How to assess infants pain experiences?
Valid and reliable pain assessment tools for infants and preverbal children are actually indirect measures of pain. Because these tools rely on observed behaviors and physiologic measures, they do not measure pain intensity but rather quantify responses to pain-related distress. Scores from these tools are influenced by contextual factors, such as gestational age and physiologic stability. Therefore pain assessment tools for infants and preverbal children are most reliable for procedural pain, rather than ongoing chronic pain assessments. These validated behavioral pain assessment tools should always be considered as proxy pain measures to be interpreted based on expected or potential tissue damage.
Tools for Assessing Pain of Infants and Preverbal Children
|TOOL (ACRONYM) AND REFERENCE (YEAR)||AGE RANGE||TYPE OF PAIN||PARAMETERS|
|Children’s and Infants’ Postoperative Pain Scale (CHIPPS)|
Bringuier et al. (2009); Buttner and Finke (2000)
|Birth to 5 years||Acute, postop||Scored from 0 to 10:|
• Cry• Facial• Leg posture motor/restlessness• Trunk poster
|COMFORT Behavior Scale|
de Jong et al. (2010); van Dijk et al. (2000, 2005)
|Neonates to 3 years||Acute, intensive care postop||Used to assess distress, sedation, and pain.|
Scored from 8 to 40:
• Alertness• Blood pressure• Calmness• Facial tension• Heart rate• Muscle tone• Physical movement• Respiratory distress
Also valid without physiologic parameters (COMFORT B).
|Crying, Requires oxygen, Increased vital signs, Expression, and Sleeplessness (CRIES)|
Ahn and Jun (2007); Krechel and Bildner (1995)
|Neonates||Acute, intensive care procedural, post-op||Scored from 0 to 10:|
• Crying• Requires oxygen—oxygenation• Increased vital signs, Expression• Sleeplessness
|Distress Scale for Ventilated Newborn Infants (DSVNI)|
|Ventilated, neonates and infants||Acute, intensive care procedural||Sum of four physiologic parameters:|
• Blood pressure• Heart rate• Oxygen saturation• Temperature differentialAnd three behavioral parameters:• Body movements• Facial expressions
|Faces, Legs, Activity, Cry, and Consolability Observational Tool (FLACC)|
Ahn and Jun (2007); Manworren and Hynan (2003); Merkel et al. (1997); Voepel-Lewis et al. (2002, 2010); Willis et al. (2003)
|0–3 years, Up to 7 years in post-anesthesia care unit||Acute, procedural, postop, disease-related||Scored from 0 to 10:|
• Faces• Legs• Activity• Cry• Consolability
|Neonatal Infant Pain Scale (NIPS)|
Lawrence et al. (1993)
|Preterm and term infants||Scored 0 to 7:|
• Breathing pattern• Crying• Facial expression• Movement of arms and/or legs• State of arousal
|Neonatal Pain, Agitation, and Sedation Scale (N-PASS)|
Hummel et al. (2008); Hummel et al. (2010)
|Premature neonates 23–40 weeks gestation||Procedural and postop during mechanical ventilation neonatal intensive care unit||Used to assess sedation and pain.|
Scored from −2 to +2 for each parameter:
• Behavior• Cry• Extremity tone• Facial expression• Vital signs
in the context of gestational age.
|Premature Infant Pain Profile (PIPP) and Premature Infant Pain Profile—Revised (PIPP-R)|
Ahn and Jun (2007); Gibbins et al. (PIPP-R, 2014); Stevens et al. (1996); Stevens et al. (2010)
|Premature and term neonates||Procedural and postop in neonatal intensive care unit||Scored from 0 to 21:|
• Brow bulge• Eye squeeze• Heart rate• Nasolabial furrow• Oxygen saturation in the context of gestational age and behavioral state.
As children gain control over their ability to express themselves verbally and control their behaviors, behavioral tools become inappropriate for assessing their pain. Toddlers can report the presence and location of pain, adopting words learned to express pain and pain location from their parents and caregivers. As children develop more complex verbal skills and cognitive understanding, they also develop a more diverse pain vocabulary.