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children and across all settings. Individual needs of the

children lead to assess and re-evaluate of pain consistently

as a mandatory in every situation. On top of that,

ethnicity, language, and cultural factors should be under

consideration as they may influence pain assessments and

its expression [5,12,26].

Most formal and commonly used means of pediatric

assessment tools for pain are available and categorized

depending the pediatrics age.

Pain Assessment in Neonates

Neonates pain rating scale (NPR-S): Major guidelines

indicate that the assessment of pain in neonates (term

babies up to 4 weeks of age) had better be use the Crying,

Requires oxygen for saturation above 95%, Increasing

vital signs, Expression and Sleepless (CRIES) scale

(Table 2) [2,24,27-30].

Several other pain scales have been designed for the

objective assessment of neonatal pain, including the

COMFORT ("behavior") score, pain assessment tool, scale

for use in newborns, distress scale for ventilated newborns

and infants. Although these assessments are validated as

research tools, the mainstay of appropriate management

includes the caregiver's awareness, knowledge of clinical

situations where in pain occurs, and sensitivity to the

necessity of preventing and controlling pain [31].

Assessment of pain in infants: On a study in Australia

hospitals, Infants (1 month to approximately 4 years) were

scored using the face, leg, activity, cancelability and cry

(FLACC) measuring tool. Scoring should be done by staff

Crying

Requires O

for sat >95%

Increased vital signs

Expression

Sleepless

No particular expression

Face

Normal position or

Legs

Lying quietly, normal

Activity

position, moves easily

Cry

Cancelability

Content or relaxed

150

Table 2. Neonatal pain rating scale [27-29]

Cries Pain Rating Scale

HR and BP <or=pre-op

None

Table 3. FLACC assessment tool [27,29,32-35]

FLACC Behavioral Pain Assessment Tool

Occasional grimace/frown withdrawn or

or smile

relaxed

squirming, shifting back and forth, tense

No cry

Moans or Whimpers, occasional complaint

Reassured by occasional touching,

hugging or being talked to, distractible

after observing the infant for 1 min. Among two observers

a reliability of FLACC was established in a total of 30

children in the post anesthetics care unit (PACU) (r=0.94).

After analgesic administration, validity was established

by demonstrating a proper decrease in FLACC scores.

Correspondingly, a high degree of association was found

between PACU nurse's global pain rating scale, FLACC

scores, and with the objective scores of pains scale. This

tool has been established in various settings and in diverse

patient populations and finds that as reliable and valuable.

It provides a simple background for computing pain

behaviors in children who may not be able to put into words

the incidence or severity of pain. Lastly, the constructed

validity is supported by analgesic administration as the

scores decreases significantly. Another recent studies

have demonstrated that FLACC was the most chosen in

terms of sensible qualities by clinicians at their respective

institutions [27,29,32-35]. Although the tool can be

used by clinicians, it is more effective with parent input

to provide a description of 'baseline' behavior. This is

supported by the findings of the Malvinas study, which

suggested that the addition of unique descriptors allowed

parents to augment the tool with individual behaviors

unique to their children. In addition, for infants who show

good comprehension and motor skills, this pain assessment

tool can be used as an alternative [36]. The FLACC scale

has 98% sensitivity and 88% specificity in assessing pain

levels [34]. Therefore, those different studies concluded

that FLACC scale is the most appropriate measurement

tool for pain assessment in infants (Table 3).

high pitched

<30%

HR and BP;

Increased <20% of

pre-op

Grimace

Wakes at frequent

intervals

disinterested

Uneasy, restless or tense

inconsolable

>30%

HR and BP; Increased >20% of

pre-op

Grimace/grunt

Constantly awake

Frequent/constant quivering

chin, clenched jaw

Kicking or legs drawn up

Arched, rigid or jerking

Crying steadily, screams or

sobs, frequent complaints

Difficult to console or comfort

Curr Pediatr Res 2017 Volume 21 Issue 1

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