Appendix G Age appropriate pain rating scales
Age appropriate pain rating scales include the following:
- Neonates, infants: Neonatal pain rating scale (NIPS) or facial expression tool
- Nonverbal children or children under 3 years: FLACC scale
- Children over 3 years of age: Wong Baker faces pain scale
- 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:
- Eyebrows lowered and drawn together
- A bulge between the eyebrows and vertical furrows on the forehead
- Eyes slightly closed
- Cheeks raised, nose broadened and bulging, deepened nasolabial fold
- Open and squarish mouth.
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| Face | No particular expression or smile | Occasional grimace or frown, withdrawn, disinterested | Frequent to constant frown, clenched jaw, quivering chin |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
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.
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.
After discussing with the child several things that have hurt or caused the child pain in the past:
- Present the child with four crayons or markers of different colours.
- 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?
- Show the four colours to the child in order, from the colour chosen for the worst pain to the colour chosen for no pain.
- 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.
- 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.
