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Children experience pain to at least the same level as adults. Multiple studies have shown that neonates and infants perceive pain and have memory of these painful experiences. Frequently, children are under prescribed and underdosed for opioid and nonopioid analgesics due to excessive concerns of respiratory depression and/or poor understanding of the need for pain medications in children. Few data are available to guide the dosing of many pain medications, and the majority of pain medications available on the market today are unlabeled for use in pediatric patients.

Birnie  KA  et al: Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag 2014 Jul–Aug;19(4):198–204. Epub 2014 May 7
[PubMed: 24809068] .
Taddio  A, Katz  J: The effects of early pain experience in neonates on pain responses in infancy and childhood. Pediatr Drugs 2005;7:245–257
[PubMed: 16118561] .


Standardizing pain measurements require the use of appropriate pain assessment tools. Typically, these tools are one of two types: observational/behavioral (measures a patient’s reaction to pain) or self-report (patients quantify and describe pain). Self-report scales are standard of care in the assessment of pain, unless a patient is preverbal, cognitively impaired, or sedated. At most institutions, pain scales are stratified by age (see Table 32–1) and are used throughout the institution from operating room to medical floor to clinic, creating a common language around a patient’s pain. Pain assessment by scales has become the “5th vital sign” in hospital settings and is documented at least as frequently as heart rate and blood pressure at many pediatric centers around the world. There are many pain scales available, all of which have advantages and disadvantages (eg, Figures 32–1 and 32–2, and Table 32–1). For example, research has shown younger and school-age children prefer facial expression pain scales as it may be more difficult for them to understand numeric order and quantify pain, whereas older children and adolescents prefer numeric ratings. It is less important what type of scale is used, but that they are used on a consistent and continuous basis.

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Table 32–1. Pain scales—description and age-appropriate use.
Name of Scale Type Description Age Group
Numeric Self-report Verbal 0–10 scale; 0 = no pain, 10 = worst pain you could ever imagine Children who understand the concept of numbers, rank, and order; approximately > 8 y
Bieri and Wong-Baker scales Self-report Six faces that range from no pain to the worst pain you can imagine Younger children who have difficulty with numeric scale; cognitive age 3–7 y
FLACC Behavioral observer Five categories: face, legs, activity, cry, and consolability; range of total score is 0.10; score ≤ 7 is severe pain. Figures 32–1 and 32–2 and Table 32–2 Nonverbal children > 1 y
CRIES, NIPS, PIPP Behavioral observer Rates a set of standard criteria and ...

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