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Health Review

Guidelines, strategies and tools for pain assessment in children

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Good pain assessment in children is crucial for effective management. This article is accompanied by a self-assessment questionnaire so you can test your knowledge after reading it


Unrelieved pain in children has several undesirable physical and psychological consequences in the short and longer term. Other effects of unrelieved pain include prolonged hospital stays, more readmissions and more outpatient visits. This article discusses why assessing pain in children is important, identifies best practice with reference to current guidelines, outlines the strategies that can be used to assess children’s pain and describes pain assessment tools for different ages and cognitive abilities. This is the first of three articles on how to manage pain in children.

Citation: Twycross A (2017) Guidelines, strategies and tools for pain assessment in children. Nursing Times [online]; 113: 5, 18-21.

Author: Alison Twycross is head of children’s nursing and professor of children’s nursing, London South Bank University, London.


Unrelieved pain in children has undesirable physical and psychological consequences that can affect them in both the short and longer term. Physiological responses include increased heart and breathing rates to facilitate vital organs’ increasing demands for oxygen and nutrients. Psychological consequences include: 

  • Anxiety, fear, distress, feelings of helplessness or hopelessness;
  • Avoidance of activity or medical procedures in future;
  • Sleep disturbances;
  • Loss of appetite.

Failure to relieve pain produces a prolonged stress state, which can result in harmful multisystem effects. There is also evidence that acute (post-operative) pain can result in chronic pain in a small but significant number of children (Lauridsen et al, 2014). Other unwanted effects of unrelieved pain include: 

  • Prolonged hospital stays; 
  • Increased rates of readmission to hospital; 
  • Increased number of outpatient visits (Schug et al, 2015). 

When considering all the above, it becomes clear why it is important to assess and manage children’s pain effectively. This article – the first of a three-part series on managing pain in children – covers pain assessment. It identifies best practice with reference to current guidelines, outlines the strategies that can be used to assess children’s pain, and describes pain assessment tools for different ages and cognitive abilities. It offers an opportunity to reflect on our own practice and identify where change may be needed.

Best practice guidelines

Pain assessment is the first step in ensuring children’s pain is managed effectively (Fig 1). If pain is not assessed, it is difficult to evaluate the effectiveness of any pain-relieving interventions and decide whether further action is needed. 

Fig 1. The stages of pain management in children

Current guidelines on assessing pain in children (Box 1) state that we should: 

  • Ask them about their pain using a developmentally appropriate self-report pain tool (if possible);
  • Involve the parents and/or carers to find out how their child normally behaves when in pain;
  • Take the child’s behavioural cues into account;
  • Note any physiological cues that may indicate the child is in pain;
  • Reassess pain after pain-relieving interventions have been implemented;
  • Document the child’s pain assessment scores.

Box 1. Current guidelines on pain assessment in children

Despite the availability of best-practice guidelines, children continue to experience unnecessary pain during hospital stays (Twycross and Finley, 2013). A recent systematic review of the evidence regarding nurses’ assessment of post-operative pain in children found that children’s behavioural cues are considered more important than their self-report of pain and that a significant proportion of children did not have pain scores recorded in the first 24 hours after surgery (Twycross et al, 2015). This suggests that practices still need to improve. 

Pain assessment strategies

The three approaches to measuring pain in children are:

  • Self-report – what the child says;
  • Behavioural indicators – how the child behaves;
  • Physiological indicators – how the child’s body reacts (Stinson and Jibb, 2014). 

Self-report strategies are normally used with children who are old enough to understand and use a self-reporting scale (that is, from three years onwards), who are not overtly distressed and/or who are not cognitively impaired (Stinson et al, 2006).

With infants, toddlers, pre-verbal children, and those who are cognitively impaired or sedated, behavioural pain assessment tools should be used. These should also be used with older children if they are overtly distressed – this allows the practitioner to estimate their pain until they are less distressed. 

Children often exhibit behaviours indicating that they are in pain (Box 2). However, their self-reports of pain do not always correlate strongly with their behaviours (Nilsson et al, 2008). Individuals differ in how they express pain, so it is important to ascertain how a child normally behaves when in pain. An assessment based on behavioural indicators will only provide an estimate of how much pain the child is experiencing. 

Box 2. Behavioural indicators of pain in children

  • Irritability
  • Unusual posture
  • Reluctance to move
  • Disturbed sleep pattern
  • Unusual quietness
  • Restlessness
  • Sobbing
  • Lethargy
  • Screaming
  • Aggressiveness
  • Increased clinging
  • Loss of appetite
  • Whimpering
  • Laying ‘scared stiff’

When used alone, physiological indicators (Table 1) are not a valid clinical measure of pain, as they can be affected by other physiological changes and occur in response to other factors including fever, anxiety and exertion. Given this, a pain assessment tool that incorporates both physiological and behavioural indicators, as well as the child’s self-report whenever possible, should be used.

Table 1. Physiological indicators of pain in children

Pain assessment tools

In the hospital setting it is usually necessary to have more than one pain assessment tool to cater for all patient groups. Ideally, pain assessment tools in a clinical area should all use a common metric – for example, pain rated from 0-10 or 0-5 in all tools (Stinson and Jibb, 2014). This means that a pain score of 5 will mean the same no matter which tool is used. This will make communication easier and pain-relieving interventions more effective. 

Tools commonly used to assess pain in children are detailed in Table 2. The tool for neonates that has been tested most often is the Premature Infant Pain Profile (PIPP). Click to see an example of how the PIPP is used in practice. The behavioural tool most frequently used with pre-verbal children in the UK is the Face, Legs, Activity, Cry and Consolability (FLACC) tool, while the revised FLACC is most commonly used with cognitively impaired children. For verbal children, the use of a faces pain scale or a numerical rating scale is recommended, depending on their age and developmental level. When using a faces pain scale it is important to explain how it is used (Box 3) and check that the child understands. 

Table 2.  Pain assessment in children: commonly used tools

Box 3. Explaining a faces pain scale to children

  • The scale consists of six faces numbered 0-10. Explain to the child that each is for a person who feels happy or sad because he/she has no pain (hurt) or some or a lot of pain:
    • Face 0 – very happy because it doesn’t hurt at all
    • Face 2  – hurts just a little bit
    • Face 4  – hurts a little more
    • Face 6  – hurts even more
    • Face 8  – hurts a whole lot more
    • Face 10  – hurts as much as you can imagine, although you do not have to be crying to feel this bad
  • Ask the child to choose the face that best describes how he/she is feeling

Source: Adapted from Hockenberry et al (2005)

More information about pain assessment tools that have been developed and validated for use with children of different ages and cognitive abilities is available; details can be found in Schug et al (2015) and the Royal College of Nursing (2009).

Reassessing and documenting

Pain should be reassessed once pain-relieving interventions – usually analgesic drugs, but also non-drug methods such as distraction – have had a chance to work so you know whether the treatment needs adjusting. Regular reassessment and documentation of pain is essential for effective treatment and good communication between members of the healthcare team, and with the child and family. Despite this, it has been noted that some health professionals do not always record pain assessment (Twycross et al, 2013). 

Standardised forms and tools – for example, admission assessment forms and observation charts – encourage the initial and ongoing assessment and documentation of pain. 


Assessing children’s pain is an important first step in managing it effectively. Pain in children can be assessed using self-report tools as well as behavioural and physical indicators. Once pain has been assessed and pain-relieving interventions implemented, it is important to reassess pain to ascertain whether further action is needed and what should be done. 

The scenarios in Box 4 are part of the Nursing Times Self-assessment test, enabling you to check your knowledge. 

Box 4. Test your skills

Scenario 1

Alfie is nine months old and had surgery two days ago to repair a cleft palate. He is playing in his cot but is reluctant to drink.

  • Which pain assessment tool(s) should you use to assess his pain and why?

Scenario 2

Julie is eight years old and had an appendectomy yesterday. She has not had any analgesic drugs for six hours and is lying rigid in the bed. 

  • How much pain do you think Julie has?
  • What tools should you use to assess Julie’s pain and why?

Scenario 3

Winston is five years old and has just started school. He can communicate verbally if things are explained to him in a way he understands. He cannot yet count to 10 and has come to accident and emergency with abdominal pain.

  • Which pain assessment tool(s) should you use to assess his pain and why?

Check your answers to these scenarios by taking the Nursing Times Self-assessment test.

Key points 

  • Unrelieved pain in children has several undesirable short- and long-term consequences, and so it is important to manage it effectively
  • Assessing a child’s pain is the first step in ensuring effective management
  • Children’s pain can be assessed using self-report tools as well as behavioural or physiological indicators
  • Whenever possible children’s self-report should be used to assess their pain
  • A child’s pain should be reassessed following the implementation of pain-relieving interventions

self assessment logo 2

  • Test your knowledge with Nursing Times Self-assessment after reading this article. If you score 80% or more, you will receive a personalised certificate that you can download and store in your NT Portfolio as CPD or revalidation evidence.
  • Take the Nursing Times Self-assessment for this article


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