A comparison of faces scales for the measurement of pediatric pain: children's and parents' ratings.

Faces scales have become the most popular approach to eliciting children's self-reports of pain, although different formats are available. The present study examined: (a) the potential for bias in children's self-reported ratings of clinical pain when using scales with smiling rather than neutral 'no pain' faces; (b) levels of agreement between child and parent reports of pain using different faces scales; and (c) preferences for scales by children and parents. Participants were 75 children between the ages of 5 and 12 years undergoing venepuncture, and their parents. Following venepuncture, children and parents independently rated the child's pain using five different randomly presented faces scales and indicated which of the scales they preferred and why. Children's ratings across scales were very highly correlated; however, they rated significantly more pain when using scales with a smiling rather than a neutral 'no pain' face. Girls reported significantly greater levels of pain than boys, regardless of scale type. There were no age differences in children's pain reports. Parents' ratings across scales were also highly correlated; however, parents also had higher pain ratings using scales with smiling 'no pain' faces. The level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used; parents overestimated their children's pain using all five scales. Children and parents preferred scales that they perceived to be happy and cartoon-like. The results of this study indicate that subtle variations in the format of faces scales do influence children's and parents' ratings of pain in clinical settings.     

The parents' postoperative pain measure: replication and extension to 2-6-year-old children

Pain assessment is a difficult task for parents at home following children's surgery. The purpose of the present study was to confirm the psychometric properties of a behavioural measure of postoperative pain developed to assist parents with pain assessment in children aged 7-12 years following day surgery. The study also examined the reliability and validity of the measure with children aged 2-6 years. Participants were 51 parents of children aged 7-12 years and 107 parents of children aged 2-6 years. For the 2 days following surgery, parents completed a pain diary that included global ratings of their children's pain and the 15-item Parents' Postoperative Pain Measure (PPPM). The older children provided self-reports of their pain intensity. The PPPM items showed good internal consistency on the two postoperative days for both samples (alpha's=0.81-0.88) and scores on the PPPM were highly correlated with children's (for the older children) and parents' (for the young children) global ratings of pain (r's=0.53-0.72). As global pain ratings decreased from Days 1 to 2, so did scores on the PPPM. Scores on the PPPM were successful in discriminating between children who had undergone low/moderate and high pain surgeries. The results of this study provide evidence of the reliability and validity of the PPPM as a measure of postoperative pain among children aged 2 through to 12 years.     

The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care

Aims and objectives: To evaluate the concurrent validity and reliability of the behavioural COMFORT and a modified version of the FLACC scale for assessment of pain and sedation in intubated and ventilated children and to evaluate the construct validity of the FLACC scale for assessment of pain. Background: Few instruments are available for assessment of pain/sedation in paediatric intensive care. Design: A prospective observational study was performed postoperatively in 40 children aged 0–10 years. Methods: Two trained nurses observed the child simultaneously and assessing COMFORT behavioural (COMFORT‐B) and FLACC scores. In comparison, two bedside nurses concurrently scored pain using an observational visual analogue scale (VAS_obs) and sedation using the Nurse Interpretation of Sedation (NIS) score: oversedated, adequately or insufficient sedated. In 20 additional patients, one nurse assessed FLACC scores before and after analgesics. Results: The majority of patients were <1 year. A moderate but significant correlation was found between each scale and both sedation and VAS_obs. COMFORT‐B differentiated better than FLACC between the three sedation levels. For those assessed to be in pain (VAS_obs > 3), both COMFORT‐B and FLACC scores were significantly different compared with VAS_obs < 3. The interrater reliability was high for COMFORT‐B and FLACC (kappa 0·71 and 0·63, respectively). For bedside nurses’ assessment of pain, the interrater reliability was high (kappa 0·63) but low for the level of sedation (kappa 0·20). After administration of analgesics, the FLACC median score decreased significantly from 5 to 0. Conclusions: The COMFORT‐B scale was a more reliable measure of children’s sedation than bedside subjective assessment and gives more substantial information about sedation than the FLACC scale. Concurrent validity for assessment of pain was supported for both scales. The modified FLACC showed construct validity for measuring pain. Relevance to clinical practice: The use of validated scales may improve the assessment and management of pain and sedation in intubated children.     

Unravelling age effects and sex differences in needle pain: ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents

Age and sex differences were investigated in children's self-report of venipuncture pain. Equal numbers of boys and girls aged 3-15 years (n = 110) made separate ratings of the intensity and unpleasantness of their needle pain, using a paired Visual Analogue Scale (VAS) technique. The parents of these children used the same method to give ratings of predicted pain and unpleasantness before the needle, as well as ratings based on observing their child during the needle. Results showed that, across age, children's intensity and unpleasantness scores were highly correlated (r = 0.78), and that both of these ratings decreased with increasing age. Analyses of covariance showed that, with the variance in the unpleasantness ratings accounted for, a significant age main effect persisted for the intensity ratings (scores decreasing with increasing age), with no effect of sex. In the corollary analysis, with intensity scores entered as a covariate, unpleasantness ratings showed no main effect of age, but a significant main effect of sex emerged: girls' ratings of pain unpleasantness, when averaged across age, were significantly higher than boys'. The interaction between age and sex was explored in analysis of the relative difference between intensity and unpleasantness ratings. The results indicated that, from approximately 8-years of age, children (especially girls) gave significantly higher ratings of unpleasantness than sensory intensity of needle pain. Prior to the age of 8 years, children tended to give equivalent ratings of intensity and unpleasantness, with no evidence of a sex difference. The agreement between parental and children's ratings was higher for parents' observed, as opposed to predicted, scores, especially for pain intensity, with no systematic influence of the child's age and sex. In conclusion, it is suggested that age effects in children's self-report of needle pain are predominantly manifest in ratings of sensory intensity, whilst sex effects are predominantly manifest in ratings of an affective (unpleasantness) dimension. It is argued that both age and sex differences are largely the function of pain reporting variables, rather than reflecting fundamental age or sex based variance in nociceptive processing.     

Parents' roles in using non-pharmacological methods in their child's postoperative pain alleviation

Increasingly nowadays, parents participate more fully in the care of their hospitalized children. The purpose of this study was to describe parents' utilization of selected non-pharmacological methods in relieving their hospitalized child's (aged 8-12 years) postoperative pain, and factors related to this function. Data were collected by a questionnaire survey completed by parents (n=192) with a child hospitalized on a paediatric surgical ward in the five university hospitals of Finland. The response rate was 90%. Results indicated that non-pharmacological methods, such as emotional support and helping with daily activities, were well utilized whereas cognitive-behavioural and physical methods were less frequently used strategies. Certain background factors specific to the parents and their hospitalized children were significantly related to the non-pharmacological methods used by the parents. The hospitalized child's gender, the time of the surgical procedure, and the parents' assessments of their child's pain intensity, were especially significantly related to many of these strategies. The findings of this study could be used in clinical practice to improve guidance provided to parents regarding interventions for children's pain relief.     

Parents' support and satisfaction with their child's postoperative care

It is recognized that parents' presence during their child's hospitalization is of benefit to the parents and the child. However, the level of parental involvement in their child's care may be influenced by many factors, such as the amount of support nurses provide for parents. This article reports on two themes from the findings of a larger study on parental involvement in children's postoperative pain management - parental support and parents' satisfaction with their child's postoperative pain management. The aim of the larger study was to explore both nurses' and parents' perceptions of parental involvement in their child's postoperative pain management. The methods used were both qualitative and quantitative. The qualitative method of phenomenology was used to guide 20 nurse and 20 parent interviews. Quantitative methods involved surveying the nurses and parents on their perceptions of how supportive the nurses were towards the parents. The charts of 20 children were reviewed for pain-related data. This article reports on the issues of parent support from the results of the survey, and on satisfaction relating to their child's postoperative pain management from the parent interviews. The findings demonstrated that nurses perceived that parents were receiving more support from them than that which parents felt they were receiving. Parents were more satisfied with their child's pain management and children received more analgesia when they were cared for by a lower grade nurse.     

Concepts of pain in preschoolers and children of early school age and their parents after painful interventions during hospitalization

Subject of the present study are individual pain concepts of preschoolers and children of early school age. Their parents' concepts of pain were considered as well. In a qualitative study interviews were performed with 9 children and their parents in a children's hospital to investigate their individual concepts of pain, their methods of pain assessment, and self-initiated strategies of pain alleviation. Already 4-6 year old children are able to remember painful experiences and to communicate about pain. Strategies of pain alleviation used by children are distraction methods as well as methods of physical relief. The child's parents play an important role concerning pain assessment and coping. The parents' presence is also very important to communicate the child's needs to nurses. Parents want nurses to consider physiological as well as behavioral aspects in the assessment of the child's pain. Besides, they expect nurses to have competences concerning prevention, assessment and alleviation of pain. To perform a trustful relationship to children and parents, more intensified counselling by nurses seems necessary.     

Assessment of acute pediatric pain: do child self-report, parent ratings, and nurse ratings measure the same phenomenon?

The purpose of this study was to determine the factors that are associated with child, parent, and nurse ratings of acute pediatric pain and distress during venipuncture. The behavior of eighty-five pediatric cancer patients during venipuncture was recorded by trained raters, and their observations were compared with ratings of pain and distress obtained from parents, pediatric patients, and pediatric nurses. Regression analyses indicated that ratings made by the child, parent, and nurse reflect different perspectives. Nurses' ratings were based upon overt distress, parents' ratings reflected their subjective perception of the child's pain, and the child's self-report was associated with the child's chronologic age.     

The effect of standard care, ibuprofen, and distraction on pain relief and patient satisfaction in children with musculoskeletal trauma.

INTRODUCTION: The purpose of this study was to determine the effectiveness of nursing interventions in decreasing pain for children with minor musculoskeletal trauma and moderate pain and to examine patient satisfaction. METHODS: Children were assigned to 1 of 3 intervention groups: (1) standard care (ice, elevation, and immobilization) only; (2) standard care and ibuprofen; or (3) standard care and distraction. Children were monitored for pain ratings for 60 minutes. Children who sustained minor musculoskeletal trauma within the past 24 hours and presented with pain ratings of 2 or greater using the 0-5 Wong/Baker faces scale were included. Two patient satisfaction questions were asked of parents upon their child's discharge from the emergency department. RESULTS: A statistically significant decrease in pain for all patients (76) occurred at 30 minutes (F = 4.39, P <.05) and was maintained at 60 minutes. The distraction group demonstrated a statistically significant reduction in pain compared with the other groups at 30 minutes; this reduction was maintained at 60 minutes (F = 47.07, P <.05). Parents of only 6 children expressed dissatisfaction with overall pain management. Twelve percent of children who were not in the group receiving medication received analgesics while in the emergency department. At discharge, only 37% of children with fractures and/or sprains had received medications for pain. DISCUSSION: Children with musculoskeletal trauma may be under-medicated. Distraction techniques can be an effective adjunct to analgesia for children with musculoskeletal pain in the emergency department and should be made available. Ibuprofen may not be an effective analgesic for children with these injuries; stronger analgesics may be required.     

Validation of the COMFORT Behavior Scale and the FLACC Scale for Pain Assessment in Chinese Children after Cardiac Surgery

Appropriate pain assessment plays a key role in understanding the pain status of critically ill children. However, the utility of the face, legs, activity, cry, consolability (FLACC) scale and the COMFORT Behavior (COMFORT-B) scale have not been extensively explored for children after cardiac surgery in China. A repeated-observation study was conducted to evaluate the concurrent validity and the sensitivity and specificity of the COMFORT-B and FLACC scales for pain assessment after cardiac surgery in 0–7-year-old patients. Patients were assessed with the observational visual analog scale (VASobs), FLACC scale, and COMFORT-B scale simultaneously at 18 fixed time periods for 3 days. Correlations among pain assessments were computed to calculate concurrent validity. Receiver operating characteristic curve analyses identified the FLACC and COMFORT-B scores that could best discriminate pain and no pain based on the VASobs. Multiple regression analyses were performed with FLACC and COMFORT-B pain scores as dependent variables and disease-related treatment characteristics as predictor variables for conducting the analysis. A total of 170 children (98 boys and 72 girls) were included. Significantly positive correlations, ranging from 0.31 to 0.86, were found among the COMFORT-B, FLACC, and VASobs pain assessment instruments. The COMFORT-B and the FLACC scores for children assessed to be in pain (i.e., VASobs ≥4), were significantly higher than scores for children not in pain (VASobs <4). COMFORT-B showed good sensitivity (86%) and specificity (83%) with a cutoff point of 13. FLACC showed excellent sensitivity (98%) and good specificity (88%) for a cutoff point of 2. The COMFORT-B and FLACC scales seem to be useful tools in pain assessment for Chinese children at postcardiac surgery stages, but the study identified that this group of children demonstrated a lower cutoff point for pain than originally set for these two instruments.     

Mothers' modeling influences children's pain during a cold pressor task

We set out to determine whether observing one's mother's reaction during a cold pressor test changes ratings of pain threshold, pain intensity, and observed pain-related facial behavior during a cold pressor test, using a Repeated Measures Mixed Factorial design in the setting of the Psychology Department, Dalhousie University, Halifax, Canada. The participants were: 96 mothers (mean age 41 years,) and 96 children (48 males, mean age 12.6 years), all in good general health. Pain intensity was measured using a 0-10 rating scale. Pain threshold was measured by asking participants to signal the moment any pain began and recording time elapsed since immersion. The Child Facial Coding System (CFCS; Revised manual for the child facial coding system (unpublished). Dalhousie University and University of British Columbia; Chambers et al., 1996) measured pain-related facial behavior. Mothers assigned to the Exaggerate condition were instructed, via videotape, to slightly exaggerate their display of pain and indicate a pain threshold within the first 10-20 s of a 4-min cold pressor task using water at 10 degrees C. Mothers in the Minimize condition were instructed to minimize their display of pain. Mothers assigned to the Control condition were given no specific instructions. All mothers privately rated their own pain intensity every 30 s. Children then completed a similar cold pressor task and made similar ratings. Children assigned to the Exaggerate Group (mean 21.7 s; SD 3.9) had lower thresholds than did children in the Control Group (mean 35.6 s; SD 21.8; t(1,76)=2.515, P=0.014). No difference in threshold was observed between the Control and the Minimize Groups (mean 32.2 s; SD 4.2; t(1,76)=0.610, P=0.544). No differences were observed in the self-report pain ratings of children between groups (F<1). CFCS Scores were significantly lower in the Minimize group compared to the Control group (95% CI 4.98-20.19, P=0.001), but no difference was noted between the Exaggerate and Control groups (95% CI -8.03-6.93, P=0.884). Children's pain threshold and their facial behavior are altered by exposure to mother's behavior during a cold pressor task suggesting that modeling has an impact on a child's pain behavior.     

Clinical validation of FLACC: preverbal patient pain scale

PURPOSE: To test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) pain assessment tool by measuring changes in scores in response to analgesics. METHOD: METHODS: Pediatric nurses used the FLACC scale to assess pain in 147 children under 3 years of age who were hospitalized in the pediatric intensive care unit (PICU), post-anesthesia care unit (PACU), surgical/trauma unit, hematology/oncology unit, or infant unit. FLACC is an observational tool for quantifying pain behaviors. Facial expression, leg movement, activity, cry, and consolability are each scored 0-2, for a total FLACC score of 0-10. The FLACC measurements were done pre-analgesia, at predicted onset of analgesia, and at predicted peak analgesia. FINDINGS: Pre-analgesia FLACC scores were significantly higher than post-analgesic scores and significantly higher for patients who received opioids than patients who received non-opioids. Peak analgesia FLACC scores across analgesia groups were not significantly different and reflect effective pain relief for patients regardless of analgesic choice. CONCLUSIONS: The FLACC pain assessment tool is appropriate for preverbal children in pain from surgery, trauma, cancer, or other disease processes. The results support pediatric nurses' clinical judgment to determine analgesic choice rather than providing distinct FLACC scores to guide analgesic selection.     

Painful pricks and prickle pains: is there a relation between children's ratings of venipuncture pain and parental assessments of usual reaction to other pains?

OBJECTIVE: The objective of this study was to examine whether parental assessment of a child's usual behavioral reaction to common painful events predicts the child's ratings of needle pain intensity from routine venipuncture. DESIGN: Children aged 3 to 12 years (n = 88) used the Faces Pain Scale to rate how much venipuncture hurt and also indicated whether the pain was more, less, or the same as expected. The child's parent (mother) used the same scale to predict how much the needle would hurt the child as well as to rate the child's pain as observed at the time of venipuncture. Parents also estimated their child's usual reaction to six common painful events. An independent observer used a behavioral checklist to rate the child's pain response at the time of venipuncture as well as to assign a global pain rating on the Faces Pain Scale. OUTCOME MEASURES: The Faces Pain Scale and a behavioral checklist (scoring facial, vocal, motor, and verbal reactions) were used in this study. RESULTS AND CONCLUSIONS: Those children who reported venipuncture as hurting more than expected also gave the highest mean needle pain ratings and tended to have their pain underpredicted by their parents before venipuncture. For these children, parental estimates of reactions to other painful events proved to be a useful predictor of self-reported needle pain. Parent and child ratings of pain agreed more closely for those parents who indicated having relied on what their child "did" rather than "said." Additionally, and consistent with previous studies, independent observation of children's facial responses was the most useful indicator of needle pain severity. Preparation of children for venipuncture may be enhanced by asking a parent beforehand how the child usually responds to everyday pain. Specifically, reaction to other sharp time-limited pains (e.g., finger pinch, stepping on a prickle) may provide a useful guide to identifying which children will report experiencing greater pain than expected from venipuncture.     

Children's pain at home following (adeno) tonsillectomy.

The aim of this study was to evaluate the prevalence and severity of children's pain at home following (adeno)tonsillectomies. The subjects were parents of 161 children (86 boys, 75 girls) undergoing myringotomies, adenoidectomies and (adeno)tonsillectomies. The mean age of the children was 5.5 years (SD=2.4; range 1-14). Parents were asked to assess the child's average pain on the day of operation and 7 days after the operation, using a 100 mm Visual Analogue Scale (VAS). Parents from (adeno)tonsillectomy patients were also interviewed by phone on day 7.The mean VAS pain intensity scores by period (day of operation until 7th day after operation) differed between the myringotomy (3.2), adenoidectomy (10.6), and (adeno)tonsillectomy (22.1) group (F(2,133)=31.65; p<0.001). The VAS ratings were highest for the tonsillectomy group (p<0.001). There was a trend that pain intensity scores for adenoidectomies were significantly higher than scores for myringotomies (p=0.07). In the interviews, 81% of the parents stated that their child suffered pain at home. However, this was not necessarily a reason to administer an analgesic. Furthermore, parents reported pain-related problems like problems regarding eating, fluid intake, vomiting and sleep disturbance. Finally, 67% of the children at home recalled severe pain experience in the hospital.It was concluded that especially following (adeno)tonsillectomies children suffer clinically significant pain at home and that the management of pain and related problems needs to be clearly improved.     

A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery.

Parents need education about pain so they can support their hospitalized child and manage their child's pain at home. The purpose of this study was to examine the effectiveness of a pain booklet on parental pain support to children experiencing postoperative pain. A randomized, repeated measures, experimental design using a pain education booklet and a standard care comparison group was used to study parents of 51 children (3 to 16 years of age) having cardiac surgery. Measurement techniques used to assess differences in parental pain management included: attitudes about pain medication, child and parent pain ratings (Oucher), opioids used, recovery, satisfaction, and comfort in communication. Results indicate that children do report moderate levels of pain postoperatively. Parents who were exposed to the pain assessment and management for parents education booklet preoperatively significantly increased their knowledge and attitudes toward pain medication scores from pre- to post-test, whereas those in the control group remained stable. Post-test scores were not significantly different between groups. Child and parent pain ratings were significantly and positively correlated. Practice implications include the use of an educational booklet about pain with parents before surgery to increase their knowledge about and attitudes toward pain management. Additionally, a parent may provide an alternative pain report when a child is unable to or unwilling to self-report their pain.     

Parents' perceptions of their child's acute pain experience

Painful procedures, experienced by many pediatric patients early in their admission, have been identified by parents in our clinical practice as a source of stress. The purpose of this study was to examine parents' perceptions and concerns about their child's acute pain experience. A convenience sample of 71 parents of 62 children was given a questionnaire that focused on the child's pain intensity, the behaviors that indicated the child was in pain, and the parents' preparation for and involvement in the child's pain experience. The majority of parents were asking for more information about and greater participation in procedures that caused their child pain.     

家长参与的疼痛护理在先天性心脏病术后的应用

【】　目的　评价父母－护士共同参与的疼痛护理在先天性心脏病手术后期的应用。方法　随机抽取对照组患儿30例及实验组患儿30例, 用疼痛行为评估量表(FLACC) 评估两组患儿术后第2～7天的疼痛情况。对照组父母不参与疼痛评估,仅参与非药物性止痛措施,实验组父母参与疼痛评估和非药物性止痛措施。结果　　术后第2～4天,实验组患儿疼痛评分低于对照组,比较差异有统计学意义( P < 0.05);术后第5～7天疼痛评分两组比较差异无统计学意义( P > 0.05) 。结论　父母－护士共同参与的交互式疼痛护理能有效减轻先心病患儿术后疼痛。     

Parental views on participation in their child's pain relief measures and recommendations to health care providers

The purpose of this study was to describe parental views on the factors influencing participation in their 8- to 12-year-old hospitalized child's surgical pain relief measures, and the recommendations to health care providers concerning alleviation of their child's pain. The data were collected by a questionnaire completed by parents (N = 192) whose child was hospitalized in one of the pediatric surgical wards in the five university hospitals of Finland. Results revealed that most of the parents (98%) agreed to having adequate opportunities to participate in their child's care according to their personal preferences; however, only 23% of the parents totally agreed that they had a clearly defined role in their child's pain relief measures. Feelings such as concern, fear, helplessness, anxiety, and depression were commonly experienced by the parents during their child's hospitalization. Most of the parents' recommendations concerned the topic of providing information. The findings of this study have implications for nursing practice.