the pain inten- provide reports of pain. It is used for toddlers from 1 to
sity. Ask the child to choose face that best describes their own pain 3–4 years of age and for cognitively impaired children of
and record the appropriate number. Continuous use of a pain assess-
ment scale for monitoring the eff ectiveness of pain therapy is recom- any age). Each of the fi ve categories is scored from 0–2,
mended. (From: Whaley LF, Wong DL. Nursing care of infants and which results in a total score between 0 and 10.
children, 3rd ed. St Louis: Mosby; 1987. Reprinted with permission.)