A systematic review of pain assessment method in children


Background and Purpose: There are various methods for assessment of pain in children, but the priority of use of tools in different circumstances is still unknown to many of the researchers. The aim of this study is to review the methods of pain assessment in children. Materials and Methods: All internal studies conducted in Iran in the past 10 years using the keywords such as pain assessment tools to evaluate pain, utilities pain in children, and ways to measure pain in children of databases including Magiran, MEDLIB, SID, Iranmedex, and databases Latin CINHAL, PubMed, Scopus, and Google Scholar search and data were analyzed using meta-analysis (random effect model). Results: Of the 485 original articles, 33 review articles in the field of pain assessment tools in Iranian children were selected based on inclusion criteria. Various pain assessment tools were used, the most important of which were the most commonly used pain evaluation tools included eight FLACC, CHEOPS, PPPRS, TPPPS, self-report tools including the Wang-Baker FACES and Numerical Rating Scale, physiological criteria, and storytelling, and the report includes Wong-Baker FACES tools and Numerical Rating Scale (NRS). Conclusion: The criteria Wong-Baker FACES and NRS were used, although emerging standards such as the FLACC are now widely used in the world.

Keywords: Children, meta-analysis, pain, tools

How to cite this article:
Alizadeh Z, Paymard A, Khalili A, Hejr H. A systematic review of pain assessment method in children. Ann Trop Med Public Health 2017;10:847-9


How to cite this URL:
Alizadeh Z, Paymard A, Khalili A, Hejr H. A systematic review of pain assessment method in children. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Aug 10];10:847-9. Available from: https://www.atmph.org/text.asp?2017/10/4/847/215851



In acute conditions, the child’s behavior is the main way of expressing children’s pain; in fact, specific behaviors represent distress, such as crying, frowning and changing faces, certain physical conditions, and lack of relaxation in children with pain.[1] Pain management is one of the important children’s rights and priorities of treatment, so the basis of post-operative pain control in children is prophylactic analgesia.[2] Stress is caused by the hyperactivity of the sympathetic pain, followed by increased heart rate, peripheral vascular resistance, blood pressure and cardiac output, and tissue ischemia. The alkalosis is due to spastic and superficial breathing, bronchiectasis and atelectasis due to insufficient lung expansion, loss of fluid and electrolyte due to rapid breathing, increased sweating, and the rate of metabolism and future psychological complications caused by nightly nightmares about pain.[3],[4]

Pain prediction management in the recent years has significantly increased.[5] But the lack of recognition of individual differences in patients about children is also true, so that the unique features of childhood have doubled the lack of adequate care for children, especially acute pain.[6] Therefore, to assess the severity of pain, using pain assessment tools is a simple and effective way to express their pains. On the other hand, the review tools provide more objective information, and less likely to overcome the painful symptoms of pain.[7]

In fact, stress behaviors such as in fact, tension behaviors such as verbal changes, facial expressions, and body movements are associated with pain.[8] Although distinguishing between pain behavior and reactions of other sources of stress such as hunger, anxiety, or other discomfort is not always easy, these factors as well as standards of behavior reduce sensitivity. However, in assessing pain in infants and children, effective communication skills are useful.[9] Unfortunately, these tools are constantly not used in medical environments.[10] The aim of this study is to perform systematic review methods of pain assessment of children in Iran.

Materials and Methods

In this structured review, all of the internal studies conducted in Iran over the past 10 years using the keywords of pain assessment tools, pain assessment, pain tools, pain in children and methods for measuring pain in children from the country’s databases, including Magiran, MEDLIB, SID Iranmedex, as well as Latin databases such as CINHAL, Pubmed, Scopus and Google scholar, and data were analyzed using meta-analysis (random effect model) and data sources of selected articles were also collected.

All articles regardless of language, place of publication, and work practices were examined. After reviewing and collecting all the articles searched, repetitive and irrelevant articles were excluded from the study. In the next step of the literature review, the articles were evaluated based on inclusion criteria from articles that had worked in the field of pain in children. Search methods such as a common and academic review of pain, Face, Legs, Activity, Cry, Consolability (FLACC), Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Parent’s Postoperative Pain Rating Scale (PPPRS), and Toddler, Preschooler, and Postoperative Pain Scale (TPPPS) were used. Self-reporting tools including the Wang-Baker FACES and the Numerical Rating Scale used physiological and storytelling criteria, extracted papers on surgical pain and published articles on pain relief methods in intensive care units and, finally, articles that The pain of children was studied comparatively or in a single group. Exclusion criteria included data from case reports, letters to the editor, review articles, meetings, and poster presentations. All ethical issues regarding the proper use of articles were extracted, and conditions of the release effect were observed.


All 485 articles that met the inclusion criteria were initially investigated. Of the 33 articles that were examined, the tools and methods for studying pain in children in the second phase were selected for review. The most commonly used pain assessment tools included facial scale, foot, activity and crying (FLACC), Eastern Aunturian Children’s Scale (CHEOPS), Post Parental Surgery Scale (PPPRS), Postoperative Scale of Early Childhood Surgery School (TPPPS), self-report tools (the child describes and evaluates the severity of the pain it experiences), including the Wong-Baker FACES and the Numerical Rating Scale, the physiological criterion (for infants and children without speech), stories, bubbles, Oucher (11 numerical scales of pain vertically and 6 realistic images of children) and the Special Care Pain Viewer (CPOT).


Children’s behavioral responses to pain vary according to the age and type of disease.[11]

Face, Legs, Activity, Cry, Consolability Scale

The FLACC scale of 5 is considered the benchmark for behavior, including facial expressions, foot movements, activity levels, crying, and relief function are measured by assigning scores of 0 to 10. This scale is used to assess pain in children aged 2 months to 7 years. It was also approved in 2010 for use by children in critical situations.[12]

Children’s Hospital of Eastern Ontario Pain Scale

In this scale, the following parameters were studied: crying, facial expressions, speech, trunk, and legs of touch with 0 score (pain), 1 (no pain behavior and failure to deal with it), 2 (mild to moderate), and 3 (severe pain). 4–13 will be the final score. This method is used in children aged 5 years and includes crying (1-3), facial expression (0-2), speech (0-2), trunk (1-2), tactile (1-2) and legs (1-2).[13]

Toddler, Preschooler, and Postoperative Pain Scale

An observational measure used to measure postoperative pain in children aged 1-5 years and includes 3 behavioral groups:

1) Expression of pain by sounds (shouting, groaning, humming, snoring and grunting), 2) Pain in the face (mouth open, lips swelling to the face, looking at the corner of the eye, Close eyes, chin on the forehead and bumps of the eyebrows), and 3) Physical pains (motor behaviors when touching the painful area). These are not local reactions to pain, but they can provide a general overview of the overall body’s disturbances in children with pain. To provide Physiological parameters as well as measures of behavior are useful for infants and children without speech.[14]

Physiological parameters as well as measures of behavior are useful for infants and children without speech. Physiological parameters indirectly examine the pain and can be used to examine their pain and severity. The pain sources can be physical and psychological problems, so at the first step, the source of pain should be distinguished. Most studies in the field of physiological parameters are related to the infant and are usually used to measure sharp pains caused by processors.[15]

Parent’s Postoperative Pain Rating Scale

The Parent’s Postoperative Pain Rating Scale (PPPRS) is a parental benchmark that reports changes in the frequency of child behavior.[16] Wong-Becker smileys (1998) has six images ranging from a smiley face (signs of pain and equal to zero) to a tearful face (the highest level and equivalent pain score of 10). This scale is used in children aged 3–8 years. Validity and Reliability of Numerical Scale Scale of pain intensity and scaling scale of Wang-Fake smears have been confirmed in many studies. Spearman’s coefficient of scalar scalar was calculated as 0.75 r = 0.87 in the Bayer study, which is a good indication of the reliability of the above scale.[17] In GarA et al., Spearman’s correlation coefficient r = 0.90 showed a good reliability of pain scaling scale for Wang- Becker smileys.[18]

Critical Care Pain Observation Tool

The CPOT has four parts and each part has different behaviors such as facial expressions, muscle contractions, and facial expressions, each of which contains three items and Ventilator compatibility consists of 4 items for Intooth patients or speaking power for extubation patients. The least in the benchmark score is 0, indicating a lack of pain and the maximum score is 8, which is equivalent to the maximum pain.[19],[20]


Pain in children in the absence of early detection could have grave consequences. Many children under 3 years of age cannot express their pain properly and are of high quality, are at greater risk for the consequences of the pain for the consequences of pain. Therefore, the existence and application of early diagnostic procedures for pain in children can prevent complications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.



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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_155_17

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