Assessment and Diagnosis of Pediatric Pain

Although in many instances adults may have the ability to communicate their pain symptoms and experiences more descriptively, for those treating pediatric patients, the task of identifying those symptoms and measuring the levels of pain being experiences are a bit more complicated.

Fortunately, there are a number of proven evidenced-based methods of assessing pain in children and young adults, and the research is only growing, according to Michelle A. Fortier, PhD. Fortier is a licensed clinical psychologist and assistant professor at the University of California, Irvine School of Medicine.

Fortier’s presentation, “Assessment and Diagnosis of Pediatric Pain” was designed to provide a review of the current literature on the prevalence of pain in children, explain theories and types of pain, and outline assessment strategies.

Fortier began her presentation by defining a number of pain conditions, including allodynia, dysesthesia, and hyperalgesia, but she also made a clear distinction between acute and chronic pain in children. Acute pain primarily consists of tissue input, and to a lesser degree equal parts thought and emotion. Chronic pain consists of about 50% emotions, about a 35% portion of thoughts, and roughly a 15% portion of tissue input.

Although chronic pain is not generally associated with children and teenagers, recent research suggests these populations can be affected, and at higher rates than previously thought, Fortier said. Some studies have shown that as many as 54% of children have experienced pain within the last three months, and 25% experience recurring pain lasting three months or more. Headache, back ache, and abdominal pain are the most common conditions.

Among the psychosocial factors impacting pain, Fortier highlighted stress and negative affect as key components. When both are present in youth, children may have an increased risk of developing chronic pain as adults.

Coping and predictability/controllability will also impact the patients’ experience of pain, she said. In youth, specifically, Fortier has seen their sense of control over their pain greatly influence the way they deal with the pain. “It’s not just the coping strategy, but also the sense of efficacy,” Fortier said. Children who report a higher sense of efficacy generally do better, she said.

Fortier said rehearsing and practicing coping strategies with teens helped increase their sense of self-efficacy. Also, performing these activities in a group setting was helpful. Like adults, Fortier mentioned, physicians examining pediatric patients should first use self-report tests followed by observational assessment.

Because pain is a subjective experience, individual self-report is favored, according to Fortier. However, in cases where verbalization is impossible, there are a number of observational methods that can be used. Some of the validated self-report exam tests include the Pieces of Hurt Tool, which utilizes four poker chips, each with a designated pain rating, and asks children ages 4 to 7 to choose which one corresponds to their pain experience.

There are also a number of pain rating scales that use illustrations or images of faces in various states of pain. For example, the Faces Pain Scale uses seven faces and asks the child to choose a face that best represents his or her own pain.

Among the methods highlighted were FLACC (face, legs, activity, crying, and consolability) and CHEOPS (Children’s Hospital of Eastern Ontario Pain Scale). The COMFORT scale can be used for those on ventilators and scores eight items on a scale of one to five. In some instances, involving parents in the diagnosis can be beneficial as well, according to Fortier. Physicians may use the Parent’s Postoperative Pain Measure.

In neonatal pain assessment, physicians should observe the following pain behaviors: crying, brow bulge, gaping mouth, and nasolabial folds. “There’s a growing recognition that pain in neonates is an important area,” Fortier said.

The Neonatal Infant Pain Scale (NIPS) assesses six behavioral indicators in response to pain, she said, including facial expression, crying, breathing, motor activity, and more. However, Fortier said, it hasn’t yet been widely accepted in hospital practice.