Can the Critical‑Care Pain Observation Tool (CPOT) be used in pediatric patients?

CPOT Should Not Be Used for Pediatric Patients in Routine Clinical Practice

The Critical-Care Pain Observation Tool (CPOT) was designed and validated specifically for adult ICU patients who cannot self-report pain, not for pediatric populations. 1 While recent research has explored pediatric adaptations, the original CPOT lacks validation in children and should be replaced with age-appropriate, validated pediatric pain assessment tools. 2

Why CPOT Is Not Appropriate for Pediatric Patients

Target Population Mismatch

• CPOT is intended exclusively for adult ICU patients unable to self-report pain, with validation studies conducted only in adult populations. 1
• The Society of Critical Care Medicine recommends CPOT specifically for adult ICU patients, not children. 1
• Pediatric patients demonstrate fundamentally different pain responses than adults, requiring developmentally appropriate assessment approaches. 2, 3

Lack of Pediatric Validation

• The ESPNIC (European Society of Paediatric and Neonatal Intensive Care) guidelines do not recommend CPOT for pediatric critical care settings. 2
• Standardized assessment tools must be validated in the specific population where they will be used to limit avoidable variability in assessment. 2

Recommended Pediatric Pain Assessment Tools

For Critically Ill Children (PICU Setting)

• Use the revised FLACC (Face, Legs, Activity, Cry, Consolability) scale for children aged 2 months to 7 years who cannot self-report. 1, 4
• The FLACC scale is validated for pediatric populations and provides objective behavioral assessment through numeric scoring across five categories. 4
• For children with cognitive impairment, the individualized r-FLACC demonstrates excellent clinical utility and agreement with pain assessments. 5

For Self-Reporting Children

• Use the Faces Pain Scale-Revised (FPS-R) for children aged 4 years and above who can self-report. 4
• The FPS-R demonstrates strong convergent validity with visual analog scales in pediatric populations. 4
• For children aged 6 years and older with persistent pain, the Visual Analog Scale (VAS) has weak recommendation for use. 2

For Neonates

• Use the N-PASS (Neonatal Pain, Agitation, and Sedation Scale) for neonates 0-100 days of age. 3
• The American Academy of Pediatrics recommends N-PASS for measuring neonatal pain and sedation. 3
• Neonates require multidimensional assessment tools combining physiologic and behavioral indicators, as they cannot self-report. 3

Emerging Research on Pediatric CPOT Adaptations

P-CPOT (Pediatric CPOT)

Recent research has developed a pediatric adaptation called P-CPOT, but this represents a different tool requiring separate validation:

• A 2020 study validated P-CPOT in 78 PICU patients, showing excellent sensitivity (98.6%) and specificity (97.6%) at a threshold of 4. 6
• P-CPOT demonstrated superior sensitivity compared to FLACC for detecting pain in ventilated patients. 6
• A 2025 study of 91 pediatric patients found CPOT strongly correlated with FLACC (ρ = 0.84) with optimal cut-off score of 3. 7
• A 2023 study validated CPOT in 24 pediatric orthopedic surgery patients (ages 10-18), finding a cut-off score of ≥2 with 61.3% sensitivity and 94.1% specificity. 8

Critical Limitations of These Studies

• These are recent, single-center studies with small sample sizes that have not been incorporated into clinical guidelines. 8, 6, 7
• The P-CPOT represents a modified tool, not the original CPOT, requiring its own validation pathway. 6
• No major pediatric critical care societies have endorsed CPOT or P-CPOT for routine clinical use. 2

Clinical Implementation Algorithm

For any pediatric patient requiring pain assessment:

1. Determine the child's age and ability to self-report:

   • Neonates (0-100 days): Use N-PASS 3
   • Children 2 months-7 years (non-verbal): Use FLACC 1, 4
   • Children ≥4 years (able to self-report): Use FPS-R 4
   • Children with cognitive impairment: Use individualized r-FLACC 5

2. Assess pain at regular intervals and before/after interventions to detect changes requiring treatment. 2

3. Combine behavioral assessment with physiologic indicators rather than relying on vital signs alone. 3

4. Screen for pain at every clinical encounter using developmentally appropriate, validated tools. 2

Critical Pitfalls to Avoid

• Never use adult-validated tools in pediatric populations without specific pediatric validation. 2, 1
• Do not assume that tools validated in one pediatric age group apply to all children—developmental stage matters critically. 4, 3
• Avoid relying solely on physiologic measures (heart rate, blood pressure) as behavioral indicators are more reliable in children. 3
• Do not use sedation scales (like RASS) for pain assessment—these measure different constructs. 3
• Healthcare professionals must use standardized tools rather than subjective clinical judgment alone to limit assessment variability. 2