Pain Assessment in Pediatric Patients
Use validated, age-appropriate pain assessment tools routinely at triage and reassess every 1-2 hours during the ED or hospital stay, with the Visual Analog Scale (VAS) or COMFORT Behaviour Scale being the primary recommended tools depending on the child's developmental stage. 1
Mandatory Assessment Framework
Pain assessment is required by Joint Commission standards for all hospitalized children and must occur at specific intervals 1:
- At triage alongside vital signs 1
- Every 1-2 hours if receiving analgesic infusions 1
- After each intervention to determine treatment effectiveness 1
- At first visit and every subsequent visit at least 7 days apart for chronic conditions 1, 2
The critical principle is that pain assessment is more than obtaining a single score—you must track changes in pain scores in response to treatment 1.
Age-Appropriate Tool Selection
Neonates and Infants
Use the PIPP (Premature Infant Pain Profile) or PIPP-Revised 1:
- Incorporates behavioral indicators and vital signs 1
- Validated for this age group where self-report is impossible 1
Children Unable to Self-Report (All Ages)
Use the COMFORT Behaviour Scale as first-line 1:
- Assesses alertness, calmness/agitation, respiratory response, physical movement, muscle tone, and facial tension 1
- Validated for ages 0-16 years 1
- Does not require verbal communication 1
Alternative: FLACC Scale (Face, Legs, Activity, Cry, Consolability) 1
Verbal Children ≥4 Years
Use the Visual Analog Scale (VAS) 1, 2, 3:
- 100-mm line with scores 0-100 or 0-10 1
- Score interpretation: 10-30 = mild pain, 40-60 = moderate pain, 70-100 = severe pain 1, 2, 3
- Takes under 1 minute to complete 1
- Available in paper or electronic formats (Painometer V2 smartphone app) 1
Alternative: Faces Pain Scale-Revised (FPS-R) for children ≥4 years 3
Children ≥8 Years with Chronic Pain
Consider the Bath Adolescent Pain Questionnaire (BAPQ) 3:
- Multidimensional assessment capturing sensory, affective, and evaluative components 1, 3
- Addresses pain quality, intensity, location, duration, emotional impact, and functional interference 1
Critical Assessment Principles
Recognize Pain as Multidimensional 1
Assess three components:
- Sensory: quality, intensity, location, duration 1
- Affective: emotional impact and unpleasantness 1
- Evaluative: interference with physical, psychological, role, and social functioning 1
Special Populations Requiring Modified Assessment
Heavily sedated or paralyzed children 1:
- Behavioral indicators are unreliable 1
- Monitor heart rate and mean arterial pressure increases as potential pain indicators 1
- In absence of behavioral signs, consider pain as a primary differential when vital signs suggest stress 1
Children with cognitive impairment or developmental delay 1:
- Use behavioral scales rather than self-report tools 1
- Recognize that pain presentation differs from typical developmental expectations 1
Environmental Factors to Rule Out First 1
Before attributing high scores solely to pain, check and modify:
Parental Involvement
Include parents in pain assessment 1:
- Parents know their child's typical pain behaviors 1
- Involve parents as coaches during procedures to reduce anxiety and distress 1
- Parent assessment should complement, not replace, validated tools 1
Common Pitfalls to Avoid
Do not rely solely on vital signs in verbal children 1:
- Heart rate and blood pressure are less reliable than behavioral indicators in children who can demonstrate pain behaviors 1
- Vital signs have only moderate correlation with pain 1
Do not use sedation scales as pain assessment tools 4:
Do not assume chronic pain patients will display typical pain behaviors 1:
- Patients with chronic pain may not exhibit the same facial cues or vocalizations as those new to pain 1
- Focus on changes from baseline rather than absolute scores 1
Quality Assurance
Conduct pain assessment audits every 12 months to evaluate care quality and patient outcomes 1.