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Appendix G Age appropriate pain rating scales

Age appropriate pain rating scales include the following:

  1. Neonates, infants: Neonatal pain rating scale (NIPS) or facial expression tool
  2. Nonverbal children or children under 3 years: FLACC scale
  3. Children over 3 years of age: Wong Baker faces pain scale
  4. Children over 7 years of age: Numeric, word pain scale and PatchSA colour tool

Neonates

Assessing a neonate’s facial expression is a useful way of identifying pain and distress. Typical facial signs of pain in neonates are the following:

  1. Eyebrows lowered and drawn together
  2. A bulge between the eyebrows and vertical furrows on the forehead
  3. Eyes slightly closed
  4. Cheeks raised, nose broadened and bulging, deepened nasolabial fold
  5. Open and squarish mouth.

Figure A

Neonatal/infant pain scale (NIPS): Score >3 = pain

Facial expression Score
1 - Relaxed muscles Restful face, neutral expression
2 - Grimace Tight facial muscles, furrowed brow, quivering chin, tight jaw
Cry
0 - No cry Quiet, not crying
1 - Whimper Mild moaning, intermittent
2 - Vigorous cry Loud scream, rising, shrill, continuous
Note: silent cry may be scored if baby is intubated and ventilated as evidenced by obvious mouth and facial movements
Breathing pattern
0 - Relaxed Usual pattern for infant
1 - Change in breathing Indrawing, irregular, faster than usual, gagging, breath holding
Arms
0 - Relaxed No muscle rigidity, occasional random movements of arms
1 - Flexed, extended Tense, straight arms, rid and/or rapid extension/flexion of arms
Legs
0 - Relaxed No muscle rigidity, occasional random movements of arms
1 - Flexed, extended Tense, straight arms, rid and/or rapid extension/flexion of arms
State of arousal
0 - Sleeping, awake Quiet, peaceful or alert, random leg movement
1 - Fussy Alert, restless and thrashing

Children 3 years of age and under

FLACC scale

Indications for use with:

  • Infants and children to 3 years of age
  • Children up to 7 years of age who are unable to validate the presence of, or quantify the severity of, pain
  • Any other non-verbal patient
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Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin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 or sobs, frequent complaints
Consolability Content, relaxed, no need to console Reassured by occasional touching, hugging or talking to, distractible Difficult to console or comfort

Children over 3 years of age

Faces pain scale revised


Figure B


Ask the child to point to the face which indicates how bad or severe their pain is.

Five-finger score

Ask the patient to show how bad the pain is with their hand.

Figure C

Ask the child to show how bad the pain is with their hand. This is the internationally recognised version of this tool. In South Africa this tool has been adapted and may vary from region to region for example, a child showing you their thumb can mean thumbs up and ‘I am okay’. Therefore, always check what is used in a particular environment and ask the child what he or she means.

Children over 7 years of age

Numerical Rating Scale for children over 7 years of age

On a scale from 0 – 10, describe how strong your pain is.

No pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible pain

Word pain scale

No pain Little pain Medium pain Severe pain Worst pain

Drawing pain

Ask a child to ‘draw’ his or her pain. This often gives insight into the intensity and nature of the pain but may also reflect its psychosocial consequences or the child’s fears.

PatchSA Colour Tool

Instructions for using the PatchSA Colour Tool:

Figure D: Based on the Eland Colour Tool (Eland & Anderson, 1977) the PatchSA Colour Tool can be used to locate and assess the intensity of pain in children.

Figure D: Based on the Eland Colour Tool (Eland & Anderson, 1977) the PatchSA Colour Tool can be used to locate and assess the intensity of pain in children.

After discussing with the child several things that have hurt or caused the child pain in the past:

  1. Present the child with four crayons or markers of different colours.
  2. Using the term that the family and child use to describe hurt or pain (the word ‘pain’ is used in these instructions), ask the following questions and, after the child has answered, mark the appropriate square on the tool.
    • Of these colours, which colour is most like the worst pain you have ever had, or the worst pain anybody could ever have?
    • Which colour is almost as much pain as the worst pain, but not quite as bad?
    • Which colour is like a little pain?
    • Which colour is like no pain at all?
  3. Show the four colours to the child in order, from the colour chosen for the worst pain to the colour chosen for no pain.
  4. Ask the child to colour within the body outlines in the places where it hurts on their own body, using the colours chosen to show how much it hurts.
  5. When finished, ask if this is a picture of how it hurts now or how it hurt earlier. Be specific about what earlier means by relating the time to an event, for example, at lunch or in the playroom.
Note
Ask the child what their favourite colour is before starting and remove that one from the group of colours, as you don’t want them to associate pain with this colour.