Pain assessment across developmental and cognitive abilities — branching viva

Opening (warm-up)

Examiner: A four-year-old is admitted overnight after a scald and lies still and silent; the registrar documents "comfortable," but the nurse scores seven out of ten. Walk me through how you assess this child's pain. ^[2]

Candidate: I start from the principle that self-report is the gold standard and that absence of behavioural signs is not absence of pain. For this four-year-old I ask the child first, offering the Faces Pain Scale-Revised, which is validated from about four to five years, and I read the self-report alongside behaviour. If self-report is not possible I score with FLACC — Face, Legs, Activity, Cry, Consolability, total out of ten — validated from two months to about seven years for acute and postoperative pain. The reason I do not trust the "comfortable" impression is that 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 like comfort but marks severe pain, and autonomic signs habituate so observations can be normal. The seven-out-of-ten score and the clinical context — a fresh scald — justify analgesia, and I reassess against the predicted response and document the trend as the fifth vital sign. ^{[1] [2]}