Scale of pain in children

A rating scale for assessing pain on the face image of Wong-Baker for children over 3 years of age

Wong-Baker Faces Pain Scale for Children 3 Years or Older (Wong D. L "Baker SM, 1988)

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

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

Face	Description	Points
Smiling	Happy, no pain	0
Easy smile	Minor soreness	1
Neutral	Light pain	2
Eyebrows slightly frowned	Average pain	3
Eyebrows strongly frowned	Strong pain	4
Cries, feels completely unhappy	Excessive pain that can only be imagined	5

[1], [2]

Children's Scale for Pain Assessment KUSS Kindliche unbehagens-und Schmerzskala (KUSS)

(Büttner W. Et al., 1998)

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

Options	Characteristic	Points
Cry	Absent	0
	Groans, whine	1
	Crying cry	2
Facial expression	Relaxed, smiling	0
	Mouth curved	1
	Grimace	2
Body position	Neutral	0
	Forced	1
	Stretches out, flexes	2
Leg position	Neutral	0
	Floundering, kicking	1
	Tightens to the body	2
Motor anxiety	Absent	0
	Slightly	1
	Worrying	2

When observing a child, five parameters are evaluated. The time for a child's examination should not exceed 15 seconds, even if the behavior of the child changes soon.

The card registers the sum of scores of all criteria, which can be ranked by 4 (AD) positions.

Interpretation of research results

Code	A	AT	FROM	D
Score on the KUSS scale	0-1	2-3	4-7	8-10

• A - there is no need for analgesia.
• C - it is necessary to strengthen the analgesic therapy.
• With - an emergency cupping of a painful syndrome.

If the pain persists for an hour, a consultation is needed to find out the cause of the pain and eliminate it.

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

[3], [4]

Scale of postoperative assessment of pain in infants and children under 5 years

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 newborns and children under 5 years of age. This scale is similar to MOPS, but an interesting feature of the scale is the need to evaluate a variety of physiological, anatomical and behavioral parameters to obtain a final assessment. The scale is intended for use in newborns and children up to 5 bed. Appreciation of crying, facial expression, trunk position, leg position, motor anxiety.

Options	Description	Points
	No	0
Cry	Moan	1
	A piercing cry	2
	Relaxed, smiling	0
Facial expression	Wry mouth	1
	Grimace	2
	Neutral	0
Torso position	Constantly changes	1
	Trying to get up	2
	Neutral	0
Leg position	Crossbred legs	1
	Tight (Crossed) Feet	2
	No	0
Motor anxiety	Moderate	1
	Expressive	2

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

Interpretation of research results

Score	Interpretation
0 to 3	Lack of pain
4 to 10	Analgesia is necessary, and the higher the score, the more urgent it is

Indicators:

1. Alfa Cronbach for infants is 0.96, for other children 0.92.
2. The confidence coefficient is 0.93.
3. The scale is well comparable to 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.

Scale for assessing acute pain in newborns, based on monitoring the behavior of the child

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

Index	Evaluation	Score
Facial expression	Calm	0
	Whimpering, opening and closing eyes	1
	Grimace of mourning: moderate, episodic	2
	Grimacing of mourning: moderate	3
	Grimace of mourning: almost constant	4
Movement of the extremities	Calm, smooth	0
	Episodic anxiety, then calmed down	1
	Moderate anxiety	2
	Expressed constant concern	3
Crying (unintubated newborns)	Does not cry	0
	Periodic groans	1
	Recurrent crying	2
	Long crying, "howl"	3
Equivalents of crying (intubated newborns)	Does not cry	0
	Restless looks	1
	Gesticulation characteristic of periodic crying	2
	Gesticulation typical of constant crying	3

Anxiety - pedaling, stretching and tension of the legs, spreading fingers, chaotic hand movements.

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

Scale of postoperative pain in children of preschool and preschool age

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 manipulation. An obligatory condition for the study is the wakefulness of the child. Pain is assessed on the following items: speech, facial expression, motor reactions.

Estimated parameters	Behavior
Speech	Complains of pain and / or crying
	Screams
	Heavy sighs, groans, grumbling
Facial expression	Open mouth, mouth angles down
	Blinks, closes his eyes
	Forehead in wrinkles, eyebrows arched
Motor reactions	Motor anxiety and / or rub or touch the sore spot

• Verbal complaints of pain: any word, phrase or statement that refers to pain, injury, or discomfort. The complaint must necessarily be formulated in the form of an assertion, and not in the form of a question.
• Crying: tears in her eyes, and / or a dull face and / or crying; Excludes crying, associated with excommunication from parents, in addition, which is caused by painful manipulation.
• Exaggerates eyebrows: the formation of a crease between the eyebrows.
• Unruly behavior: behavior with constant bodily activity and / or activity of the head; There may be random (unrelated) activity or lack of directed actions.
• Touches, scratches or massages a part of the body that has undergone surgical or other medical intervention.
• Scream: sharp, loud, high-pitched crying, grumble, moan, murmuring: monotonous, low-tonal; may be moaning or abrupt muttering.
• He opens his mouth with his lips pressed in the corners: he opens his mouth with his lips pressed in the corners, continuing to lower his lower jaw in the future.
• He frowns, closes his eyes: his eyelids are tight, tense, his eyes are open or half-open with wrinkles in the lateral part of his eyes.
• Wrinkles forehead or frowns.

Behavior Assessment	Points
If the pain is present for 5 minutes of follow-up	1
If pain is absent for 5 minutes of follow-up	0

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

Pain score = The sum of scores for all evaluated parameters. The minimum score is 0 points, the maximum score is 7 points. The higher the score, the worse for the child. 6.

The Pain Scale of the Children's Hospital of Eastern Ontario

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

CHEOPS is a behavioral, a scale for assessing postoperative pain in children. It is used to dynamically evaluate the effectiveness of interventions aimed at reducing pain and discomfort. Initially, the scale was created for use in children aged 1 to 5 years, but it was also used in adolescents, but the data in this age group may be unreliable. According to Mitchell (1999), the scale is designed for use in children from 0 to 4 years.

Estimated parameters		Description	Points
Cry	No crying	The child does not cry	1
	Groans	The child moans softly, cries, but not at all	2
	Cry	The baby cries, but the crying is blurred, closer to the whine	2
	Scream	Crying with full lungs, such a score can be put in the presence of complaints or in their absence	3
Expression of the face	Smile	Such a score can only be given with a definitely positive expression	0
	Calm	Neutral facial expression	1
	Grimace	Such a score can only be given with a definitely negative expression	2
Words that says baby	Positive		0
	No words	The child does not speak	1
	Says, but does not complain about pain	The child complains, but not on pain, for example "I want my mother to come" or "I want to drink"	1
	Complains of pain	The child complains of pain	2
	Speaks of pain and other problems	In addition to complaints of pain whines, for example "I want my mother to come"	2
Position of the child's body	Neutral	Body (not limbs) in a calm state	1
	Unstable	The child shifts in bed back and forth, can wriggle	2
	Stressed	The body is arched or rigid	2
	Shiver	The body shudders involuntarily or trembles	2
	Vertical	The body is straight, vertical	2
	Limited	The body is constrained	2
Touch	Not applicable	The child does not touch the wound and does not rub it	1
	It stretches to the wound	The child reaches for the wound, but it does not concern	2
	Concerning Wounds	The child gently touches the wound or the area around it	2

Estimated parameters		Description	Points
	Treading the wound	The child rubs the wound	2
	Enough of the wound	The child sharply and vigorously grabs the wound	2
	Stiffness	Arms constrained	2
	Neutral position	Legs can be in any position, but they are not strained, unsharp movements are included (as when swimming or wriggling)	1
Legs	Awkwardness, Kicking	Definitely a restless leg movement, a child can kick one or two legs	2
	Lifting / tensioning	Legs are tense and / or constantly tightened to the body	2
	Getting up on your feet	The child gets up, including can squat on his knees	2
	Stiffness	Limited movement: can not stand on its feet	2

Assessment on the Pain Scale CHEOPS = Sum of the scores of all evaluated parameters. The minimum score is 4 points, the maximum score is 13 points. If the total score is 8 or more points, it means that the child is in pain.

RIPS Pain Scale Riley

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. Mimicry (face), motor reactions, sleep, speech / voice, whether it is calming, reaction to movement / touch is estimated. 

Options	Characteristic	Points
Face	Neutral / smiling	0
	Frown / grimaces	1
	Clenched teeth	2
	Expression typical of crying	3
Motor reactions	Calm, relaxed	0
	Does not find rest / fussiness	1
	Moderate agitation or moderate mobility	2
	Throwing, unceasing excitement or a strong tendency to limit one's own movements, numbness	3
Sleep	Sleeps quietly, with a light breathing	0
	Worried about a dream	1
	Sleep intermittent (alternating with short intervals of wakefulness)	2
	Long sleep alternates with convulsive jerks, or the child can not sleep	3
Speech / voice	Does not cry	0
	Snorts, complains	1
	Crying in the voice - pain	2
	Screaming, crying on high notes	3
How much calms down	Does not need to be soothing	0
	It is easy to calm down	1
	Difficult to give	2
	Can not calm down	3
Reaction to movement / touch	Easy to move	0
	Shudders when touched or moved	1
	Shouts at touches or movements	2
	Crying in high tones or screaming	3

Score on score = Sum of points for all 6 parameters. Mean = (Score on the Riley scale) / 6.

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

Scale of postoperative assessment of pain in infants

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

Assessment of pain in children who can not speak can be done using a scale developed by Barrier et al.

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

1. Sleep in the last hour.
2. Mimicry expressing pain.
3. Characteristics of crying.
4. Spontaneous motor activity.
5. Spontaneous excitability and reactions to external stimuli.
6. Constant and excessive bending of fingers on hands and feet.
7. Sucking.
8. General assessment of the tone.
9. How much calms.
10. Communication skills (contact with eyes), reaction to voice, to the appearance of a person.

Options	Characteristics	Points
Sleep in the last hour	Did not sleep at all	0
	Short periods of sleep (5-10 min)	1
	Longer periods of sleep (at least 10 minutes)	2
Mimicry expressing pain	Strong, constant	0
	Less pronounced, not all the time	1
	Facial expression calm	2
Characteristics of crying	Scream, with an expression of pain, high pitch	0
	Is amenable to external influences - ceases to cry when he hears ordinary sounds	1
	Does not cry	2
Spontaneous motor activity	It is anxious in different directions, constant excitement	0
	Moderate excitement	1
	The child is calm	2
Spontaneous excitability and responses to external stimuli	Tremor, clone, spontaneous Moro reflex	0
	Strong reaction to any stimulus	1
	Calm response	2
Constant and excessive bending of fingers on hands and feet	Very strong, noticeable and permanent	0
	Less pronounced, unstable	1
	Absent	2
Sucking	Missing or disorganized	0
	Intermittent (3-4 sucking movements, then crying)	1
	Strong, rhythmic, with soothing effect	2
Overall assessment of tone	Severe hypertonia	0
	Moderate hypertonicity	1
	Age norm	2
How much calms down	No effect for 2 min	0
	Calms down after a minute After active actions	1
	Calms down in the first minute	2
Sociability (eye contact), reaction to voice, to the appearance of a person	Absent	0
	It is difficult to achieve	1
	Arises easily and for a long time	2

Total score of postoperative pain = Sum of points for all 10 evaluation criteria. A minimum score of zero means strong pain, and a maximum score of 20 indicates that the child feels very well and does not experience pain.

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

CRIES-scale of assessment of postoperative pain for newborns

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

The acronym CRIES is composed by the first letters of the signs evaluated by this technique: crying, requires oxygen (oxygen supply required), increased vital signs, expression, sleep. The word "cries" in English means "crying".

Initially, this scale was developed to evaluate postoperative pain in newborns, but it can also be used to dynamically assess the intensity of chronic pain. The scale should be used in newborns with a gestation period of 32-60 weeks and in infants who are in the ICU, after surgery. Assessment of the intensity of pain is done every hour.

Criteria for the CRIES scale:

1. Crying, which in pain has a characteristic high tonality.
2. Is oxygen required to maintain Sp02 at 95% or higher. In newborns that experience pain, oxygenation is reduced.
3. Elevated values of vital indicators: these parameters are determined last, since the measurement procedure can awaken a child.
4. Facial expression. With pain on the face is often a grimace. Other possible signs: omission of the eyebrows, contraction of the eyelids, deepening of the nasolabial furrow, open lips, open mouth.
5. Absence of sleep - information about a dream or its absence is recorded for an hour preceding evaluation by other parameters.

Options	Characteristics	Points
	There is no crying, or the child cries, but the crying tone is not high	0
Cry	The child cries, the tonality of crying is high, but the child can be soothed	1
	The child can not be soothed	2
	Not required	0
Oxygen therapy	To maintain SpO2> 95% oxygen therapy with FiO2 <30% is required,	1
	To maintain SrO2> 95% oxygen therapy with FiO2> 30% is required,	2
Increasing the values of vital parameters	Heart rate and mean BP are less or the same as before surgery	0
	Heart rate and mean BP are increased, but less than 20% of the preoperative level	1
	Heart rate and mean blood pressure are increased by more than 20% from the preoperative level	2
	No grimaces of pain	0
Facial expression	There is only a grimace of pain	1
	The grimace is combined with sounds not related to crying (moaning, wheezing, groaning)	2
Sleep	The child has a long dream	0
	Frequently wakes up	1
	He is always awake	2

The total score for the CRIES scale is calculated as the sum of the scores for all five criteria. The maximum score is 10, the minimum score is zero, the higher the score, the greater the pain.

As usual values, use indicators obtained before surgery, outside the state of stress. The normal heart rate is multiplied by 0.2 to determine which heart rate is greater by 20%. Do the same with the usual blood pressure, use the arithmetic mean of the systolic and diastolic blood pressure.

A high correlation of the CRIES estimate with the OPS score was noted.

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

The objective scale of pain Hanallah et al. For assessing 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 an OPS scale for the dynamic evaluation of postoperative pain in children aged 8 months to 13 years.

A prerequisite for the study is the availability of the mean values of the three previous measurements of systolic blood pressure. During the study, systolic blood pressure, crying, motor reaction, general behavior, the presence of complaints of pain (can not be assessed in young children) are evaluated.

Options	Characteristics	Points
Systolic blood pressure	Increase <20% from preoperative indicators	0
	Increase> 20% of preoperative indicators	1
	Increase> 30% of preoperative indicators	2
Cry	Absence of	0
	Yes, but the child can be comforted	1
	There is, and the child can not be comforted	2
Motor activity	Does not move, relaxed	0
	Restless, constantly moving in bed	1
	Severe agitation (risk of injury)	2
	Fixed (frozen)	2
General behavior	Quiet or asleep	0
	Grimaces, voice trembles, but you can calm down	1
	Scared, not torn from parents, it is impossible to calm (hysterical)	2
Complaints of pain	Quiet or asleep	0
	Do not complain about pain	0
	Average non-localized pain, general discomfort, or sitting with his arms around his stomach with sloping legs	1
	Localized pain that a child describes or points to its place with a finger	2

The total score on the scale is equal to the sum of the scores of all the evaluated parameters. The minimum score is 0, and the maximum is 10 points. It should be noted that the maximum score in young children who can not complain about 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 assessment of pain

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

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

Modified scale is designed to assess postoperative pain. As an expert, the scale allows parents to be used. The use of this scale has been studied in children aged 2 to 11 years. The parameters evaluated in the scale include crying, motor reaction, agitation, posture and speech.

The difference of this scale from the scale OPS Broadman et al. Lies in the fact that instead of arterial pressure the pose of the child is estimated.

Options	Characteristic	Points
Cry	No	0
	You can calm down	1
	You can not calm down	2
The motor reaction	No motor anxiety	0
	Can not be at rest	1
	Meticulous	2
Excitation	Sleeping	0
	Quiet	0
	Moderate excitement	1
	Hysterical	2
Pose	Normal	0
	Bending prevails	1
	Holds on the sore spot	2
Speech	Sleeping	0
	The complaints do not show	0
	Complains, but can not localize pain	1
	Complains and can localize pain	2

Since Wilson and Doyle (1996) included only children who underwent surgery for hernia and tonsillitis, they indicated only two variants of the "sore spot" when assessing the child's posture: the groin or throat.

Score on the scale MOPS = Sum of scores of all 5 parameters. The minimum score is 0, and the maximum score is 10 points. High scores on the scale indicate a strong pain that the child suffers.

The scale can not be used in children who do not know how to talk, but it can be modified for this group of children.

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

A scale that takes into account the expression of the face, the movement of the legs, the nature of the scream, and also the extent to which the child lends itself to calming and the behavior

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

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

It is often used in situations where a small child can not accurately describe in words pain and ill health. It is designed to assess the intensity of pain in children aged 2 months to 7 years who underwent various surgical procedures. In the event that the child has a delay in psychomotor development, the use of this scale is not justified. The study evaluates the facial expressions, the position of the legs, the motor reaction, the crying and how much the child succumbs to calming. 

Options	Characteristics	Points
Face	Uncertain expression or smile	0
	Rarely - a grimace or shifted eyebrows. Closed. Not interested	1
	Frequent or persistent jawing of the chin. Compression of the jaws	2
Legs	Normal position, relaxation	0
	Can not find a comfortable position, constantly moves his legs; legs are tense	1
	Kicking or lifting legs	2
Movement	Lies calmly, the position is normal, it moves easily	0
	Wrinkles, moves forward and backward, strained	1
	Arched by an arc; stiffness; twitching	2
Cry	No crying (in waking state and in a dream)	0
	He moans or whimpers; from time to time complains	1
	Long cry, cry or sob; often complains	2
How amenable calm	Satisfied, calm	0
	Calms down from touching, hugging or talking; can distract	1
	It's hard to calm	2

The overall score on the FLASS scale is the sum of the scores for all the points of the description.

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