CHICAGO – The best pain scales to use when assessing a child’s level of discomfort are those that have been empirically validated for the intended age and setting, according to Mark Connelly, Ph.D., the acting director of integrative pain management at Children’s Mercy Hospitals and Clinics in Kansas City, Mo.
Validated pain scales include the FLACC (Face, Legs, Activity, Cry, and Consolability) observational scale and Pieces of Hurt Tool (sometimes called the Poker Chip Tool) for toddlers, the Faces Pain Scale-Revised for school-age children aged 4-12 years, and the visual analog scale and numeric rating scale for those 8 years and older. The Non-Communicating Children’s Pain checklist is useful for the cognitively impaired, who can be particularly difficult to evaluate because of limited or lack of verbal skills as well as atypical pain behaviors like smiling when in pain.
Patrice Wendling/IMNG Medical Media
Dr. Mark Connelly, Ph.D.
"If you don’t assess pain in children in an age-appropriate manner you can miss an important diagnosis," he said at a symposium sponsored by the American College of Rheumatology.
Pain intensity measures should only make up a very small portion of a multidimensional pediatric pain assessment. Other elements that need to be considered include current pain data such as intensity, duration and etiology, pain history, and contributing physiological, cognitive, emotional, and spiritual factors.
Dr. Connelly and his colleagues have developed a brief multidimensional pain assessment tool for pediatric rheumatology called Super-KIDZ that assesses pain features and impact on functioning, coping, and mood. When tested among 24 children aged 4-7 years and 77 youth, aged 8-18 years, completing the measure online took about 5 minutes, just slightly longer compared with a paper version. Most children preferred the computer version, as did a test group of rheumatologists and pain experts, who said they would recommend the computer summary to their colleagues (Pediatr. Rheumatol. Online J. 2012 Apr 10;10:7. [Epub ahead of print]). SuperKIDZ is still undergoing additional validation testing as well as translation. Eventually, the Child Arthritis and Research Rheumatology Alliance site may host the tool online, making it available to providers to use, Dr. Connelly said in an interview.
Among other top 10 tips Dr. Connelly offered for why kids are not just "little adults" when it comes to pain were:
• Pain behaviors vary from child to child; some kids react to pain by sleeping or eating more, other by doing so less. Some children may curl up and become inactive or cling to their parents, while others may actually run around the room to distract themselves from pain, he said.
• Minor pains are not so minor. Clinicians need to be proactive in treating kids’ pain because even pain from minor procedures can set up a child for more pain in the future, he said. Long-term consequences of undertreated pain include hypersensitivity, hyperinnervation, wind-up of pain pathways, and avoidance of health care.
• Chronic pain can be disabling. It is the minority of children that are disabled by persistent pain, but for those who are, there can be increased direct and indirect costs totaling about $12,000 per year, resulting from social and school difficulties, increased depression and anxiety, and loss of activity and disability into adulthood. When Dr. Connelly and his colleagues asked nine school-age children with juvenile idiopathic arthritis and their parents to use electronic diaries thrice daily to assess their pain, the children reported reducing up to 82% of total activities at any given assessment (J. Pain Symptom Manage. 2010;39:579-90).
• Kids live with their parents. Parents’ responses to a child’s pain can facilitate or hinder functioning. Natural protective behaviors, catastrophizing, personal distress, and modeling of disability are just some of the factors that come into play. The key here is to make parents an essential partner in lessening pediatric pain and disability.
• Children’s pain is plastic. Regardless of disease presentation, a variety of continually changing biological, social, and psychological factors can influence how children experience and express pain. They can include repeated experiences of pain in infancy, hospital experiences, understanding of health care, school or social failures, emotional lability and social isolation. Thus, pain assessment and treatment should always be based on a biopsychosocial understanding of pain.
• Kids go to school, except when they don’t. Having children medical homebound is generally contraindicated for treatment of persistent pain in children because of a growing body of evidence showing that regular exercise and maintenance of routines is beneficial, Dr. Connelly said. Providers can help facilitate regular school attendance by writing an accommodations plan that may include a modified physical education curriculum, additional time or rest breaks in a quiet area, extra time for tests/assignments, or a modified school day.