Question

Read Chapters 29 to 30 for Quiz # 7 ( Next Week)

II. Pain Assessment and management in children.

a) Write a description and interpretation of the several pain assessment scales

FLACC

CHEOPS

TPPPS, PPPRS, PPPM

COMFORT

FACES ( FPS-R and Wong-B

Answer 1

1) FLACC

The FLACC scale or Face, Legs, Activity, Cry, Consolability scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain. The scale is scored in a range of 0–10 with 0 representing no pain. The scale has five criteria, which are each assigned a score of 0, 1 or 2.The FLACC scale has also been found to be accurate for use with adults in intensive-care units (ICU) who are unable to speak due to intubation. The FLACC scale offered the same evaluation of pain as did the Checklist of Nonverbal Pain Indicators (CNPI) scale which is used in ICUs

Criteria	Score 0	Score 1	Score 2
Face	No particular expression or smile	Occasional grimace or frown, withdrawn, uninterested	Frequent to constant quivering chin, clenched jaw
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	Reassured by occasional touching, hugging or being talked to, distractible	Difficult to console or comfort

2) CHEOPS

The CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) is a behavioral scale for evaluating postoperative pain in young children. It can be used to monitor the effectiveness of interventions for reducing the pain and discomfort.

Patients: • The initial study was done on children 1 to 5 years of age. • It has been used in studies with adolescents but this may not be an appropriate instrument for that age group. • According to Mitchell (1999) it is intended for ages 0-4.

Parameter	Finding	Points
cry	no cry	1
	moaning	2
	crying	2
	screaming	3
facial	smiling	0
	composed	1
	grimace	2
child verbal	positive	0
	none	1
	complaints other than pain	1
	pain complaints	2
	both pain and non-pain complaints	2
torso	neutral	1
	shifting	2
	tense	2
	shivering	2
	upright	2
	restrained	2
touch	not touching	1
	reach	2
	touch	2
	grab	2
	restrained	2
legs	neutral	1
	squirming kicking	2
	drawn up tensed	2
	standing	2
	restrained	2

where:

• no cry: child is not crying • moaning: child is moaning or quietly vocalizing silent cry • crying: child is crying but the cry is gentle or whimpering • screaming: child is in a full-lunged cry; sobbing may be scored with complaint or without complaint • smiling: score only if definite positive facial expression • composed: neutral facial expression • grimace: score only if definite negative facial expression • positive (verbal): child makes any positive statement or talks about other things without complaint • none (verbal): child not talking • complaints other than pain: child complains but not about pain ("I want to see mommy: or "I am thirsty") • pain complaints: child complains about pain • both pain and non-pain complaints: child complains about pain and about other things (e.g. It hurts; I want mommy. ) • neutral (torso): body (not limbs) is at rest; torso is inactive • shifting: body is in motion in a shifting or serpentine fashion • tense: body is arched or rigid • shivering: body is shuddering or shaking involuntarily • upright: child is in a vertical or upright position • restrained: body is restrained • not touching: child is not touching or grabbing at wound • reach: child is reaching for but not touching wound • touch: child is gently touching wound or wound area • grab: child is grabbing vigorously at wound •

restrained: child's arms are restrained • neutral (legs): legs may be in any position but are releaxed; includes gently swimming • squirming kicking: definitive uneasy or restless movements in the legs and/or striking out with foot or feet • drawn up tensed: legs tensed and/or pulled up tightly to body and kept there • standing: standing crouching or kneeling • restrained: child's legs are being held down CHEOPS pain score = SUM(points for all 6 parameters)

Interpretation:

minimum score: 4

maximum score: 13

3)

TPPPS, PPPRS, PPPM

Toddler, Preschooler, and Postoperative Pain Scale (TPPPS )

An observational measure used to measure postoperative pain in children aged 1-5 years and includes 3 behavioral groups:

1)Expression of pain by sounds (shouting, groaning, humming, snoring and grunting)

2) Pain in the face (mouth open, lips swelling to the face, looking at the corner of the eye, Close eyes, chin on the forehead and bumps of the eyebrows), and

3) Physical pains (motor behaviors when touching the painful area). These are not local reactions to pain, but they can provide a general overview of the overall body's disturbances in children with pain. To provide Physiological parameters as well as measures of behavior are useful for infants and children without speech.

Physiological parameters as well as measures of behavior are useful for infants and children without speech. Physiological parameters indirectly examine the pain and can be used to examine their pain and severity. The pain sources can be physical and psychological problems, so at the first step, the source of pain should be distinguished. Most studies in the field of physiological parameters are related to the infant and are usually used to measure sharp pains caused by processors

Parent's Postoperative Pain Rating Scale(PPPRS)

The Parent's Postoperative Pain Rating Scale (PPPRS) is a parental benchmark that reports changes in the frequency of child behavior.Wong-Becker smileys (1998) has six images ranging from a smiley face (signs of pain and equal to zero) to a tearful face (the highest level and equivalent pain score of 10). This scale is used in children aged 3–8 years. Validity and Reliability of Numerical Scale Scale of pain intensity and scaling scale of Wang-Fake smears have been confirmed in many studies. Spearman's coefficient of scalar scalar was calculated as 0.75 r = 0.87 in the Bayer study, which is a good indication of the reliability of the above scale. In GarA et al., Spearman's correlation coefficient r = 0.90 showed a good reliability of pain scaling scale for Wang- Becker smileys

4) COMFORT

Many pediatric intensive care units use the COMFORT-Behavior scale (COMFORT-B) to assess pain in 0- to 3-year-old children. The objective of this study was to determine whether this scale is also valid for the assessment of pain in 0- to 3-year-old children with Down syndrome. These children often undergo cardiac or intestinal surgery early in life and therefore admission to a pediatric intensive care unit. Seventy-six patients with Down syndrome were included and 466 without Down syndrome. Pain was regularly assessed with the COMFORT-B scale and the pain Numeric Rating Scale (NRS). For either group, confirmatory factor analyses revealed a 1-factor model. Internal consistency between COMFORT-B items was good (Cronbach's α=0.84-0.87). Cutoff values for the COMFORT-B set at 17 or higher discriminated between pain (NRS pain of 4 or higher) and no pain (NRS pain below 4) in both groups. We concluded that the COMFORT-B scale is also valid for 0- to 3-year-old children with Down syndrome. This makes it even more useful in the pediatric intensive care unit setting, doing away with the need to apply another instrument for those children younger than 3.

5) FACES ( FPS-R and Wong-B)

Proper pain assessment is the cornerstone for proper pain treatment. Below we have listed commonly used age and developmental stage specific guidelines for pediatric pain assessment.

Physiologic Measures Many times on rounds clinicians are overheard saying, “The heart rate and blood pressure are normal, how could this patient have 8 out of ten pain?” Actually, a child, teenager or adult may experience severe pain and not have a change in their heart rate or blood pressure. These measures may be the only currently useful index of pain in the intraoperative setting but are non-specific and must be analyzed in context.

~3-7 years old: Faces Pain Scale – Revised (FPS-R) In the child who is developmentally able, self-report is the gold standard. Fortunately, instruments exist for children ~3-7 years old to aid in their self-report. Many readers are probably familiar with the Wong-Baker FACES scale (Wong-Baker, shown). The FACES pain scale has been revised so that the scale is from zero to ten rather than zero to five as in the WongBaker measure or zero to six as in the Bieri Faces Pain scale (not shown). The affective qualities including the smile and tears have been removed. When using the Faces Pain Scale Revised, you no longer have to include a statement such as “You can experience the worst pain and not be crying.

Instruction for Faces Pain Scale-Revised "These faces show how much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] – it shows very much pain. Point to the face that shows how much you hurt [right now]." Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so ’0’ = ’no pain’ and ’10’ = ’very much pain.’ Do not use words like ’happy’ and ’sad’. This scale is intended to measure how children feel inside, not how their face looks. (Once again, say "hurt" or "pain," whichever seems right for a particular child.)

The Faces Pain Scale-Revised is not a scale that our pediatric pain management service is using on a daily basis yet. When we initiate an educational initiative in pediatric pain management later this year, medical student, residents, fellows and nurse practitioners will be taught how to administer the Faces Pain Scale-Revised.

~8years or greater: Numeric rating scale for pain This is the method that almost everybody is probably familiar with. The provider asks, "On a scale of zero to ten, where zero means no pain and ten equals the worst possible pain, what is your current pain level?"

Common mistakes include the interviewer saying, “On a scale from ONE to ten” or “and ten equals the worst pain THAT YOU EVER HAD”. In the first example, the error is stating that one is the low end of the scale. As the second example shows, it is important not to put the highest end of the scale in terms of past experience. Remember that for children it often useful to substitute the terms “ouch” or “hurt” for the word “pain”.

The numeric rating scale may be categorized into no pain (0), mild pain (1-3), moderate pain (4-6), and severe pain, (7-10). These categories have been used in the past to indicate whether an opioid is indicated. Children with acute pain and some forms of chronic pain that is greater than six are frequently treated with an opioid.