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]