Page 81 Guide to Pain Management in Low-Resource Settings

Pain History and Pain Assessment 69

How long should an assessment take? What are the challenges for pain
assessment with the young?
Th e time needed for assessment will vary according to
individual patients, their presenting problems, and the Th e term “the young” refers to children of varying ages
specifi c demands on clinic time. For example, the pa- and cognitive development: neonates (0–1 month); in-
tient may be in such severe pain that they are unable fants (1 month to 1 year); toddlers (1–2 years); pre-
to provide any meaningful information to produce a schoolers (3–5 years); school-aged children (6–12
comprehensive pain history. Similarly, there will be oc- years); and adolescents (13–18 years). Children at each
casions when the assessment has to be relatively brief stage of development pose distinct challenges to eff ec-
(investigating the intensity, quality, and location of the tive pain assessment.
pain) so that urgently required eff ective pain manage-
ment can be provided quickly. Neonates (0–1 month)
It is also important to remember that, in gen- At this age, behavioral observation is the only way to
eral terms, it is the quality of the pain assessment that assess a child. Observation can be conducted with the
results in eff ective pain management rather than the involvement of the child’s family or guardian, who can
quantity of time spent on it. advise on what are “normal” and “abnormal” behav-
ior patterns (e.g., whether or not the child is unusu-
Does pain assessment diff er ally tense or relaxed). Importantly, for all children,

with children and young people? the health care provider should follow national ethi-
cal guidelines concerning the presence of a parent or
Th e response to this question is mixed. On the one guardian at the assessment process and any associated
hand, no, it does not, because, despite the previously issues (e.g., informed consent). Additionally, it must be
held misconception that children do not experience remembered that behavior is not necessarily an accurate
pain due to underdeveloped neurological systems, indicator of the patient’s pain level and that the absence
children do feel pain. Consequently, an eff ective pain of behavioral responses (e.g., facial expressions such as
assessment process is as important for children as it is crying and movements indicating discomfort) does not
for adults. always equate with the absence of pain.
On the other hand, yes it does, because the ex-
Infants (1 month to 1 year)
pression and detection of children’s pain can be more
challenging than it is for adults (see below). At this age, the child may exhibit body rigidity or
thrashing, exhibit facial expression of pain (e.g., brows
Is there a specifi c assessment lowered and drawn together, eyes tightly closed, mouth
process for children open and squarish), cry intensely or loudly, be inconsol-
able, draw the knees to the chest, exhibit hypersensitiv-
and young people? ity or irritability, have poor oral intake, or be unable to
sleep. Th e issues raised above for neonates resonate for
Th e specifi cs of assessing pain in children have given
infants, too.
rise to the “QUESTT” approach:
Question the child if verbal, and the parent or guardian Toddlers (1–2 years)
in both the verbal and nonverbal child. Toddlers may be verbally aggressive, cry intensely, exhibit
Use pain rating scales if appropriate. regressive behavior or withdraw, exhibit physical resis-
Evaluate behavior and physiological changes. tance, guard the painful area of the body, or be unable to
Secure the parent’s involvement. sleep. While toddlers may still be unable to communicate
their feelings verbally, their behavior can express their
Take the cause of pain into account.
emotional and physical disposition. At this age, generat-
Take action and evaluate the results (Baker and Wong ing an accurate assessment of the location and severity of
1987). the child’s pain may require the use of play and drawings,

off ering children a nonverbal means of expressing what
they are feeling and thinking. However, some children,