Guidelines, Strategies and Tools for Pain Assessment in Children

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Nursing Practice Keywords Pain score/Faces Pain Scale/ Pain indicators/Self-report/Guidelines Review This article has been Paediatrics double-blind peer reviewed In this article... ● Why it is crucial to assess, reassess and document pain in paediatric patients ● Three types of approach to pain assessment in children ● Pain assessment tools most frequently used with children of different ages and abilities

Guidelines, strategies and tools for pain assessment in children

Key points Author Alison Twycross is head of children’s nursing and professor of children’s Unrelieved pain in nursing, London South Bank University, London. 1children has several undesirable Abstract Unrelieved pain in children has several undesirable physical and psychological short- and long-term consequences in the short and longer term. Other effects of unrelieved pain include consequences, and prolonged hospital stays, more readmissions and more outpatient visits. This article so it is important to discusses why assessing pain in children is important, identifies best practice with manage it effectively reference to current guidelines, outlines the strategies that can be used to assess Assessing a children’s pain and describes pain assessment tools for different ages and cognitive 2child’s pain is abilities. This is the first of three articles on how to manage pain in children. the first step in ensuring effective Citation Twycross A (2017) Guidelines, strategies and tools for pain assessment in management children. Nursing Times [online]; 113: 5, 18-21. Children’s pain 3can be assessed using self-report nrelieved pain in children has harmful multisystem effects. There is also tools as well as undesirable physical and psy- evidence that acute (post-operative) pain behavioural or chological consequences that can result in chronic pain in a small but physiological Ucan affect them in both the significant number of children (Lauridsen indicators short and longer term. Physiological et al, 2014). Other unwanted effects of Whenever responses include increased heart and unrelieved pain include: 4possible breathing rates to facilitate vital organs’ l Prolonged hospital stays; children’s self-report increasing demands for oxygen and nutri- l Increased rates of readmission to should be used to ents. Psychological consequences include: hospital; assess their pain l Anxiety, fear, distress, feelings of l Increased number of outpatient visits A child’s pain helplessness or hopelessness; (Schug et al, 2015). 5should be l Avoidance of activity or medical When considering all the above, it reassessed following procedures in future; becomes clear why it is important to assess the implementation l Sleep disturbances; and manage children’s pain effectively. of pain-relieving l Loss of appetite. This article – the first of a three-part series interventions Failure to relieve pain produces a pro- on managing pain in children – covers longed stress state, which can result in pain assessment. It identifies best practice with reference to current guidelines, out- Box 1. Current guidelines on pain assessment in children lines the strategies that can be used to l Association of Paediatric Anaesthetists of Great Britain and Ireland (2012) Good assess children’s pain, and describes pain practice in postoperative and procedural pain management. Pediatric Anesthesia; assessment tools for different ages and 22: Suppl 1. Bit.ly/APAPostopProcPain cognitive abilities. It offers an opportunity l Schug SA et al (2015) Acute Pain Management: Scientific Evidence. Melbourne: to reflect on our own practice and identify Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. where change may be needed. Bit.ly/ANZACAcutePainManag2015 l Royal College of Nursing (2009) The Recognition and Assessment of Acute Pain in Best practice guidelines Children: Update of Full Guideline. London: RCN. Bit.ly/RCPAcutePainChildren Pain assessment is the first step in ensuring children’s pain is managed

Nursing Times [online] May 2017 / Vol 113 Issue 5 18 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Review effectively (Fig 1). If pain is not assessed, it Fig 1. The stages of pain management in children is difficult to evaluate the effectiveness of any pain-relieving interventions and decide whether further action is needed. Current guidelines on assessing pain in children (Box 1) state that we should: Assess l Ask them about their pain using a child’s pain developmentally appropriate self- report pain tool (if possible); l Involve the parents and/or carers to find out how their child normally behaves Select when in pain; Evaluate the appropriate l Take the child’s behavioural cues into effectiveness of pain-relieving account; interventions l Note any physiological cues that may interventions indicate the child is in pain; l Reassess pain after pain-relieving interventions have been implemented; Implement l Document the child’s pain assessment pain-relieving scores. interventions Despite the availability of best-practice guidelines, children continue to experi- ence unnecessary pain during hospital Source: Twycross and Williams (2014) stays (Twycross and Finley, 2013). A recent systematic review of the evidence regarding nurses’ assessment of post- from three years onwards), who are not Box 2. Behavioural indicators operative pain in children found that chil- overtly distressed and/or who are not cog- of pain in children dren’s behavioural cues are considered nitively impaired (Stinson et al, 2006). more important than their self-report of With infants, toddlers, pre-verbal chil- l Irritability pain and that a significant proportion of dren, and those who are cognitively l Unusual posture children did not have pain scores recorded impaired or sedated, behavioural pain l Reluctance to move in the first 24 hours after surgery (Twycross assessment tools should be used. These l Disturbed sleep pattern et al, 2015). This suggests that practices should also be used with older children if l Unusual quietness still need to improve. they are overtly distressed – this allows the l Restlessness practitioner to estimate their pain until l Sobbing Pain assessment strategies they are less distressed. l Lethargy The three approaches to measuring pain in Children often exhibit behaviours indi- l Screaming children are: cating that they are in pain (Box 2). How- l Aggressiveness l Self-report – what the child says; ever, their self-reports of pain do not l Increased clinging l Behavioural indicators – how the child always correlate strongly with their behav- l Loss of appetite behaves; iours (Nilsson et al, 2008). Individuals l Whimpering l Physiological indicators – how the differ in how they express pain, so it is l Laying ‘scared stiff’ child’s body reacts (Stinson and Jibb, important to ascertain how a child nor- 2014). mally behaves when in pain. An assess- Self-report strategies are normally used ment based on behavioural indicators will When used alone, physiological indica- with children who are old enough to under- only provide an estimate of how much tors (Table 1) are not a valid clinical stand and use a self-reporting scale (that is, pain the child is experiencing. measure of pain, as they can be affected by other physiological changes and occur in response to other factors including fever, Table 1. Physiological indicators of pain in children anxiety and exertion. Given this, a pain Indicator Evidence assessment tool that incorporates both physiological and behavioural indicators, Heart rate Increases immediately after a pain stimulus and decreases as as well as the child’s self-report whenever pain diminishes except in infants, in whom an initial decrease is possible, should be used. followed by a rise Respiratory rate Conflicting evidence about whether respiratory rate increases Pain assessment tools and pattern or decreases, but significant shift from baseline. Breathing may In the hospital setting it is usually neces- become rapid and/or shallow sary to have more than one pain assess- Blood pressure Increases when a child is in acute pain ment tool to cater for all patient groups. Ideally, pain assessment tools in a clinical Oxygen saturation Decreases when a child is in acute pain area should all use a common metric – for Source: Sweet and McGrath (1998) example, pain rated from 0-10 or 0-5 in all

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Table 2. Pain assessment in children: commonly used tools Neonates PIPP (bit.ly/ l Indicators: post-menstrual age (gestational age + chronological age), behavioural state, heart rate, PIPPExample) oxygen saturation, brow bulge, eye squeeze, nasolabial furrow l Can be used with pre-term and term infants l Initially developed for procedural pain; requires further evaluation in neonates with very low birth weight and in non-acute and post-surgical pain populations l Indicators scored 0-4; total score of 0-21 based on gestational age; <6 = minimal/no pain, >12 = moderate-severe pain l Pain assessment takes one minute l Evidence of reliability, validity and ability to detect change (Stevens et al, 2010) l Includes contextual indicators (for example, post-menstrual age and behavioural state) Pre-verbal children FLACC (Merkel et al, l Indicators: facial expression, leg movement, activity, cry, consolability 1997; bit.ly/ l Intended for children aged 2 months-8 years but has been used in children aged 0-18 years PainFLACCTool) l Scored 0-2; total score 0-10, so simple to use and interpret l Validated for procedural pain in children aged 5-16 years (Nilsson et al, 2008) l Valid for post-operative, trauma-related and cancer pain in children aged 0-2 years (Manworren and Hynan, 2003), and post-operative pain in children aged 1-5 years (Hartrick and Kovan, 2002) and 4-18 years l Consolability requires subjective rating of response to an attempt to console, which complicates scoring l May be useful in ventilated patients (Voepel-Lewis et al, 2010); not to be used with paralysed patients Children with cognitive impairment rFLACC (Malviya et al, l Revised FLACC, incorporating pain behaviours 2006) l Used in cognitively impaired children aged 4-19 years post-operatively l Scored 0-2; total score 0-10, so simple to use and interpret (Voepel-Lewis et al, 2008) l Considered by nurses and parents to be best tool for children with cognitive impairment (Chen-Lim et al, 2012) l Rated higher than other tools for neurologically impaired children (Voepel-Lewis et al, 2008) Verbal children FPS-R (Hicks et al, l Six graphically depicted faces with neutral anchors, scored 0-10 2001; bit.ly/FacePain l Intended for use in children aged 5-12 years but has been used in children aged 4-18 years ScaleRevised) l Well-established evidence of reliability, validity and ability to detect change (Stinson et al, 2006) l Demonstrates strong psychometric properties in children aged 4-17 years in acute pain l Quick and easy to use Wong-Baker Faces l Six cartoon faces ranging from smiling to crying, scored 0-5 or 0-10 (better to use a common metric if Pain Rating Scale using more than one tool) (Wong and Baker, l For children aged 3-18 years 1988) l Well-established evidence of reliability, validity and ability to detect change (Stinson et al, 2006) l Quick and simple to use; requires minimal instructions l Well-liked by children and health professionals l Translated into more than 10 languages l Readily available free of charge (wongbakerfaces.org), easily reproduced l Disadvantages: smiling ‘no hurt’ face results in higher reported pain scores than neutral face (Chambers et al, 2005) and ‘hurts worst’ face has tears but not all children cry when in pain Numerical pain rating l Consists of a range of numbers (for example, 0-10 or 0-100), spoken or presented in graphic format scale l Lowest number represents no pain, highest represents most pain possible l Reliable; valid in children aged >8 years for acute pain (Page et al, 2012) FLACC = Face, Legs, Activity, Cry and Consolability. FPS-R = Faces Pain Scale, Revised. PIPP = Premature Infant Pain Profile. rFLACC = Revised FLACC.

Source: Adapted from Stinson and Jibb (2014)

tools (Stinson and Jibb, 2014). This means in practice can be found online (bit.ly/ on their age and developmental level. that a pain score of 5 will mean the same no PIPPExample). The behavioural tool most When using a faces pain scale it is impor- matter which tool is used. This will make frequently used with pre-verbal children tant to explain how it is used (Box 3) and communication easier and pain-relieving in the UK is the Face, Legs, Activity, Cry check that the child understands. interventions more effective. and Consolability (FLACC) tool (bit.ly/ More information about pain assess- Tools commonly used to assess pain in PainFLACCTool), while the revised FLACC ment tools that have been developed and children are detailed in Table 2. The tool is most commonly used with cognitively validated for use with children of different for neonates that has been tested most impaired children. For verbal children, the ages and cognitive abilities is available; often is the Premature Infant Pain Profile use of a faces pain scale or a numerical details can be found in Schug et al (2015) (PIPP). An example of how the PIPP is used rating scale is recommended, depending and the Royal College of Nursing (2009).

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Manworren RCB, Hynan LS (2003) Clinical Box 3. Explaining a faces Box 4. Test your skills validation of FLACC: preverbal patient pain scale. pain scale to children Pediatric Nursing; 29: 2, 140-146. Scenario 1 Merkel SI et al (1997) The FLACC: a behavioral l The scale consists of six faces Alfie is nine months old and had scale for scoring postoperative pain in young numbered 0-10. Explain to the child surgery two days ago to repair a cleft children. Pediatric Nursing; 23: 3, 293-297. Nilsson S et al (2008) The FLACC behavioral scale that each is for a person who feels palate. He is playing in his cot but is for procedural pain assessment in children aged happy or sad because he/she has no reluctant to drink. 5-16 years. Pediatric Anesthesia; 18: 8, 767-774. pain (hurt) or some or a lot of pain: l Which pain assessment tool(s) should Pagé MG et al (2012) Validation of the numerical l very happy because it you use to assess his pain and why? rating scale for pain intensity and unpleasantness Face 0 – in pediatric acute postoperative pain: sensitivity to doesn’t hurt at all change over time. Journal of Pain; 13: 3, 359-369. l Face 2 – hurts just a little bit Scenario 2 Royal College of Nursing (2009) The Recognition l Face 4 – hurts a little more Julie is eight years old and had an and Assessment of Acute Pain in Children: Update of Full Guideline. Bit.ly/RCPAcutePainChildren l Face 6 – hurts even more appendectomy yesterday. She has not Schug SA et al (2015) Acute Pain Management: l Face 8 – hurts a whole lot more had any analgesic drugs for six hours Scientific Evidence. Bit.ly/ANZACAcutePain2015 l Face 10 – hurts as much as you and is lying rigid in the bed. Stevens B et al (2010) The premature infant pain l profile: evaluation 13 years after development. can imagine, although you do not How much pain do you think Julie has? Clinical Journal of Pain; 26: 9, 813-830. have to be crying to feel this bad l What tools should you use to assess Stinson J, Jibb L (2014) Pain assessment. In: l Ask the child to choose the face that Julie’s pain and why? Twycross A et al (eds) Managing Pain in Children: best describes how he/she is feeling A Clinical Guide for Nurses and Healthcare Professionals. Oxford: Wiley-Blackwell. Source: Adapted from Hockenberry et al (2005) Scenario 3 Stinson J et al (2006) Systematic review of the Winston is five years old and has just psychometric properties and feasibility of started school. He can communicate self-report pain measures for use in clinical trials in children and adolescents. Pain; 125: 1-2, 143-157. Reassessing and documenting verbally if things are explained to him Sweet SD, McGrath PJ (1998) Physiological Pain should be reassessed once pain- in a way he understands. He cannot yet measures of pain. In: Finley GA and McGrath PJ relieving interventions – usually analgesic count to 10 and has come to accident (eds) Measurement of Pain in Infants and Children, and emergency with abdominal pain. Progress in Pain Research Management. Seattle: drugs, but also non-drug methods such as IASP Press. distraction – have had a chance to work so l Which pain assessment tool(s) should Twycross A et al (2015) Paediatric nurses’ you know whether the treatment needs you use to assess his pain and why? postoperative pain management practices in adjusting. Regular reassessment and docu- Check your answers to these scenarios hospital based non-critical care settings: a narrative review. International Journal of Nursing mentation of pain is essential for effective by taking the Nursing Times Self- Studies; 52: 4, 836-863. treatment and good communication assessment test (see box below left). Twycross A, Williams A (2014) Why managing between members of the healthcare team, pain in children matters. In: Twycross A et al (eds) Managing Pain in Children: A Clinical Guide for and with the child and family. Despite this, Nurses and Healthcare Professionals. Oxford: it has been noted that some health profes- tools as well as behavioural and physical Wiley-Blackwell. sionals do not always record pain assess- indicators. Once pain has been assessed Twycross A, Finley GA (2013) Children’s and ment (Twycross et al, 2013). and pain-relieving interventions imple- parents’ perceptions of postoperative pain management: a mixed methods study. Journal of Standardised forms and tools – for mented, it is important to reassess pain to Clinical Nursing; 22: 21-22, 3095-3108. example, admission assessment forms and ascertain whether further action is needed Twycross A et al (2013) Pediatric nurses’ observation charts – encourage the initial and what should be done. postoperative pain management practices: an observational study. Journal for Specialists in and ongoing assessment and documenta- The scenarios in Box 4 are part of the Pediatric Nursing; 18: 3, 189-201. tion of pain. Nursing Times Self-assessment test, ena- Voepel-Lewis T et al (2010) Reliablity and validity of bling you to check your knowledge. NT the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Conclusion American Journal of Critical Care; 19: 1, 55-61. References Assessing children’s pain is an important Voepel-Lewis T et al (2008) A comparison of the Chambers CT et al (2005) Faces scales for the clinical utility of pain assessment tools for children first step in managing it effectively. Pain in measurement of postoperative pain intensity in with cognitive impairment. Anesthesia and children can be assessed using self-report children following minor surgery. Clinical Journal of Analgesia; 106: 1, 72-78. Pain; 21: 3, 277-285. Wong DL, Baker CM (1988) Pain in children: Chen-Lim ML et al (2012) Optimizing the assessment of pain in children who are cognitively comparison of assessment scales. Pediatric Nursing Times Nursing; 14: 1, 9-17. Self-assessment impaired through the quality improvement process. Journal of Pediatric Nursing; 27: 6, 750-759. Test your knowledge Hartrick CT, Kovan JP (2002) Pain assessment following general anesthesia using the toddler This is part 1 in a series on pain in with Nursing Times preschooler pain scale: a comparative study. neonates, children and young people Self-assessment after reading this Journal of Clinical Anesthesia; 14: 6, 411-415. Part 2 Non-pharmacological management article. If you score 80% or more, you Hicks CL et al (2001) The Faces Pain Scale – of procedural pain in neonates Jun Revised: toward a common metric in pediatric pain will receive a personalised certificate measurement. Pain; 93: 2, 173-183. Part 3 Procedural pain management in that you can download and store in Hockenberry MJ et al (2005) Wong’s Essentials of children and young people Jul your Nursing Times Learning Passport Pediatric Nursing. St Louis, MO: Mosby. Lauridsen MH et al (2014) Chronic pain in children or professional portfolio as CPD or after cardiac surgery via sternotomy. Cardiology in For more on this topic go online... revalidation evidence. the Young; 24: 5, 893-899. l Pain management 1: physiology To take the assessment visit Malviya S et al (2006) The revised FLACC observational pain tool: improved reliability and – how the body detects pain stimuli nursingtimes.net/NTSAPainChildren validity for pain assessment in children with cognitive Bit.ly/NTPainPhysiology impairment. Pediatric Anesthesia; 16: 3, 258-265.

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