Assessing pain by age and developmental level

The healthcare team will assess pain based on your child’s age and developmental level. Their assessment usually includes listening to how a child describes pain and using pain measurement tools. They also pay attention to a child’s behaviours, such as facial expressions, and how their bodies react to pain, such as increased heart rate. These measures also help the healthcare team measure pain in children who are developmentally challenged or who can’t talk about their pain for other reasons.

The best way to assess pain in babies is to observe how they behave. The FLACC (faces, legs, activity, cry, consolability) scale is an easy-to-use tool that helps measure pain in children who are too young to talk. The FLACC scale uses a checklist to assess pain by watching for facial expressions, body movements, body posture, crying, activity and appearance. It is most valid for acute, short-term pain and can be used for children as young as 2 months old.

Babies may show their pain by:

• kicking legs and waving arms
• arching the body
• having a rigid body
• making different facial expressions
• crying, screaming or groaning
• drawing knees to the chest
• being easily irritated
• not eating
• not sleeping
• not being easily comforted
• showing signs of sadness or anger

Toddlers can usually describe their pain and may even explain what caused their pain. Even children who can’t yet speak or who have limited speech can usually tell you how much pain there is, where it is and what it feels like. If possible, encourage your child to express pain in words that they understand, such as “boo-boo,” “owie” or “hurt.” Children may be better able to express their pain to a parent because there is already trust and a common language between them.

Pain assessment for toddlers may include:

• using a face pain scale to show how much pain they feel
• using a doll to show where the pain is
• watching how they behave or asking questions about how they behave

The healthcare team will look for or ask parents about:

• intense crying or yelling
• kicking legs and waving arms
• guarding, protecting or tugging a limb or other part of the body
• refusing a favourite toy, food or activity
• not being able to sleep
• showing physical resistance (for example, pushing a needle or doctor away)
• acting younger or becoming clingy
• being uncooperative

Preschoolers can usually express how bad their pain is. They may need someone to take the time to listen and encourage them to talk about it. Some preschoolers may see pain as punishment, so it is important to encourage them to tell you how they feel and reassure them that they haven’t done anything wrong.

Pain assessment for preschoolers may include:

• using a face pain scale to show how much pain they feel
• using a doll to show where the pain is
• watching how they behave or asking questions about how they behave

The healthcare team will look for or ask parents about:

• intense crying or yelling
• kicking legs and waving arms
• guarding, protecting or tugging a limb or other part of the body
• refusing a favourite toy, food or activity
• being unable to sleep
• showing physical resistance (for example, pushing a needle or doctor away)
• acting younger
• being uncooperative
• becoming clingy and asking for hugs and kisses

School-age children can talk more clearly about their pain. Older school-age children usually have a very good understanding of pain and can give detailed information. They understand that pain is usually due to an injury, that it will not last and that there are ways to manage it.

When trying to assess pain, it is important to remember that boys aged 8 to 11 years may be less able to express their pain than girls of the same age. School-age children may also be influenced by cultural beliefs. These beliefs may mean children are not as willing to talk about pain or they may think that pain is something they must put up with.

Pain assessment in school-age children may include:

• using a pain scale (numerical rating scale, face pain scale or visual analogue scale) to show how much pain they feel
• using their hands to show how big the pain is
• watching how they behave or asking questions about how they behave

The healthcare team will look for or ask parents about their child:

• becoming more clingy and asking for hugs or kisses
• guarding, protecting or tugging a limb or other part of the body
• refusing a favourite toy, food or activity
• being uncooperative
• being unable to sleep or having nightmares
• showing physical resistance (for example, pushing a needle or doctor away)
• avoiding things
• clenching fists, gritting teeth, contracting limbs, muscle tension, body stiffness, closing eyes or wrinkling forehead
• having changes in appetite, activity or sleep patterns
• acting younger

By the time they are teenagers, most children have had some experience with and a reasonable understanding of pain. They may even know how their emotional state influences the level of pain they feel or how their pain can be eased. Teenagers can use most of the self-reporting ways of assessing pain that are used with adults. But they may not want to express their pain because when they’ve done so in the past they have been told not to complain or that they should be stronger.

A teenager’s behaviour can be greatly influenced by their parents and by people their own age. A teenager may deny pain if friends are around. The healthcare team may need to do a private interview to get an accurate picture of a teenager’s pain.

When they are in pain, teenagers may display the following behaviours:

• changes in appetite, activity or sleep patterns
• muscle tension
• acting younger
• being unable to sleep

Assessing the pain of children with disabilities can be difficult for the child, parents and healthcare team. Assessment may include:

• observing the child’s mood (for example, if they are cranky)
• observing how the child acts (for example, if they seek comfort or gesture to the part of the body that hurts)
• looking for changes in the child’s eyes, such as avoiding eye contact or looking distracted
• watching for changes in how active the child is
• observing if the child cries or gasps