Pain Assessment in Pediatric Appendicitis
For a pediatric patient with appendicitis and severe pain, use the Faces Pain Scale-Revised (FPS-R) as the primary pain assessment tool, as it has the strongest psychometric properties and is validated for children aged 4 years and older. 1
Recommended Pain Scale Selection
Primary Choice: Faces Pain Scale-Revised (FPS-R)
- The FPS-R (scored 0-10) is recommended for research and clinical use based on superior utility and psychometric features in children. 1
- The FPS-R demonstrates strong positive correlations with other validated self-report pain intensity measures and has been extensively validated in pediatric populations. 2, 1
- This scale can be administered either on paper or electronically with excellent concordance (weighted Kappa 0.846, Spearman correlation 0.911), and children aged 4-12 years prefer the electronic version when given a choice. 2
- The FPS-R avoids the confounding of pain intensity with emotional affect because it does not use smiling or crying anchor faces, unlike some other scales. 1
Alternative Options Based on Age and Context
For children aged 8-18 years with acute abdominal pain:
- Both the Visual Analog Scale (VAS) and Color Analog Scale (CAS) demonstrate acceptable agreement (95% limits of agreement: -18.6 to 14.4) and can be used interchangeably. 3
- The Verbal Numerical Rating Scale (vNRS) shows equal efficacy to the FPS-R in children aged 8-17 years (p=0.9144), making it a reasonable alternative in this age group. 4
Critical caveat: The verbal numeric scale shows poor agreement with other pain scales in children with moderate to severe acute abdominal pain, particularly when compared to visual scales (95% limits of agreement ranging from -38.7 to 20.7 with various scales). 3 Therefore, avoid relying solely on verbal numeric scales in younger children or those with severe pain.
For Children Under 5 Years
- Data are sparse for children below age 5 years, and simplified measures with clearer instructions and anchors are needed for this population. 1
- In preschool-aged children with appendicitis (who already present with atypical symptoms and diagnostic challenges), observational pain assessment methods may need to supplement self-report scales. 5, 6
Clinical Implementation
Pain assessment should be performed systematically:
- Administer the FPS-R at initial presentation to establish baseline pain severity. 2, 1
- Reassess pain intensity 30 minutes after analgesic administration to evaluate treatment response. 3
- Pain control with opioids, NSAIDs, and acetaminophen should be a priority and does not result in delayed diagnosis or unnecessary intervention in suspected appendicitis. 7
Important Pitfall to Avoid
- Do not withhold adequate pain assessment or analgesia based on concerns about masking diagnostic findings—proper pain management does not compromise diagnostic accuracy in appendicitis. 7
- Do not use the Wong-Baker FACES Pain Rating Scale (WBFPRS) as the primary tool despite its popularity with children, because the smiling and crying anchor faces confound pain intensity measurement with emotional affect. 1