Pain Assessment in Kids-1.11.2011

8/13/2019 Pain Assessment in Kids-1.11.2011

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PAIN ASSESSMENT IN CHILDREN

PRADEEP


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DEVELOPMENTAL MILESTONE


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Pain in infants and children can be difficult to

assess which has led to the creation of numerous

age-specific pain management tools and scores.

Health care workers need to be able to detect the

symptoms and signs of pain in different age

groups and determine whether these symptoms

are caused by pain or other factors Effective care in paediatrics requires special

attention to the developmental stage of the child.


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Accurate pain measurement in children is

difficult to achieve.

Three main methods are currently used to

measure pain intensity:

Self report

BehaviouralPhysiological measures.


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Self measures:

Pain is a subjective experience so assessment ofchildrens pain must emphasize the childsperception of experience.

Self reports are the optimal and most validindicators of childs subjective experience of pain.

When carefully taught pain measuring stimulus,children are able to describe the varying levels and

characteristics of their discomfort.


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Physiological measures:Physiological measures include assessment of heart rate,blood pressure, respiration, oxygen saturation, palmersweating, and sometimes neuroendocrine responses.

They are however generally used in combination withbehavioural and self-report measures, as they are usuallyvalid for short duration acute pain and differ with thegeneral health and maturational age of the infant or child

Behavioural measures: Behaviours associated with paininclude facial expression, posture and vocalization orverbalization


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Neonates and Infants

Despite early studies, current research supports thatinfants possess the anatomical and functionalrequirements to perceive pain.

Recent studies also demonstrate that infants elicitcertain behavioural responses to pain perception.

Pain in infants, despite this data, remains under-treated and often mismanaged.

The most common pain measures used for infants arebehavioural. These measures include crying, facialexpressions, body posture, and movements.

The quality of these behaviours depends on the

infants gestational age, and maturity


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Numerous scales are currently available to measurebehavioural indicators in infants, the most common

being-Neonatal Facial Coding System (NFCS) and

-Neonatal Infant Pain Scale (NIPS).

Some scales also take into consideration gestational

age and the general behavioral state of the infant.Examples of these scales are

-Premature Infant Pain Profile (PIPP),

Crying Requires Increased Vital Signs

Expression Sleeplessness (CRIES)

-Maximally Discriminate Facial Movement CodingSystem(MAX)


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Neonatal Facial Coding System (NFCS).

It is used to monitor facial actions in newborns.

The system looks at eight indicators to measure

pain intensity:

brow bulge, eye squeeze, nasolabial furrow, open

lips, stretched mouth (horizontal or vertical), lip purse,

tout tongue, and chin quiver . The indicators are recorded on videotape, coded,

and scored.

It has been proven reliable for short duration, acute

pain in infants and neonates.

The system is also difficult to assess in intubated

neonates


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Neonatal Infant Pain Scale (NIPS)

It was developed at the Childrens Hospital of EasternOntario.

The scale takes into account pain measurement before,during and after a painful procedure, scored in one-minuteintervals.

The indicators include: face, cry, breathing pattern, arms,legs, and state of arousal.

Results are obtained by summing up the scores for the sixindicators (where 0 indicates no pain, and 2 indicates pain),

with a maximum score of 7.It is a good system to measure responses to acute painfulstimuli.

Although it has been fully validated, it is time consumingand hard to interpret in intubated infants.


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Premature Infant Pain Profile (PIPP).

7-indicator composite measure that was developed at the

University of Toronto and McGill University to assess acutepain in preterm and term neonates.

The indicators include (1)gestational age, (2) behavioralstate before painful stimulus, (3) change in heart rateduring stimulus, (4) change in oxygen saturation, (5) brow

bulge during painful stimulus, (6) eye squeeze duringstimulus, and (7) nasolabial furrow during painful stimulus[14].

Scoring is initially done before the painful procedure. Theinfant is observed for 15 seconds and vital signs recorded.

Infants are then observed for 30 seconds during theprocedure where physiological and facial changes arerecorded and scored.

The score ranges from 021, with the higher scoreindicating more pain.


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Crying Requires Increased Vital SignsExpression Sleeplessness (CRIES).

It is an acronym of five physiological and

behavioural variables proven to indicate neonatalpain.

It is commonly used in neonates in the first monthof life.

The scale was developed at the University ofMissouri and may be recorded over time tomonitor the infants recovery or response todifferent interventions


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CRIES SCALE

0 1 2

Crying No High pitched Inconsolable

Requires O2 for

saturation >95%

No 30% O2

Inc vital signs HR & BP preop Inc in HR or BP 20%

Expression None Grimace Grimace/grunt

Sleepless No Wakes at freq

intervals

Constantly awake


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Toddlers

In toddlers, verbal skills remain limited and

quite inconsistent.

Pain-related behaviours are still the main

indicator for assessments in this age group


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Toddler-Preschooler PostoperativePain Scale (TPPPS)

It is most commonly used for children aged 15 years. In order to observe verbal, facial, and bodily movement,

the child needs to be awake.

The TPPPS includes seven indicators divided into three pain

behavior groups: vocal pain expression, (verbal complaint,cry, moan) facial pain expression (open mouth, squintedeyes, brow bulging and furrowed forehead) and bodily painexpression (restlessness, rubbing touching painful area). .

If a behaviour is present during a 5-minute observation

period, a score if 1 is given whereas a score of 0 is given ifthe behaviour was not present. The maximum scoreobtained is 7, which indicates a high pain intensity.


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Childrens Hospital of Eastern Ontario Pain Scales(CHEOPS)

It is one of the earliest tools used to assess and

document pain behaviours in young children It is used to assess the efficacy of interventions

used in alleviating pain.

It includes six categories of behaviour: cry,

facial, child verbal, torso, touch, and legs.

Each is scored separately (ranging from 02 or13)and calculated for a pain score ranging

from 413.


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Faces Legs Activity Cry Consolability Scale

(FLACC).

It is a behavioural scale for measuring the intensity ofpostprocedural pain in young children.

It includes five indicators (face, legs, activity, cry, and

consolability) with each item ranking on a three pointscale (02) for severity by behavioural descriptions

resulting in a total score between 010.

FLACC is an easy and practical scale to use in

evaluating and measuring pain especially in pre-verbal children from 2 months to 7 years.


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CategoriesScoring

0 1 2

Face No particular expression or

smile

Occasional grimace or frown,

withdrawn, disinterested

Frequent to constant frown,

clenched jaw, quivering chin

Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up

Activity Lying quietly, normal position,

moves easily

Squirming, shifting back and forth,

tense

Arched, rigid, or jerking

Cry No cry(awake or asleep) Moans or whimpers, occasional

complaint

Crying steadily, screams, sobs,

frequent complaints

Consolability content, relaxed, does not

require consoling

Reassured by occasional touching,

hugging,

or talking to. Distractible

Difficult to console or comfort

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which

results in a total score between zero and ten.

FLACC PAIN SCALE


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The COMFORT Scale. This scale is composed of 8 indicators: alertness,

calmness/agitation, respiratory response, physicalmovement, blood pressure, heart rate, muscletone, and facial tension.

Each indicator is given a score between 1 and 5depending on behaviours displayed by the childand the total score is gathered by adding allindicators (range from 840). Patients aremonitored for two minutes.

The COMFORT scale has been proven to beclinically useful to determine if a child isadequately sedated


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Observational Scale of

Behavioural Distress (OSBD) It remains the most frequently used

measurement in procedure-related distress

studies. It consists of 11 distress behaviours identified

by specialists to be associated with paediatricprocedure-related distress, anxiety, and pain.

Scores are calculated from summing up all 11distress behaviours.


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Observational Pain Scale (OPS) It is intended to measure pain in children aged 1

to 4 years, and is used to assess pain of short orlong duration.

The scale measures 7 parameters: facialexpression, cry, breathing, torso, arms and fingers,legs and toes, and states of arousal.

The OPS has a simple scoring system whichmakes it easy to use by all healthcareprofessionals to obtain valid and reliable results.

The indicators are rated from 0-1 with amaximum score of 7, where the higher scoreindicates greater discomfort


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Preschoolers

By the age of four years, most children areusually able to use 4-5 item pain discriminationscales.

Their ability to recognize the influence of painappears around the age of five years when theyare able to rate the intensity of pain.

Facial expression scales are most commonly usedwith this age group to obtain self-reports of pain.

These scales require children to point to the facethat represents how they feel or the amount ofpain they are experiencing


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Child Facial Coding System (CFCS) It is adapted from the neonatal facial coding system and

developed for use with preschool children (aged 25years).

It consists of 13 facial actions: brow lower, squint, eyesqueeze, blink, flared nostril, nose wrinkle, nasolabialfurrow, cheek raiser, open lips, upper lip raise, lipcorner puller, vertical mouth stretch, and horizontal

mouth stretch. The CFCS has been useful with acute short-duration

procedural pain


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Poker Chip Tool

It was developed for preschoolers to assess pieces of

hurt.

The tool uses four or five poker chips, where one chip

symbolizes a little hurt and four/five chips the most

hurt you could experience.

The tool is used to assess pain intensity

Targets 4-13 years


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Faces Pain Scale.

It was developed by Wong and Baker and isrecommended for children ages 3 and older.

The scale requires health care professionals to point

to each face and describe the pain intensity

associated with it, and then ask the child to choose

the face that most accurately describes his or her

pain level


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The OUCHER Scale. It was developed by Beyer in 1980.

It is an ethnically based self-report scale, whichhas three versions: Caucasian, African-American, and Hispanic.

Even though it covers a wide array of patients,it still has limits. For example, females are notrepresented, as well as other cultures.

It is used for children older than 5 years The tool has two separate scales: the numeric

scale (i.e.,0100) and the photographic scaleusually used for younger children.

The photographic scale entails six differentpictures of one child, portraying expressionsof no hurt to the biggest hurt you can everhave

Children are asked to choose the picture ornumber that closely corresponds to theamount of pain they feel


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Elands Colour scale

Children select colours to indicate:

Worst Hurt

Hurt not as much as

just a little Hurt

no Hurt at all.

then they colour their hurt on a bodyoutline.

Elands Colour scale


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Ladder scale- Children select the level

of pain from drawing of a ladderwith higher rungs indicating greater

pain.

Pain discomfort scale(AIIMS)-It is agood,clinically relevant scoringsystem.It provides:

allowance for thirst and hungerand

includes H.R.,respiration.


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PAIN DISCOMFORT SCALE (AIIMS)

Respiratory rate + 20%

+ 20-50%+ 50%

Pre op

Pre opPre op

0

12

Heart rate + 10%

+ 20%

+ 30%

Pre op

Pre op

Pre op

0

1

2

Discomfort Calm

Restless

Agitated

0

1

2

Cry No cry

Cry respond to water food

Cry respond to tender lovingcare

Cry not responding to tender

love

0

0

12

Pain at operative

site

No pain

States pain vague

Can localize pain

0

1

2


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Age Group Self Report Behavioural Physiological

Pre Verbal

(Neonate &

Infants)

Cry characteristics

Cry time

Facial expression

Visual tracking

Response time to

stimulus

Behavioural state

HR

BP

RR

Sweating

Pre Schoolers FACES pain scale

Oucher scale

Poker chip tool

Ladder scale

Eland colour scale

FLACC Scale

CHEOPS

Schoolers VAS

NRS11 , 101

VRS

Objective pain scale

Pain behaviour rating

scale

Pain behaviour check-

list

Pain Assessment Method


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School Aged Children

Although children at this age understand pain,their use of language to report it is different fromadults.

At roughly 7 to 8 years of age children, begin to

understand the quality of pain. Self-report visual analogue and numerical scales

are effective in this age group.

A few pain questionnaires have also proveneffective for this age such as the pediatric painquestionnaire and the adolescent pediatric paintool


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Visual Analog Scale(VAS)

It is a horizontal line, 100mm in length, attachedto word descriptions at each end, not hurtingor no pain to hurting a whole lot or severepain.

The children are asked to mark on the line thepoint that they feel represents their pain at thismoment.

A color analogue scale can also be used, where

darker more intense colors (i.e., red) representmore pain


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Paediatric Pain Questionnaire It is a self-report measure to assess children and

adolescents coping abilities using 8 subscales informationseeking, problem solving, seeking social support, positiveself-statements, behavioural distraction, cognitivedistraction, externalizing and internalizing as well as threemore complex scales (approach, distraction, and emotion-

focused avoidance). It contains 39 items in total, with scores ranging from 1

(never) to 5 (very often).

Children or adolescents are requested to state how oftenthey say, do, or think certain items when they hurt or in

pain. The questionnaire usually takes about 1015 minutes to

complete


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Adolescent Pediatric Pain Tool (APPT) It is a valid all encompassing pain assessment tool used for

individual pain assessments and measures intensity,location, and quality of pain in children older than 8 yearsof age.

The APPT is most useful with children and adolescents whoare experiencing complex, difficult to manage pain.

It consists of a body map drawing to allow children to pointto the location of pain on their body and a word graphicscale to measure pain intensity.

The word graphic rating scale is a 67 word list describing

the different dimension of pain and a horizontal line withwords attached that range from no, little, medium,large, to worst possible pain


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Adolescents

Adolescents tend to minimize or deny pain, especially infront of friends, so it is important to provide them withprivacy and choice.

They expect developmentally appropriate information

about procedures and accompanying sensations. Some adolescents regress in behavior under stress.

They also need to feel able to accept or refusestrategies and medications to make procedures moretolerable.

To assess pain and, specifically chronic pain, theadolescent pediatric pain tool or the McGill painquestionnaire are helpful.


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CONCLUSION

The score itself is not all important.

Reducing the score is only one measure

available to reduce overall pain and

suffering. The goal of pain assessment is to improve

objective component (function) and

manage the subjective component (pain).


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THANK YOU

Pain Assessment in Kids-1.11.2011

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