New Study Evaluates Pain Assessment Tools for Infants and Young Children

New study evaluates pain scales for infants and toddlers in emergency settings. Research aims to improve assessment and management of procedural pain in young children.


A groundbreaking study is shedding light on how healthcare providers can better assess pain in infants and young children undergoing medical procedures. Researchers at the Royal Children’s Hospital in Melbourne, Australia have launched an ambitious project to evaluate the effectiveness of several commonly used pain scales for children aged 6 to 42 months.

As any parent knows, seeing your child in pain is heart-wrenching. But for babies and toddlers who can’t verbalize their discomfort, how can doctors and nurses accurately gauge their pain levels? This challenge is especially critical in busy emergency departments, where young patients often undergo painful procedures like IV insertions or nasogastric tube placements.

The Need for Better Pain Assessment

“Despite increasing evidence that infants’ and children’s experience of pain has negative short-term and long-term impacts, pain continues to be poorly managed, particularly in emergency departments,” the study authors note. They cite issues like poor recognition of significant pain by medical providers as key reasons for suboptimal pain management in young children.

To address this problem, the research team is embarking on a comprehensive evaluation of three widely used observational pain scales:

  1. The Face, Legs, Activity, Cry and Consolability (FLACC) scale
  2. The Modified Behavioural Pain Scale (MBPS)
  3. The Visual Analogue Scale (VAS) for observer pain assessment

Understanding the Pain Scales

The FLACC Scale

The FLACC scale, as its name suggests, looks at five behavioral indicators: facial expression, leg movement, activity, crying, and consolability. Each category is scored from 0-2, for a total possible score of 10. Originally designed for post-operative pain in young children, it’s now commonly used for procedural pain as well.


The MBPS focuses on three key behaviors: facial expression, crying, and body movements. Scores range from 0-10, with higher scores indicating more pain. This scale was specifically created to capture pain responses in infants undergoing immunizations.

The VAS Observer Scale

The VAS observer scale asks the healthcare provider to mark a point on a 10 cm line, with one end representing “no pain” and the other “worst possible pain.” The distance from zero becomes the pain score.

Study Design and Methodology

The research team, led by Dianne J. Crellin, has carefully designed a protocol to rigorously test the psychometric properties of these scales. But what does that mean in plain English? Essentially, they want to determine how reliable, valid, and practical these tools are for real-world clinical use.

Here’s how they plan to do it:

  1. Recruit 100 young patients undergoing common procedures in the emergency department.
  2. Video record each child during their procedure.
  3. Divide videos into short segments showing different phases: baseline (before the procedure), preparation, and during the actual painful stimulus.
  4. Assemble two groups of reviewers: 25 clinicians (doctors and nurses) from the emergency department, and 6 psychologists.
  5. Have reviewers watch the video segments and use the pain scales to score the children’s pain levels.
  6. Have reviewers score the same videos twice, at least 4 weeks apart.

This clever design allows the researchers to assess both the consistency between different raters (inter-rater reliability) and how consistent individual raters are over time (intra-rater reliability).

Why This Study Matters

Accurate pain assessment is essential for proper pain management. If healthcare providers can’t reliably measure a child’s pain, they may under-treat it – leading to unnecessary suffering and potential long-term consequences.

On the flip side, overestimating pain could lead to overuse of pain medications, which comes with its own set of risks. Finding the right balance is critical, and that starts with having tools we can trust.

The researchers hope their findings will guide both clinical practice and future research. By identifying the most reliable and valid scale for assessing procedural pain in this age group, they aim to improve pain management for our littlest patients.

Innovative Aspects of the Study

Feasibility and Clinical Utility

The researchers are also examining the feasibility and clinical utility of these tools. In the fast-paced environment of an emergency department, a pain scale needs to be quick and easy to use. The study includes measures of how long it takes reviewers to assign scores and how confident they feel in their assessments.

Diverse Reviewer Pool

One particularly innovative aspect of this study is its use of both clinician and non-clinician reviewers. Previous research has often relied on small numbers of raters, assuming they represent the larger pool of potential users. By including a larger, more diverse group of reviewers, this study aims to capture a more realistic picture of how these scales perform in practice.

Addressing the Lack of a Gold Standard

The researchers are also tackling a common challenge in pain research – the lack of a true “gold standard” for measuring pain, especially in young children who can’t self-report. To address this, they’re using multiple strategies to validate the scales, including comparing scores between scales and examining how scores change across different phases of a procedure.

Distinguishing Pain from Distress

This study recognizes the complex nature of pain assessment in young children. It’s not just about detecting pain, but also distinguishing it from other forms of distress. The inclusion of both painful and non-painful but distressing procedures (like taking oxygen saturation measurements) allows the researchers to test how well these scales differentiate between pain and general upset.

Implications and Future Directions

As we eagerly await the results of this groundbreaking study, it’s worth reflecting on the broader implications for pediatric healthcare. Imagine a world where every child’s pain is accurately assessed and appropriately managed, regardless of their age or ability to communicate. This research brings us one step closer to that goal.

For parents, this study offers hope that future trips to the emergency department might be less traumatic for their little ones. For healthcare providers, it promises more confidence in their pain assessments and treatment decisions. And for researchers, it sets a new standard for rigorous evaluation of pediatric pain scales.


This innovative study on pain assessment tools for infants and young children represents a significant step forward in pediatric pain research. By rigorously evaluating commonly used pain scales, the researchers aim to provide healthcare providers with more reliable and valid tools for assessing procedural pain in babies and toddlers.

The study’s comprehensive approach – including a large sample size, multiple types of reviewers, and examination of both painful and non-painful procedures – sets it apart from previous research in this field. Its findings have the potential to influence clinical practice guidelines, improve pain management strategies, and ultimately enhance the quality of care for young children in emergency departments and beyond.

As we eagerly anticipate the results of this important study, it serves as a powerful reminder of the ongoing need for evidence-based approaches in pediatric healthcare. By continuing to ask tough questions and pursue rigorous scientific inquiry, we can work towards a future where no child suffers unnecessarily from unrecognized or undertreated pain.

For parents, healthcare providers, and researchers alike, this study offers hope for more effective, compassionate care for our littlest patients. And that’s something we can all get behind.



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  1. […] The FLACC pain scale, an acronym for Face, Legs, Activity, Cry, and Consolability, was developed in 1997 by Sandra Merkel, Patricia Voepel-Lewis, and Terri Shay at the University of Michigan Health System. This behavioral pain assessment tool was designed to address the need for a reliable and valid method to measure pain in children and non-verbal patients. Since its inception, the FLACC scale has become a widely-accepted standard in pediatric and adult care settings for pain assessment. […]