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11 Articles in Volume 10, Issue #6
Assessing Pain of the Pediatric Patient in the Emergency Setting
Testosterone Replacement in Chronic Pain Patients
Why Some Patients Require High Dose Opioid Therapy
Raising Pain Tolerance Using Guided Imagery
Long-Standing Groin Pain in a Male Athlete
FDA’s Proposed Risk Evaluation and Mitigation Strategy (REMS) for Opioids
Platelet Rich Plasma Prolotherapy as First-line Treatment for Meniscal Pathology
Cluster Headache
Effectiveness of Laser and Non-Coherent Light Therapies
Opinion on Preliminary Guidelines for the Clinical Diagnostic Criteria for Fibromyalgia
Doctors May Now Electronically Prescribe Schedule II Drugs

Assessing Pain of the Pediatric Patient in the Emergency Setting

The reliability of subjective pain scales for the pediatric patient depends on the particular scale being used, the demographics of the child, the origin of the child’s pain, as well as any social and environmental factors surrounding the child at the time of self-report.

A pain scale measures pain intensity and is based on self-report, observational (behavioral), or physiological data. Self-report is usually considered primary and should be obtained if possible. Pain scales are also available for neonates, infants, children, adolescents, adults, seniors, and persons whose com-munication is impaired.

Quantifying and standardizing pain intensity in children in an acute setting is a difficult task. Currently, there exists a myriad of self-report scales that aim to facilitate this process. Although these scales are ubiquitous in modern healthcare, there is continuous scrutiny in regards to their reliability. This review aims to demonstrate the important var-iables that can alter a child’s perception of pain, and therefore his or her report of pain intensity.

Assessing Reliability of Pain Scales

The reliability of self-reported pain intensity in children can be assessed by careful consideration of the following factors:

  • The advantages and shortcomings of the type of pain scale being used
  • The demographics of the patient
  • The qualities of the health care provider conducting the assessment
  • The etiology of the pain that the child is suffering from
  • The physical and social environment the child is in at the time of self-report.

These five variables must be taken into account to be able to reliably utilize a sub-jective pain report as an efficacious tool for accurate means of assessing a child’s pain severity in the emergency department.

First, it is important to consider the attributes of the particular pain scale chosen. Although many self-report pain scales exist, they can generally be categorized into pictorial scales and numerical analogue scales. The quintessential pictorial scale is the Faces Pain Scale-Revised1 (see Figure 1). The Faces Pain Scale-Revised consists of six faces, beginning with a neutral face and advancing to a crying face, as shown below. The neutral face is assigned a pain rating of 0/10, and each face increases by an increment of 2/10. Each face is explained to the child as increasing levels of “hurt,” with the first face being designated “no hurt” and the last face designated as “the worst hurt you have ever felt.” The child is then instructed to point to the face that corresponds to his/her level of perceived pain.

Figure 1. The Faces Pain Scale-Revised.

The Faces Pain Scale-Revised is very easy to implement in the emergency setting, as it does not require much explanation to the patient and/or his/her family. Also, since the scale lacks many words, it is quite convenient for use with a foreign-speaking patient. Although it is seemingly obvious that each face seems to be in more pain than the last, few studies have analyzed whether or not these faces are accurate and precise representations of pain. Rather, these faces may be more representative of anxiety, which is described as more general feelings of apprehension and fear.2 Situational, as well as demographic, factors may have a large impact on a child’s level of anxiety and may pose a threat to this test’s overall validity and reliability—these factors will be discussed later. Also, with only six faces, simplified scales such as the Faces Pain Scale may not provide enough sensitivity to be useful for monitoring smaller or more gradual changes in pain during long-term management of the patient.

Another option for subjective pain assessment is the use of numerical analogue scales (see Figure 2). Numerical analogue scales are also popular because of their ease of use. These types of scales also may overcome the simplicity of pictorial scales. Most scales are ranked from 0-10, on either a horizontal or vertical axis as seen in Figure 3. The patient is requested to mark on a linear scale a number that corresponds to his/her perceived pain level.

Figure 2. Numerical analogue pain scale. Figure 3. Oucher scale utilizes both a visual analogue and a numerical rating scale.

Numerical scales provide specific challenges, especially in the pediatric population. Children have a propensity to have response biases, which are systemic biases that may cause self-reported answers to not reflect reality because of the respondent’s misperception. A commonly seen and well-researched example of a type of response bias is anchoring. Anchoring is a cognitive bias that describes the common human tendency to rely too heavily, or “anchor,” on one trait or piece of information when making decisions. In children, this manifests as choosing either the lowest or the highest number on a pain scale, with disregard for the numbers in between. Previous studies have suggested that anchor biases can occur in up to 1 out of 5 children who use self-report pain scales.3 Such biases also correlate with the age and cognitive ability of the patient, which will be discussed later. Although numerical analogue scales attempt to provide a more precise measurement of pain, the presence of such biases suggest that they may not be a reliable indicator of pain for the pediatric population.

The Oucher Scale4 utilizes both a visual analogue and a numerical rating scale side-by-side in a vertical fashion as depicted in Figure 3. The child is asked to point to the picture that correlates to his/her level of “hurt” and this is then translated into a number score. This allows the scale to be utilized by most pediatric patients over the age of three. Also, the scale comes in many cultural versions (Caucasian, African American, Hispanic, Asian). Although this scale covers a wide variety of patients, several other cultures are not covered. For patients whose cultures are not represented, this scale can be confusing and alter their perception of pain severity. Also, the relevance between the facial expressions and designated numeric values have not yet been validated. This can be potentially misleading to the child as well as the provider interpreting the response. The simultaneous utilization of both formats (photographic, numeric) diminishes clarity on whether the patient used only one format or was influenced by the other in making a decision of his or her pain.

Recent research on African-American and Hispanic versions of the Oucher scale have approached the problem of simultaneous presentation by eliminating the lines connecting the photographs and the numbers and placing the photographs on one side of the poster and the numeric format on the other.5 Overall, each pain scale has something different to offer the clinician in assessing a child’s pain but each scale’s shortcomings must also be taken into account when choosing which one to employ.

Lastly, it is important to note that a pain score, regardless of which scale is used, is more useful for comparing changes over time within an individual, rather than comparing the score itself between individuals.6 It is impossible to tell if child A’s pain of an 8 is more severe than child B’s pain of a 7. However, if child A’s pain decreases to a 2, and child B’s to a 6, that would be considered a measurable and significant change specific to each child.

Demographic Effect

The demographics of the patient may also affect the reliability of subjective pain reporting in the emergency room. The most influential attribute of a child’s ability to accurately report his/her pain is his/her age. Children’s ability to understand these scales change dramatically, especially before seven years of age.6 Anchor biases, as mentioned before, are more apparent in children under five than older children.3 Another study reported that five and six year old children are significantly more accurate in the use of the Faces Pain Scale-Revised in response to hypothetical situations than children three and four years old.7 This suggests that age is a significant marker of a child’s ability to use the scale as an appropriate means of accurately reporting pain. Also, for younger children, it may be more difficult to explain how a particular scale is supposed to be used. For example, when explaining the Faces Pain Scale, the provider must clarify to the child that each face is an interpretation of pain—as opposed to anxiety, fear, and other emotions.8 These age-related complications are indications that although seemingly simple, these scales may be too complex for younger children to answer readily and appropriately.

Although a child’s sex may also play a role in subjective pain reporting, no studies have yet to suggest a significant impact. However, one study noted a trend that fathers give their sons higher pain scale ratings than their daughters.9 This same study also suggested that fathers tended to be more accurate judges of their children’s pain. Therefore, it may be useful to take into account the sex not only of the patient, but that of the accompanying parent(s) as well. Finally, cultural considerations must be acknowledged when using self-report scales. Although language and cultural differences may exist, the overall simplicity of these scales allow them to be easily translated cross-culturally.10 Major demographics such as age, gender, and ethnic background may have significant effects on self-report reliability and must be taken into consideration.

Impact of Provider on Pediatric Self-Reported Pain

It is also necessary to assess the qualities of the health care worker who is providing the subjective pain report to the child. Whether the provider is a nurse, medical student, resident physician, or attending physician, there is a wide disparity in the knowledge level of the health care workers regarding pain assessment in children.11 In a study comprised of pediatric residents and nurses, nearly two-thirds of the respondents felt that non-pharmacological methods (i.e., gentle reassurance) were better than medication to control a child’s pain. This may be an indication that the knowledge level as well as the personal preferences of the health care provider may have an effect on the reliability of the self-report. In addition, a caregiver’s physiological response to administering a painful procedure (i.e., venipuncture) to a child has been reported to be a positive predictor of a child’s self-reported pain and distress.12 In a recent study, caregivers witnessing and/or performing an IV cannulation in their pediatric patient had significant increases in heart rate, blood pressure, and anxiety. These changes were noticeable by the pediatric patient and produced significant changes in the child’s assessment of his/her own pain. These studies suggest that the variation of individual characteristics of health care workers themselves may alter the child’s perception of pain, and therefore interfere with the reliability of the subjective pain assessment.

Weighing the Importance of a Self-Reported Pain Rating

Subjective pain scales do not focus on the specific etiology of the pediatric patient’s pain. Is the pain acute or chronic? Is it a result of trauma or organic disease? Although these questions may be answered when taking the patient’s history, it is imperative to keep this in mind when weighing the importance of a self-reported pain rating. If one of the purposes of pain assessment is to determine level of functioning, one must assume that the lower the pain score, the more functional the patient. However, this may not always be the case. For example, one study demonstrated that functional mobility did not match subjective ratings of pain on the Faces Pain Scale-Revised in children with juvenile rheumatoid arthritis.13 Other clinicians suggest that the context of the child’s pain should determine the appropriateness of one subjective pain scale over another.14 Therefore, one can postulate that no single observational measure can be broadly recommended for pain assessment across all contexts.

Physical and Social Environmental Factors

Finally, the physical and social environment in which the child is in during a subjective pain assessment can potentially contribute to a child’s perception of pain severity, therefore impacting the test’s reliability. One study mentioned that pain ratings were generally lower when assessed in a triage area of the emergency department as opposed to a waiting room.15 Also, since self-reported pain is a form of social communication, it may be influenced by the social environment in which the child is in during the time of assessment.16 Self-reported pain intensity can be influenced by the child’s expected consequences of reporting a lower versus a higher pain score. For example, a child who wants to stay home from school may report a inappropriately high pain score, whereas a child who fears receiving an injection of analgesia may report an inappropriately low pain score.

Children’s self-reports must be assessed with a firm knowledge of the social context, as well as the child’s possible motivations and expectations at the time of assessment.6 It has been suggested that a possible way to decrease the environmental effect on the reliability of subjective pain reporting is to combine observer estimation of pain with the children’s self-reports, since each may be measuring separate constructs.5


There are numerous factors that can threaten the reliability of a self-reported pain scale of the pediatric patient in the emergency setting. The health care provider should pay careful attention to the particular scale being used, the demographics of the child, the origin of the child’s pain, as well as any environmental factors surrounding the child at the time of self-report. To maintain the reliability of these assessments, it is also imperative for the clinician to acknowledge that not every child will be able to use such scales. Finally, pain scores should be interpreted between points in time with the same patient, not between children. Having a heightened awareness of the many potential variables that alter a child’s perception of pain severity allows the clinician to have a better understanding of the overall context of the child’s condition.

Last updated on: November 18, 2013
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