Use the right tool to measure childrens' pain

When managing children's pain, choosing the right assessment tool is key. "It's important to be comfortable with the tool you are using, and to be familiar with a variety of tools," says Nancy Eckle, RN, MEN, CEN, clinical nurse specialist at Children's Hospital in Columbus, OH. Children pose unique challenges in pain assessment, and choosing the right tool is key, she adds.

Here are some commonly used tools to assess pain in children:

Wong-Baker FACES Pain Rating scale. (See page 142). The FACES pain rating scale consists of six faces with expressions ranging from smiling to crying. "The scale was developed by school-aged children. They drew these faces, so this is their idea of pain, not an adult's idea," explains Donna Wong, PhD, PNP, CPN, FAAN, a co-developer of the scale. The children's drawings evolved into the current scale, which assigns a number ranging from 0 to 5 for each face.

Although it was developed to enable children to self-report pain, some clinicians use the scale as an observational tool. "The FACES scale can be used by an observer or parent by matching the child's face to the scale," says Joseph Tobias, MD, director of pediatric anesthesiology/pediatric critical care at the University of Missouri in Columbia.

Numerical scale. A Visual Analogue Scale tool is not effective with younger children. "We found that a numerical scale didn't really work well with our younger population," says Mary Royce, RN, BSN, CEN, nursing educator at Harborview Medical Center in Seattle, WA.

However, this scale is often effective with older children. "For patients greater than 8 years of age, a visual analogue scale like the one used in adults is often sufficient," says Tobias.

Numerical scales are excellent for trending pain. "A child might say they have a score of three, but that doesn't mean they don't need pain medication," says Eckle. "The idea isn't only to determine if the child does or doesn't have bad pain. It's used more as a trending tool."

Oucher scale. This scale uses photographs of a child's face to show varying degrees of pain. "You can get different ethnically diverse versions, including African-American, Hispanic, or Asian, so the face they are seeing looks like the child's own face," says Kathleen Ferket, RN, MSN, pediatric clinical specialist at Northwest Community Hospital in Arlington Heights, IL

Poker chips. This tool gives children four chips and asks how many pieces of pain they have. "It can be a little difficult to use in the ED setting, since you would need a certain amount of space to use it, and need to have all the poker chips on hand, whereas other scales you can just stick in your pocket," notes Ferket.

FLACC Behavioral Scale. This scale is currently being tested in Harborview's ED. "We are now using this tool for kids under the age of seven. It depends heavily on nursing observation," says Royce. The FLACC tool (an anacronym for face, legs, activity, cry, and consolability) includes five categories of pain behaviors to quantify pain. Each of the five categories is scored from 0 to 2, which results in a total score between zero and ten.

Assess children's pain

Assessing the severity of pain in children can be a difficult task. "A number of studies have shown that pain is typically undertreated in kids," says Eckle. "They're not telling you `I'm in pain and need something' like an adult would, so you need to find other ways to assess pain."

Here are some ways to improve assessment of pain in children:

Consider needs of chronically ill children. Some children with chronic illnesses are trained to use a particular tool to assess their pain. "Typically during a pain free period, they are taught to use a tool to describe their pain to help health care people understand," says Eckle. "It's good for nurses to use the tool the child was trained with."

Reduce separation anxiety. "Unfortunately, many things besides pain make children unhappy, and the tools we use need to assess pain and not separation anxiety or anything else," says Tobias. To eliminate that confusion, try to assess pain with parents present, he recommends.

Ask parents to explain the scale. "The parents are usually best at explaining to their own children in a manner most appropriate for the particular child," says Tobias.

Present several options. "Regardless of the age of the child, it is a good idea to try several tools and use the one that works the best," Tobias recommends.

Assess pain in non-verbal children. Assessing the pain of children younger than two years is particularly difficult. "Most of the traditional pain scales are for older children," says Ann Dietrich, MD, an emergency physician at Children's Hospital in Columbus. "With younger children, there is also a component of being held still and the fear of a stranger coming at you, which makes it very difficult to assess pain versus a child's reaction to other stressors."

If a child is preverbal, nurses need to go by behavioral cues and physiological responses such as heart rate, blood pressure, and respiratory rate. "But there is no physiologic response that is unique to pain, so heart rate can be elevated for a number of reasons," notes Eckle.

Still, there are clear signs of pain in infants. "Look at the infant's vital signs and activity level," says Ferket. "They may be grimacing, pulling away, protecting a part of their body, or seem like they don't want to move, since movement may increase pain. Generally, kids in pain are not willing to suck or eat."

Ask questions if no tools seem to work. "If the child has significant pain and is calling it a one or two, we can tell they are not understanding the tool," says Eckle. "In that scenario, you have to talk to them. Ask about where it hurts, does it hurt a little bit, have you been hurt that much before?"

Don't misinterpret behaviors. Nurses need to rid themselves of misconceptions about children and pain, urges Eckle. "A lot of people believe if a child can sleep or be distracted, then they're not in pain, and that's not true," she says. "A child in a great deal of pain may be quiet and still. Even if a child is playing, they can still have a degree of pain."

Children in pain demonstrate a vast variety of behaviors. "Some writhe and roll around and get a lot of attention, while the poor kid whose coping mechanism is to be very quiet gets overlooked," says Eckle. "Some chronically ill children have been taught to act in a certain way to get relief from pain-if they cry and whimper, then the parents realize he needs pain medication."

Older children may deny pain even when it exists. "Sometimes, you just have to assume a child's broken arm has got to be hurting," says Eckle. "The stoic kid gets shortchanged sometimes. That can be socialized in family; for example, if the family plays sports, the child may be taught to take the pain. So, the child may be very stoic and not tell you even if you ask them directly."

Have children self-report pain when possible. Parents may report a child's pain incorrectly. "They know their kids, so nurses should listen to what they say. But many times, parents will report all pain as severe," says Royce. "You also get the other extreme. When one little boy was in a bicycle accident, his dad was at the bedside and kept saying he is fine, there is nothing wrong."

Still, parents can give valuable information. "We depend very much on help of the caretaker, because no one knows the child better than that person," says Ferket. "We ask parents how your child generally responds to pain. This is very useful information for us to build on as a base."