Pain assessment across developmental and cognitive abilities — formative SAQs

SAQ 1 (10 marks)

A four-year-old is admitted overnight for observation after a scald to the forearm. On the ward round the child is lying still, not crying, and the registrar documents "comfortable, pain controlled." The bedside nurse, using a validated tool, scores the child at seven out of ten. You are the paediatric registrar asked to review the assessment. [2] [3]

1. Explain why the child's stillness does not exclude severe pain, naming the mechanisms by which behaviour and physiology diverge from the underlying pain. (3) [2]
2. State which validated tool you use to assess this four-year-old's pain and why, including the tool you would use at the next developmental band up and the age at which the Numerical Rating Scale becomes reliable. (4) [3] [4] [5]
3. Describe how you score FLACC for this child, the reassessment you perform after analgesia, and how you document the assessment as the fifth vital sign. (3) [1] [2]

Model answer — SAQ 1

(1) Stillness does not exclude severe pain (3). Pain is the subjective, centrally-constructed experience, and behaviour is only an indirect window onto it; the window is fogged by developmental stage, cognition, sedation and habituation. A young child in severe pain can freeze rather than cry, become still rather than thrash, and withdraw rather than seek comfort — the freeze response looks, at the bedside, like comfort. Autonomic signs such as tachycardia rise early but habituate, so a child in sustained pain can have normal observations. A child who has cried themselves out with exhaustion can be quiet while still in severe pain. The principle is that absence of behavioural signs is not absence of pain; when the clinical situation implies pain — a fresh scald — the score is read against the context and analgesia proceeds. [2]

(2) Tool selection by developmental age (4). I ask the child first, because self-report is the gold standard whenever the child can understand the task. For this four-year-old I offer the Faces Pain Scale-Revised, six gender-neutral faces scored 0 to 10 in two-point steps, which is validated from about four to five years and is the appropriate self-report instrument for this age. I read the self-report alongside behaviour, because a frightened preschool child may under-report. If self-report is not possible I use FLACC (Face, Legs, Activity, Cry, Consolability, total 0 to 10), validated from two months to about seven years for acute and postoperative pain. At the next developmental band — the school-age child — the Faces scale remains useful and the Numerical Rating Scale (0 to 10) is added; the Numerical Rating Scale is reliable and preferred from about eight years and should not be used routinely below that age, because younger children cannot reliably map an abstract number onto an internal state. [3] [4] [5]

(3) FLACC scoring, reassessment and documentation (3). I score the five FLACC categories — Face, Legs, Activity, Cry, Consolability — each 0, 1 or 2, summing to a total out of 10, observing for the full window the tool requires and reading the result against the clinical context. After the analgesic I reassess at the interval appropriate to the drug — minutes for intravenous opioids, up to about an hour for oral agents — and compare the new score with the reduction I predicted; a score that has not moved prompts a review of the dose, the route, the diagnosis and whether fear or distress rather than nociception is driving the behaviour. I document the score in the observation chart as the fifth vital sign, so that the trend rather than a single number is what the next clinician inherits. [1] [2]

SAQ 2 (10 marks)

A nine-year-old boy with severe cerebral palsy (Gross Motor Function Classification System level V), a gastrostomy and scoliosis is admitted day one after spinal fusion surgery. He is non-verbal and the ward team is unsure how to assess his pain; the nurse notes he is "settled" and has not required breakthrough analgesia. His mother says he is "not right." You are the paediatric registrar. [6] [9]

1. Explain why generic FLACC is unsuitable for this child and which tools you use instead, justifying your choice with the evidence. (4) [6] [7] [8]
2. Describe how you involve the mother in the assessment and what you mean by reading the baseline change rather than the baseline level. (3) [6]
3. Outline the reassessment and documentation plan that protects this child across the postoperative course, and explain how the plan changes if he is subsequently admitted to the PICU and requires neuromuscular blockade. (3) [10]

Model answer — SAQ 2

(1) Why generic FLACC fails, and the correct tools (4). Generic FLACC is corrupted in this child because the Legs and Activity domains are confounded by his baseline dystonia, spasticity, scoliosis and immobility — the very features of his cerebral palsy — so a generic score can read as comfort while he is in severe postoperative pain, and under-recognition in this population is the persistent signal across studies. I use the revised FLACC, which retains the FLACC structure but allows individualised, parent-described behaviours to be added under each category and which demonstrated improved reliability and validity for pain assessment in children with cognitive impairment. I also use the Non-communicating Children's Pain Checklist, validated in its postoperative version, which scores seven domains of behaviour over a short observation window for non-verbal children with cognitive impairment; a head-to-head comparison of the clinical utility of pain tools in this population confirmed that the individualised instruments serve these children best. [6] [7] [8]

(2) The mother as expert, and baseline change (3). The mother is the expert on what this child's pain normally looks like, because his pain behaviour is individual and idiosyncratic — vocalisation changes, grimacing, arching, rocking, abrupt changes in tone or sleep, and withdrawal may all be his pain. I ask her to describe his baseline pain behaviour and to tell me how today differs from that baseline, and I score against that individualised description. The key principle is that baseline change matters more than baseline level: a child whose behaviour has moved away from his own normal is in trouble even if the absolute score looks modest, because a habituated child in longstanding or complex pain may show little absolute behaviour while experiencing significant pain. Her report that he is "not right" is a baseline-change signal I act on. [6]

(3) Reassessment, documentation and PICU paralysis (3). I record the revised FLACC or Non-communicating Children's Pain Checklist score in the chart at regular intervals, reassess after every analgesic against the predicted response, and document the trend so the team inherits a trajectory. If he is admitted to the PICU and requires neuromuscular blockade, I switch to COMFORT-behaviour within an explicit sedation-and-pain framework, but I recognise that neuromuscular blockade removes the movement and much of the behaviour the tools depend on, so his behavioural score cannot be the sole basis for analgesia. He therefore carries an explicit, scheduled analgesic plan that matches the anticipated noxious stimulus — the surgical incision and the critical-care interventions — with the behavioural and physiological signs read as supportive rather than decisive, and the plan revisited as sedation lightens. [10]