Copyright EMAP Publishing 2017 This article is not for distribution 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... l Why it is crucial to assess, reassess and document pain in paediatric patients l Three types of approach to pain assessment in children l 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 Nursing Times [online] May 2017 / Vol 113 Issue 5 19 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Review 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