Pediatric Pain Rating Scale

Wong-Baker Facial Pain Rating Scale for Children Over 3 Years of Age

Wong-Baker Faces Pain Scale for Children 3 Years or Older (Wong D. L„ Baker S. M., 1988)

The Wong-Baker scale is designed to assess pain intensity in children. It includes pictures of faces - a smiling face, which means no pain (0 points out of 5), a face distorted by a grimace and crying, which means the greatest pain intensity (5 points out of 5). This scale is convenient for use in children and in patients with difficulty verbal communication. The Wong-Baker scale also has a close relationship with the visual analogue scale and facial pain scale.

Note: The schematic representation of the faces resembles the photographs from the Oucher scale, where, to assess the degree of pain, the child can choose one of the photographs of the faces of children with increasing expression of pain and without it.

Face	Description	Points
Smiling	Happy, no pain	0
A slight smile	Minor soreness	1
Neutral	Mild pain	2
The eyebrows are slightly furrowed.	Average pain	3
The eyebrows are deeply furrowed.	Severe pain	4
Cries, feels absolutely miserable	The most pain imaginable	5

[ 1 ], [ 2 ]

Children's pain scale KUSS Children's pain scale (KUSS)

(Büttner W. et al., 1998)

The scale includes five criteria: crying, facial expression, body position, leg position, motor restlessness. All parameters are assessed in the range from 0 to 5 points.

Parameters	Characteristic	Points
Cry	Absent	0
	Moans, whimpers	1
	A plaintive cry	2
Facial expression	Relaxed, smiling	0
	The mouth is crooked	1
	Grimace	2
Body position	Neutral	0
	Forced	1
	Stretches, bends	2
Position of the legs	Neutral	0
	Floundering, kicking	1
	Pulls to the body	2
Motor restlessness	Absent	0
	Insignificantly	1
	Worried	2

When observing a child, 5 parameters are assessed. The time of examining a child should not exceed 15 seconds, even if the child's behavior changes shortly after that.

The map records the sum of points of all criteria, which can be ranked according to 4 (AD) positions.

Interpretation of research results

Code	A	IN	WITH	D
KUSS scale assessment	0-1	2-3	4-7	8-10

• A - there is no need for analgesia.
• B - it is necessary to increase pain-relieving therapy.
• C - emergency relief of pain.

If the pain persists for an hour, a consultation is necessary to determine the cause of the pain and eliminate it.

Later, based on the KUSS scale, the authors created a new scale, which is known as CHIPPS.

[ 3 ], [ 4 ]

Postoperative pain assessment scale for infants and children up to 5 years of age

Children's and Infants' Postoperative Pain Scale (CHIPPS) (ButtnerW., FinkeW., 2000)

The CHIPPS scale was developed by W. Buttner and W. Finke to assess the need for postoperative analgesia in neonates and children up to 5 years of age. This scale is similar to the MOPS, but an interesting feature of the scale is the need to assess many physiological, anatomical and behavioral parameters to obtain a final assessment. The scale is intended for use in neonates and children up to 5 years of age. Crying, facial expression, body position, leg position, and motor restlessness are assessed.

Parameters	Description	Points
	No	0
Cry	Moan	1
	A piercing cry	2
	Relaxed, smiling	0
Facial expression	Twisted mouth	1
	Grimace	2
	Neutral	0
Body position	Constantly changing	1
	Trying to get up	2
	Neutral	0
Position of the legs	Crossed legs	1
	Tense (crossed) legs	2
	No	0
Motor restlessness	Moderate	1
	Expressed	2

Grand Total = Sum of points for all 5 parameters. The minimum score is 0, and the maximum is 10 points, and the higher the score, the more intense the pain.

Interpretation of research results

Score	Interpretation
0 to 3	No pain
4 to 10	Analgesia is needed, and the higher the score, the more urgent it is.

Indicators:

1. Cronbach's alpha for infants was 0.96 and for other children it was 0.92.
2. The reliability coefficient is 0.93.
3. The scale compares well with the TPPPS scale.
4. The sensitivity of the scale for the need for analgesia is 0.92-0.96, and the specificity is 0.74-0.95.

A behavioral-based scale for assessing acute pain in newborns

Douleur Aiguë du Nouveaune (DAN) (Carbajal R., Paupe A. et al., 1997)

Indicator	Grade	Score
Facial expression	Calm	0
	Whimpers, opens and closes eyes	1
	Crying grimace: moderate, episodic	2
	Crying grimace: moderate	3
	Crying grimace: almost constant	4
Limb movements	Calm, smooth	0
	Occasional anxiety, then calms down	1
	Moderate anxiety	2
	Marked persistent anxiety	3
Crying (non-intubated neonates)	Doesn't cry	0
	Periodic groans	1
	Intermittent crying	2
	Prolonged crying, "howling"	3
Crying equivalents (intubated neonates)	Doesn't cry	0
	Restless looks	1
	Gestures characteristic of periodic crying	2
	Gestures characteristic of constant crying	3

Restlessness - pedaling, stretching and tensing the legs, spreading the fingers, chaotic arm movements.

The minimum score on the scale is 0 points (no pain), and the maximum is 10 points (the most severe pain).

Postoperative pain scale for toddlers and preschool children

Toddler-Preschooler Postoperative Pain Scale (TPPPS) (Tarbell SE, Marsh J. L, Cohen IT C„ 1991)

This scale can be used to assess the pain experienced by young children aged 1 to 5 years during and after medical and surgical procedures. The child must be awake. Pain is assessed by the following points: speech, facial expression, motor reactions.

Estimated parameters	Behavior
Speech	Complains of pain and/or cries
	Screams
	Heavy sighs, groans, grumbles
Facial expression	Open mouth, corners of mouth turned down
	Squints, closes eyes
	The forehead is wrinkled, the eyebrows are arched
Motor reactions	Restlessness and/or rubbing or touching the sore spot

• Verbal complaints of pain: any word, phrase, or statement that refers to pain, injury, or discomfort. The complaint must be phrased as a statement, not as a question.
• Crying: tears in the eyes and/or sad expression on the face and/or sobbing; crying associated with separation from parents is excluded, except for that caused by painful manipulations.
• Protruding eyebrows: formation of a crease between the eyebrows.
• Restless behavior: behavior with persistent bodily and/or head activity; may include random (unrelated) activity or lack of directed action.
• Touching, scratching, or massaging a body part that has undergone surgery or other medical intervention.
• Scream: sharp, loud, high-pitched cry, growl, groan, mumble: monotonous, low-pitched; may be moaning or abrupt muttering.
• Opens mouth with lips pursed at the corners: opens mouth with lips pursed at the corners, continuing to lower the lower jaw further.
• Squints, closes eyes: eyelids are pulled up, tense, eyes are open or half-open with wrinkles in the lateral part of the eyes.
• Wrinkles forehead or frowns.

Behavior assessment	Points
If pain is present within 5 minutes of observation	1
If there is no pain within 5 minutes of observation	0

1 point is awarded if the symptom is stable for 5 minutes of observation.

Pain score = Sum of points for all assessed parameters. Minimum score is 0 points, maximum is 7 points. The higher the score on the scale, the worse the child feels. 6.

Children's Hospital of Eastern Ontario Pain Scale

Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) in Young Children (McGrath PJ, Johnson G. et al., 1985)

CHEOPS is a behavioral, pediatric postoperative pain scale. It is used to dynamically assess the effectiveness of interventions to reduce pain and discomfort. The scale was originally developed for use in children aged 1 to 5 years, but it has also been used in adolescents, but data in this age group may be unreliable. According to Mitchell (1999), the scale is intended for use in children aged 0 to 4 years.

Estimated parameters		Description	Points
Cry	No crying	The child does not cry	1
	Moans	The child moans quietly, cries, but not at the top of his voice	2
	Cry	The child is crying, but the cry is not sharp, closer to whining.	2
	Scream	Crying with full lungs, this score can be given in the presence of complaints or in their absence	3
Facial expression	Smile	Such a score can only be given if the expression is definitely positive.	0
	Calm	Neutral facial expression	1
	Grimace	Such a score can only be given if the expression is definitely negative.	2
Words that a child says	Positive		0
	There are no words	The child does not speak	1
	Speaks but does not complain of pain	The child complains, but not about pain, for example, “I want mommy to come” or “I want to drink”	1
	Complains of pain	The child complains of pain	2
	Talks about pain and other problems	In addition to complaining about pain, he whines, for example, “I want mommy to come.”	2
Position of the child's body	Neutral	Body (not limbs) in a calm state	1
	Inconstant	The child shifts back and forth in bed and may wriggle	2
	Tense	The body is arched or rigid	2
	Shiver	The body shakes or trembles involuntarily	2
	Vertical	The body is positioned straight and vertical	2
	Limited	The body is shackled	2
Touch	Does not apply	The child does not touch the wound or rub it.	1
	Reaches for the wound	The child reaches for the wound but does not touch it	2
	Touches the wound	The child gently touches the wound or the area around it	2

Estimated parameters		Description	Points
	Rubs the wound	The child rubs the wound	2
	Grabs the wound	The child grabs the wound sharply and vigorously	2
	Stiffness	Hands are shackled	2
	Neutral position	The legs can be in any position, but not tense, gentle movements are included (as when swimming or wriggling)	1
Legs	Awkwardness, kicking	Definitely restless leg movements, the baby may kick with one or both legs	2
	Lifting/tensioning	Legs are tense and/or constantly pulled towards the body	2
	Getting back on your feet	The child stands up, including being able to squat and kneel	2
	Stiffness	Limited movement: cannot stand on his feet	2

CHEOPS pain scale score = Sum of all assessed parameters. Minimum score is 4 points, maximum is 13 points. If the total score is 8 points or more, it means that the child is experiencing pain.

RIPS Riley Pain Scale

Riley Infant Pain Scale (RIPS) (Joyce BA, Schade JG et al., 1994)

The scale is designed to assess pain in children who have not yet learned to speak. Facial expressions (face), motor reactions, sleep, speech/voice, whether the child can be calmed, and reaction to movement/touch are assessed.

Parameters	Characteristic	Points
Face	Neutral/smiling	0
	Frowning/grimacing	1
	Clenched teeth	2
	An expression characteristic of crying	3
Motor reactions	Calm, relaxed	0
	Can't find peace/fussiness	1
	Moderate agitation or moderate mobility	2
	Throwing about, constant agitation or strong tendency to limit one's own movements, numbness	3
Dream	Sleeps peacefully, breathing lightly	0
	Restless in sleep	1
	Sleep is intermittent (alternating with short periods of wakefulness)	2
	Long sleep alternates with convulsive twitching, or the child cannot sleep	3
Speech/voice	Doesn't cry	0
	Whining, complaining	1
	Crying in the voice - pain	2
	Screaming, crying at high notes	3
How reassuring is it?	Doesn't need reassurance	0
	It's easy to calm down	1
	It's hard to give in to	2
	Can't calm down	3
Reaction to movement/touch	Moves easily	0
	Flinches when touched or moved	1
	Screams when touched or moved	2
	Crying in high tones or screaming	3

Scale score = Sum of scores for all 6 parameters. Average = (Riley scale score)/6.

The minimum score is zero, the maximum is 18. The higher the score, the more severe the pain.

Infant Postoperative Pain Rating Scale

Postoperative Pain Score (POPS) for Infants of Barriers et al. (Barrier G., Attia J. et al., 1989)

Pain level assessment in non-verbal children can be performed using the scale developed by Barrier et al.

This scale includes both neurological and behavioral criteria. Although it was developed to quantify postoperative pain, it can be used in other clinical situations. The following parameters are assessed:

1. Sleep in the last hour.
2. Facial expressions expressing pain.
3. Characteristics of crying.
4. Spontaneous motor activity.
5. Spontaneous excitability and reactions to external stimuli.
6. Constant and excessive bending of the fingers and toes.
7. Sucking.
8. General assessment of tone.
9. How reassuring is it?
10. Sociability (eye contact), reaction to voice, to appearance of face.

Parameters	Characteristics	Points
Sleep in the last hour	I didn't sleep at all	0
	Short periods of sleep (5-10 min)	1
	Longer periods of sleep (at least 10 minutes)	2
Facial expressions expressing pain	Strongly expressed, constant	0
	Less pronounced, not observed all the time	1
	The facial expression is calm	2
Characteristics of crying	A scream, with an expression of pain, high pitched	0
	Succumbs to external influence - stops crying when he hears normal sounds	1
	Doesn't cry	2
Spontaneous motor activity	Throwing himself in different directions, constant agitation	0
	Moderate agitation	1
	The child is calm	2
Spontaneous excitability and reactions to external stimuli	Tremor, clonus, spontaneous Moro reflex	0
	Increased response to any stimulus	1
	Calm response	2
Constant and excessive bending of the fingers and toes	Very strong, noticeable and constant	0
	Less pronounced, inconstant	1
	Absent	2
Sucking	Absent or disorganized	0
	Intermittent (3-4 sucking movements, then crying)	1
	Strong, rhythmic, with a calming effect	2
General assessment of tone	Severe hypertonicity	0
	Moderate hypertonicity	1
	Age norm	2
How reassuring is it?	No effect for 2 min.	0
	Calms down after a minute of active actions	1
	Calms down within the first minute	2
Sociability (eye contact), response to voice, appearance of face	Absent	0
	Difficult to achieve	1
	It occurs easily and lasts a long time.	2

Total postoperative pain score = Sum of scores for all 10 assessment criteria. The minimum score of zero means severe pain, and the maximum (20) shows that the child feels very well and does not experience pain.

The higher the score, the less pain and the better the general well-being. Scores on the scale >15 points indicate a satisfactory level of postoperative pain. 9.

CRIES Neonatal Postoperative Pain Scale

The CRIES Scale for Neonatal Postoperative Pain Assessment (Krechel SW, Bildner J., 1995)

The acronym CRIES is made up of the first letters of the signs assessed by this method: crying, requires oxygen, increased vital signs, expression, sleep. The word "cries" in English means "crying".

Initially, this scale was developed to assess postoperative pain in neonates, but it can also be used for dynamic assessment of chronic pain intensity. The scale is appropriate for use in neonates with a gestation period of 32-60 weeks and in infants in the intensive care unit after surgical interventions. Pain intensity is assessed every hour.

CRIES scale criteria:

1. Crying, which has a characteristic high pitch when in pain.
2. Is oxygen required to maintain Sp02 at or above 95%? Oxygenation is decreased in newborns in pain.
3. Elevated vital signs: These parameters are determined last, as the measurement procedure may wake the child.
4. Facial expression. When there is pain, the face often shows a grimace. Other possible signs include drooping eyebrows, clenched eyelids, deepening of the nasolabial fold, parted lips, and an open mouth.
5. Sleep deprivation - information about sleep or lack of sleep in the hour preceding the assessment by other parameters is recorded.

Parameters	Characteristics	Points
	There is no crying, or the child is crying, but the tone of the cry is low	0
Cry	The child is crying, the tone of the cry is high, but the child can be calmed down	1
	The child cannot be calmed down	2
	Not required	0
Oxygen therapy	To maintain SpO2 > 95%, oxygen therapy with FiO2 < 30% is required.	1
	To maintain SpO2 > 95%, oxygen therapy with FiO2 > 30% is required.	2
Increase in vital parameters	Heart rate and mean blood pressure are lower or the same as before surgery	0
	Heart rate and mean arterial pressure are elevated, but by less than 20% of preoperative levels	1
	Heart rate and mean arterial pressure are increased by more than 20% from preoperative levels	2
	No grimace of pain	0
Facial expression	There is only a grimace of pain	1
	The grimace is combined with sounds that are not related to crying (groaning, wheezing, grunting)	2
Dream	The child has a long sleep	0
	Wakes up often	1
	Stays awake all the time	2

The overall CRIES score is calculated as the sum of the points for all five criteria. The maximum score is 10, the minimum is zero, the higher the score, the more severe the pain.

For normal values, use the values obtained before surgery, without stress. Multiply the normal HR value by 0.2 to determine which HR is 20% higher. Do the same with the normal BP value, using the arithmetic mean of the systolic and diastolic BP.

A high correlation was noted between the CRIES score and the OPS score.

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ]

Objective pain scale of Hanallah et al. for assessment of postoperative pain

Objective Pain Scale (OPS) of Hanallah et al. for postoperative pain assessment (Hannallah R., Broadman L. et al., 1987)

Hannallah R. et al. (1987) developed the OPS scale for the dynamic assessment of postoperative pain in children aged 8 months to 13 years.

A mandatory condition for the study is the presence of average values of three previous measurements of systolic blood pressure. During the study, systolic blood pressure, crying, motor response, general behavior, the presence of complaints of pain (cannot be assessed in small children) are assessed.

Parameters	Characteristics	Points
Systolic blood pressure	Increase < 20% from preoperative values	0
	Increase > 20% from preoperative values	1
	Increase > 30% from preoperative values	2
Cry	Absence	0
	Yes, but the child can be consoled	1
	There is, and the child cannot be consoled	2
Physical activity	Doesn't move, relaxed	0
	Restless, constantly moving in bed	1
	Strong arousal (risk of injury)	2
	Motionless (frozen)	2
General behavior	Calm or sleeping	0
	He grimaces, his voice trembles, but you can calm him down	1
	Scared, can't be separated from parents, impossible to calm down (hysterical)	2
Complaints of pain	Calm or sleeping	0
	Does not complain of pain	0
	Moderate non-localized pain, general discomfort, or sitting with arms around stomach with legs bent	1
	Localized pain that the child describes or points to with a finger	2

The overall score on the scale is equal to the sum of points for all assessed parameters. The minimum score is 0, and the maximum is 10 points. It should be noted that the maximum score for small children who cannot complain of pain is 8 points. High scores on the scale indicate severe pain.

Nb!: Systolic BP values may be distorted due to pre- or postoperative hypotension!

Modified objective quantitative pain assessment

Modified Objective Pain Score (MOPS) (Wilson GA M., Doyle E., 1996)

In 1996, Wilson and Doyle modified the Objective Pain Score (OPS) scale.

The modified scale is designed to assess postoperative pain. The scale allows parents to be used as experts. The use of this scale has been studied in children aged 2 to 11 years. The parameters assessed in the scale include crying, motor response, agitation, posture, and speech.

The difference between this scale and the OPS scale of Broadman et al. is that instead of blood pressure, the child's posture is assessed.

Parameters	Characteristic	Points
Cry	No	0
	You can calm down	1
	Can't calm down	2
Motor reaction	No motor restlessness	0
	Cannot remain at rest	1
	He's rushing about	2
Excitation	Sleeping	0
	Calm	0
	Moderate arousal	1
	Hysteria	2
Pose	Normal	0
	Flexion predominates	1
	Holds onto a sore spot	2
Speech	Sleeping	0
	No complaints	0
	Complains but cannot localize the pain	1
	Complains and can localize pain	2

Since the study by Wilson and Doyle (1996) included only children who had undergone surgery for hernias and tonsillitis, when assessing the child's posture they indicated only two options for the "sore spot": groin or throat.

MOPS score = Sum of all 5 parameters. Minimum score is 0, maximum is 10. High scores on the scale indicate severe pain experienced by the child.

The scale cannot be used with children who are preverbal, but it can be modified for this group of children.

The doctor usually gives lower ratings on the scale than the parents.

A scale that takes into account facial expression, leg movement, cry pattern, and the child's soothability and behavioral characteristics

The FLACC Behavioral Scale for Postoperative Pain in Young Children (Merkel SI, Voeoel-Lewus T. et al., 1997)

The FLACC (face, legs, activity, cry, consolability) behavioral scale was developed to assess postoperative pain.

It is often used in situations where a small child cannot accurately describe pain and poor health in words. It is designed to assess the intensity of pain in children aged 2 months to 7 years who have undergone various surgical procedures. If the child has a delay in psychomotor development, the use of this scale is not justified. The study evaluates facial expressions, leg position, motor response, crying, and how amenable the child is to calming.

Parameters	Characteristics	Points
Face	Vague expression or smile	0
	Rarely - grimace or furrowed brow. Withdrawn. Shows no interest.	1
	Frequent or constant trembling of the chin. Clenching of the jaws.	2
Legs	Normal position, relaxed	0
	Cannot find a comfortable position, constantly moves legs; legs are tense	1
	Kicking or lifting legs	2
Movements	Lies quietly, position is normal, moves easily	0
	Writhing, shifting back and forth, tense	1
	Arched; rigid; twitching	2
Cry	No crying (when awake or asleep)	0
	Moans or whines; complains occasionally	1
	Cries, screams, or sobs for a long time; complains often	2
How reassuring is it ?	Satisfied, calm	0
	Calms with touch, hugs, or conversation; can be distracted	1
	It's hard to calm down	2

The overall score on the FLACS scale is equal to the sum of the points for all description items.

The minimum score is 0, and the maximum is 10. The higher the score, the more severe the pain and the worse the child feels.