INTRODUCTION:

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain, recognized as "the fifth vital sign" by the American Pain Society (2003), is one of the most common and distressing symptoms experienced by children in hospital settings.¹

Pain in children can arise from medical procedures, surgeries, injuries, infections, and disease exacerbations.² Pain should be assessed regularly, before and after analgesia, and during activities, with frequency depending on treatment intensity.³Despite advancements in pediatric care, many children and adolescents still endure inadequately managed pain across various types. This undertreatment often stems from inconsistencies in pain assessment, administering analgesics at subtherapeutic doses, and prolonged intervals between medication administrations. Pain assessment helps identify cause, intensity, and impact on function, supporting effective management.⁴ Key components include onset, duration, treatment response, triggers, associated symptoms, and effect on mood and family.⁵

Nurses play a critical role in assessing and managing pain in pediatric patients; however, young children often struggle to communicate the intensity, duration, and frequency of their pain. To address these challenges, various age-appropriate pain assessment scales are available, enabling nurses to effectively evaluate and respond to the unique pain needs of each child^..This article aims to summarise the pain assessment scales for easy understating of the beneficiary.

METHOD OF PAIN ASSESSMENT:

Scales are used as tool to measure the level of pain. It measures the Verbal response, Behavioral response and Physiological response⁶

VERBAL RESPONSE TO PAIN BY CHILDREN:

While questioning the child

1. Use Child-Friendly Language: Use words the child understands, like "sore," "ouch," or "hurt," to make communication clear and comforting.

2. Be Developmentally Appropriate: Tailor questions and interactions to the child's age and developmental level for effective engagement.

3. Use Dolls or Toys: Consider using dolls, toys, or other familiar objects as tools to help children express where and how they feel pain.

4. Address Additional Concerns: Be mindful of any other issues the child may have, such as fear, anxiety, or cultural considerations, that could affect their expression of pain.

5. Ask Specific Questions: For children who can verbalize, ask about the location, intensity, quality, onset, and duration of the pain, as well as factors that aggravate or alleviate it, and any additional symptoms.

6. Non-verbal Children: Recognize that non-verbal children are at higher risk of their pain being underestimated, so pay extra attention to behavioral and physiological signs of discomfort.⁷

Behavioural Response to Pain:

Behavioral assessment helps detect pain in infants, preverbal children, and those unable to communicate due to developmental or cognitive limitations, ensuring proper pain management.

Preterm Infant: Pain response may be blunted or absent, grimacing, showing minimal reactions.

Young Infant:

· Physical Response: Generalized body rigidity or thrashing, often with a local reflex withdrawal from the painful area.

· Vocalization: Loud crying.

· Facial Expression: Distinct pain indicators such as furrowed brows, tightly closed eyes, and an open, square-shaped mouth.

· Anticipation: No association is observed between an approaching stimulus and the experience of pain.

Older Infant:

· Physical Response: Generalized rigidity or thrashing, along with localized withdrawal from the painful area.

· Vocalization: Loud crying.

· Facial Expression: Same as young infants, with brows lowered, eyes tightly closed, and mouth open.

Toddler:

· Physical Response: Localized body response with deliberate withdrawal from the stimulus.

· Vocalization: Loud cry.

· Facial Expression: Signs of pain or anger.

· Behavior: Physical resistance, such as pushing away the painful stimulus after it is applied.

Preschooler:

· Vocalization: Loud crying and screaming, with verbal expressions like "ow," "ouch," or "it hurts."

· Physical Response: Thrashing of arms and legs.

· Behavior: Lack of cooperation, asking for the procedure to stop, seeking emotional support by clinging to parents or caregivers.

· Anticipatory Response: Signs of pain or fear before the painful procedure begins, with restlessness and irritability if pain continues.

School-Age Child:

· Vocalization: Similar to preschoolers, but with less anticipatory behavior.

· Behavior: Stalling tactics such as "I'm not ready" or "wait a minute."

· Physical Response: Muscular rigidity, including clenched fists, white knuckles, gritted teeth, tense limbs, and a stiffened body.

Adolescent:

· Vocalization: Reduced vocal protests.

· Behavior: Less motor activity but increased verbal expression of pain.

· Physical Response: Higher muscle tension and better body control.⁸

Physiological Responses to Pain in Children:

Physiological responses can serve as indicators of pain, though they are often nonspecific and influenced by various factors. Observing these responses can be helpful but should not be relied upon in isolation, as they may also stem from conditions such as fear, anger, anxiety, sepsis, or hypovolemia.

Common Physiological Responses are-

· Vital Signs: Changes in heart rate, blood pressure, and respiration may decrease or fluctuate with pain.

· Sleep Pattern: Disruptions in sleep, including difficulty sleeping or waking frequently.

· Skin Color and Sweating: Pallor, flushing, or increased sweating, especially in response to acute pain.

· Posture and Muscle Tone: Altered body posture or increased muscle tone, often seen as rigidity or withdrawal from touch.

· Eating Patterns: Decreased appetite or reluctance to eat.

· Breathing Patterns: Breath-holding, sharp intakes of breath, or sudden gasping.

· Tears: Crying or tearfulness, particularly in younger children.

· Oxygen Saturation: May decrease, especially with prolonged or severe pain.

These indicators, while informative, can vary significantly among children and should be interpreted within the context of other assessments to ensure a comprehensive evaluation of the child’s pain.⁹

Pain Assessment Scales for Various Age Group Children:

Pain assessment Scale for Newborn:

1. CRIES neonatal postoperative pain scale:

The CRIES scale is a validated tool specifically designed to assess postoperative pain in neonates, especially in preterm and full-term infants. It evaluates five criteria related to pain responses, each scored from 0 to 2, for a total possible score ranging from 0 to 10. The CRIES scale enables healthcare providers to assess pain based on observable physiological and behavioral responses, which are critical in newborns who cannot verbally express pain. This tool is commonly used in neonatal intensive care units and postoperative settings to guide pain management in neonates.

Table-1: CRIES Scale

Category	0	1	2
C- Crying	No	High pitched	Inconsolable
R- Required SpO₂>95%	No	F_IO₂<30%	F_IO₂<30%
I-Increased vital signs	Heart Rate and Blood pressure equal to or less than preoperative valuses	Less than 20% of preoperative values	Greater than 20% of preoperative value
E-Expression	None	Grimace	Grimace/Grunt
S-Sleeplessness	No	Awakens frequently	Awake

Interpretation of CRIES Score: 0-3:

Minimal or no pain; likely comfortable, 4-6: Moderate pain; some intervention may be considered depending on clinical context, 7-10: Severe pain; requires immediate intervention and pain management.¹⁰

2. The Neonatal Infant Pain Scale (NIPS):

The Neonatal Infant Pain Scale (NIPS) is a behavioral tool to assess pain in newborns based on observable signs. This scale helps assess and monitor pain in neonates during procedures and after interventions, providing a quick, standardized tool for effective pain management in non-verbal infants. It evaluates six indicators: facial expression, cry, breathing pattern, arm and leg movements, and alertness. Each is scored 0 to 2, except alertness (0 or 1). The total score reflects the infant’s pain level, with higher scores indicating more pain. NIPS is commonly used for infants who cannot express discomfort verbally, helping guide pain management.¹⁰

Table-2: NIPS Scale

Category	0	1	2
Facial Expression	Relaxed	Grimacing, frowning	Furrowed brow, open mouth, tense expression
Cry	No cry or whimpering	Whimpering or whiny cry	Vigorous crying
Berathing patterns	Regular breathing	Irregular, shallow breathing	Abnormal breathing, gasping
Arm and Leg Movements	Relaxed, calm	Restlessness, jerky movements	Abnormal or rigid movements, tense posture
Alertness	Quiet, calm	Alert or startled	-
State of Arousal	Sleeping or quiet alert state	Fussy, crying, active alert state	-

Interpretation:

0-2: No pain or minimal discomfort, 3-4: Mild pain or distress, 5-7: Moderate pain, 8-10: Severe pain.¹¹

3. PIPP (Premature Infant Pain Profile):

The Premature Infant Pain Profile (PIPP) is a multidimensional scale for assessing pain in preterm (from 28 weeks gestation) and full-term neonates (up to 6 weeks). It evaluates seven indicators: gestational age, behavioral state, heart rate and oxygen saturation changes, and facial actions (brow bulge, eye squeeze, nasolabial furrow). Each is scored 0–3, considering gestational age differences. The total score (maximum 21) reflects pain intensity. PIPP combines physiological and behavioral cues, making it effective in NICU settings for procedural pain assessment.¹¹

Table-3: PIPP Scale

Process	Indicator	Score 0	Score 1	Score 2	Score 3
Gestational age (at that time)		≥ 36 weeks	32 to < 36 weeks	28 to < 32 weeks	< 28 weeks
Observe infant 15 sec Heart rate Oxygen saturation	Behavioral state	Active/awake Eyes open Facial movements Crying with eyes open	Quiet/awake Eyes open No facial ovements	Active/sleep Eyes closed Facial movements	Quiet/sleep Eyes closed No facial movements
Observe infant 30 sec	Heart rate max increase	0–4 beats/min increase	5–14 beats/min increase	15–24 beats/min increase	≥ 25 beats/min increase
	Oxygen saturation min decrease	0–2.4% decrease	2.5–4.9% decrease	5–7.4% decrease	≥ 7.5% decrease
	Brow bulge	None (0% of time ≤ 3 sec)	Minimum (10%–39% of time, ≤ 12 sec)	Moderate (40%–69% of time, ≤ 21 sec)	Maximum (≥ 70% of time, ≥ 21 sec)
	Eye squeeze	None (0% of time ≤ 3 sec)	Minimum (10%–39% of time, ≤ 12 sec)	Moderate (40%–69% of time, ≤ 21 sec)	Maximum (≥ 70% of time, ≥ 21 sec)
	Nasolabial furrow	None (0% of time ≤ 3 sec)	Minimum (10%–39% of time, ≤ 12 sec)	Moderate (40%–69% of time, ≤ 21 sec)	Maximum (≥ 70% of time, ≥ 21 sec)

Figure-1: Neonate facial expression for pain

Score and interpretation: 0-6:

Minimal or no pain, 7-12: Moderate pain and >12: Severe pain¹¹

Pain Assessment Scale for Infant:

1. FLACC Pain Rating Scale can be used 2 months to 7 Years:

The FLACC scale assesses pain in children (2 months to 7 years) unable to self-report. It scores five behaviors—face, legs, activity, cry, consolability—each from 0 to 2, totaling 0–10. Useful in postoperative care and for non-verbal or cognitively impaired children, it helps evaluate pain through observed behaviors.

Table-4 FLACC Scale

Categories	0	1	2
F-Facial expression	No special expression	Occasional grimace or frown, withdrawn, disinterested	Frequent to constant frown, clenched jaw, quivering chin
L-Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking, or legs drawn up
A-Activity	Lying quietly, normal position, moves easily	Squirming, shifting back and forth, tense	Arched, rigid, or jerking
C-Cry	No cry (awake or asleep)	Moans or whimpers, occasional complaints	Crying steadily, screams or sobs, frequent complaints
C- Consolability	Content, relaxed	Reassured by occasional touching, hugging or “talking to”. Distractable	Difficult to console or comfort

Interpretation of FLACC Score: 0:

Relaxed and comfortable; likely no pain., 1-3: Mild discomfort or pain; may not require intervention, 4-6: Moderate pain; intervention may be needed based on clinical assessment and 7-10: Severe pain; requires immediate intervention for pain management.¹²

2. The CHEOPS (Children's Hospital of Eastern Ontario Pain Scale):

The CHEOPS scale assesses pain in children aged 1–7 years who cannot verbalize pain. It is useful for postoperative, procedural, or cognitively impaired children. The scale includes six behavioral indicators scored 0–2 based on observed responses. Higher total scores indicate greater pain intensity. The CHEOPS scale assesses pain in young children unable to verbalize discomfort, using behaviors like crying, facial expressions, and movements. It is valuable post-surgery and in emergencies for guiding pain management. Its simplicity, reliability, and ability to reflect pain intensity make it widely used in clinical practice.

Scoring and Interpretation:

The scores from all 6 indicators are added together to give a total score, which can range from 0 to 12. 0-2: No or minimal pain, no intervention needed, 3-5: Mild pain, may require some intervention (e.g., distraction, mild analgesics), 6-8: Moderate pain, analgesia or further intervention is needed and 9-12: Severe pain, urgent need for strong pain management interventions.¹³

Table-5: The CHEOPS scale

Categories	0	1	2
Cry	No cry	Whimpering or moaning	Continuous or loud crying
Facial Expression	Relaxed, no tension	Grimacing, furrowing of	Intense grimace, eyes squeezed shut
Verbal Expression (for children who can speak)	No words or complaints	Whining or complaining	Screaming or shouting words like “it hurts”
Posture	Relaxed, no tension	Tense posture, stiff body	Rigid or curled posture, pulling limbs toward the body
Movement	No movement or relaxed movements	Restless, fidgeting, or shifting positions	Struggling, thrashing, or aggressive movement
Physical Interaction	Calm, no response to touch	Mild response, pulling away	Strong resistance or withdrawal, trying to escape or fight off touch

Pain Assessment Scale for Toddler:

1. Wong baker FACES Pain Rating Scale:

The Wong-Baker FACES Pain Rating Scale is a simple tool designed to help children as young as 3 years communicate their pain intensity. It uses six cartoon faces combined with numbers and descriptive words to visually represent varying levels of pain, from “no hurt” (face 0, smiling) to “hurts worst” (face 5, tearful). This multi-dimensional approach helps children easily point to a face that reflects how much they hurt. The scale avoids emotional terms like “happy” or “sad” to focus on pain, not mood. Face Descriptions: 1. Face 0: Very happy face, representing “no hurt.” 2. Face 1: Slight smile, representing “hurts just a little bit.” 3. Face 2: Neutral face, representing “hurts a little more.” 4. Face 3: Slightly frowning face, representing “hurts even more.” 5. Face 4: Frowning face, representing “hurts a whole lot.” 6. Face 5: Tearful face, representing “hurts as much as you can imagine.” To use, simply ask the child, “Choose the face that shows how much you hurt,” and record the number. Widely used in clinical settings, this tool is valued for its clarity, ease of use, and effectiveness in assessing pediatric pain levels.¹⁴

Figure-2: Wong baker FACES Pain Rating Scale

Pain Assessment Scale for Preschooler:

1. Poker Chip Tools. (Hester 1998) (Children as young as 4 yr)

The Poker Chip Tool is a simple, effective pain assessment tool for children, particularly those as young as 4 years old, who may not yet have the cognitive ability to use numbers or describe their pain in detail. It involves using four red poker chips placed horizontally in front of the child, each representing a level of pain intensity.

How It Works:

· The nurse or clinician explains the tool by saying:
"These are pieces of hurt. This (first chip) is just a little bit of hurt, and this (fourth chip) is the most hurt you could ever have." "This means this (1st chip) is just a little hurt, this (2nd chip) is a little more hurt, this (3rd chip) is more yet, and this (4th chip) is the most hurt you could ever have."

· The child is then asked to choose how many poker chips best represent their pain. This allows the child to select a visual and concrete representation of their pain intensity.

Interpretation of the Scale: 1 Chip: Slight pain, 2 Chips: Mild pain, 3 Chips: Moderate pain and 4 Chips: Severe pain¹⁵

Figure-3: Poker Chip Tools

2. Numerical scale:

The Numerical Pain Rating Scale (NPRS) is a simple tool used to assess pain in children aged 5 and above who understand numbers. It consists of a straight line labeled from 0 (“no pain”) to either 5 or 10 (“worst pain imaginable”), depending on the facility’s protocol. Sometimes, a midpoint (“medium pain”) is marked to aid understanding. The child is asked to select a number that best represents their pain. For example, "0 means no pain, and 10 means the worst pain you can imagine." Interpretation: 0: No pain, 1–3: Mild pain, 4–5: Moderate pain, 6–7: Severe pain, 8–9: Very severe pain and 10: Excruciating pain. NPRS is flexible, easy to use, and aligns with standard clinical documentation, making it a reliable choice for older children’s pain assessment.¹⁶

Figure-4: Numerical pain scale

3. Color tool: (Eland and Banner, 1999):

The Color Tool helps children (as young as 4 years) express pain intensity by linking colors to discomfort levels. It suits children who know colors, aren’t color-blind, and can relate colors to pain. The tool helps visualize pain intensity and location, aiding children who struggle to verbalize pain. It supports self-expression and improves pain assessment.

Instructions: Set Up: Give the child eight randomly arranged colored markers. Severe Pain: Ask, "Which color feels like the worst pain you've had?" Set it aside. Moderate Pain: Ask, "Which color feels like pain, but less than the worst?" Place next to severe. Mild Pain: Ask, "Which color is for pain that hurts just a little?" Add to the sequence. No Pain: Ask, "Which color shows no pain at all?" Arrange colors from worst to no pain. Pain Location: Provide a body outline. Ask the child to color painful areas using chosen colors. Clarify if these are current or past pains. Clarification: If unclear, ask gently why the area hurts.¹⁷

4. The Oucher pain scale:

The Oucher Pain Scale is a tool used to assess pain in children aged 3 to 12 years. It includes a photographic scale with six images of children's facial expressions ranging from "no pain" to "worst pain," and a corresponding numeric scale from 0 to 10. Children under 3 years may not be able to use this scale, so alternatives like the FLACC scale are preferred. To use the scale, the child is shown the photographs and asked to point to the face that best shows how they feel. The corresponding number on the numeric scale is then recorded. Pain is interpreted as follows: 0 indicates no pain, 1–3 indicates mild pain, 4–6 indicates moderate pain, and 7–10 indicates severe pain. The scale is quick to use, features real child photos for easier understanding, is available in versions for different ethnicities, and has proven effective in clinical settings for assessing pain in children.¹⁸

Figure-5: Numerical pain scale: OUCHER Pain assessment scale

5. Faces Pain Scale – Revised (FPS-R):

The Faces Pain Scale – Revised (FPS-R) is a self-report tool for children aged 4 years and older. It uses six neutral facial expressions, arranged from no pain (left) to worst pain (right), allowing children to point to the face that best shows their pain level. Unlike earlier scales, it avoids smiling or crying to reduce emotional bias.

How to Use: Show the child all six faces and say: “These faces show how much something can hurt. The face on the left means no pain, and the face on the right means the most pain possible. Point to the face that shows how much you hurt right now.” Record the score.

Scoring and Interpretation:

Faces are scored as 0, 2, 4, 6, 8, and 10, aligning with the standard 0-10 numerical pain scale.¹⁹

Figure-6: FPS-R scale

Pain Assessment Scale for Older Children (4-18yrs)

1. Word graphic rating scale: uses descriptive words. (Tester 1991):

The Word Graphic Rating Scale is used for children aged 4–17 to describe pain using words instead of numbers. Descriptive terms like "no pain," "a little pain," "some pain," "a lot of pain," and "worst possible pain" are placed along a line. The child is asked to point to the word that best matches their current pain. The response is documented to help guide pain management. This tool is helpful for children who struggle with numeric scales, allowing them to express pain using familiar language.²⁰

Figure-7: Word graphic rating scale

2. Visual analogue scale (Cline 1992):

The Visual Analogue Scale (VAS) is a 10 cm straight line used to assess pain in children, with one end labeled "no pain" and the other "worst pain imaginable." Children are asked to mark a point on the line that best represents their pain. The distance from the "no pain" end to the mark is measured in centimeters and recorded as the pain score (0–10 cm). Suitable for children aged 7 years and above, VAS provides a simple, continuous measure of pain intensity, though younger children may prefer more visual or descriptive scales.

Considerations:

The VAS provides a continuous scale that reflects the subjective experience of pain. While effective for children who can understand the concept, it may not be as popular with younger children, as they might prefer scales with simpler visual or descriptive elements. Nonetheless, it remains a valuable tool in pain assessment for older children and adolescents.²¹

Figure-8: Visual Analogue scale

3. The COMFORT-B scale:

The COMFORT-B scale (Behavioral version) is an observational tool used to assess pain and distress in non-verbal children, especially in critical care settings such as neonatal and pediatric intensive care units. It evaluates six behavioral indicators: alertness, calmness or agitation, respiratory response (or crying in non-ventilated children), physical movement, muscle tone, and facial tension. This scale is particularly useful for assessing sedated or ventilated children who cannot express pain verbally. It provides a systematic and objective approach to guide sedation and pain management and allows for continuous monitoring. To use the scale, the child is observed for two minutes, and each of the six items is scored from 1 to 5 based on defined criteria. The total score, ranging from 6 to 30, indicates the child’s level of pain and discomfort.

Score and interpretation:

6–10: Deep sedation (possibly too much sedation), 11–22: Adequate comfort (acceptable sedation and analgesia) and 23–30: Insufficient sedation or pain management (distress or pain likely present)²²

Pain Assessment in Children with Communication And Cognitive Impairment:

Children with communication or cognitive impairments, such as those with cerebral palsy, intellectual disabilities, autism, severe brain injuries, or sensory challenges, often struggle to express pain verbally. In such cases, pain assessment depends on observing behavioral cues and subtle physical signs, as these children may be unable to communicate their discomfort directly.

Common Pain-Related Behaviors:

The most frequently reported indicators of pain in these children include:

· Crying or Moaning: Vocal expressions may vary, with some children producing subtle sounds or moans that can signal discomfort.

· Decreased Activity: Reduced engagement in usual activities or play may indicate pain, as the child may be conserving energy or avoiding movements that exacerbate discomfort.

· Seeking Comfort: Increased need for physical closeness or consolation may indicate that the child is experiencing distress.

· Irritability and Non-Cooperation: A child may show reluctance to engage in routine activities or display irritability when approached.

· Changes in Facial Expression: This may include furrowed brows, grimacing, or other changes in facial tension that reflect discomfort.

· Physical Tension and Rigidity: Signs of stiffness, spasticity, or tense body posture may be reactions to pain or discomfort.

· Sleep Disturbances: Disrupted sleep patterns, including sleeping less or waking frequently, are often associated with unrelieved pain.

· Difficulty in Being Pacified: These children may be hard to comfort or console, indicating persistent discomfort.

· Flinching or Protective Movements: Flinching or moving a body part away when touched may indicate localized pain or discomfort.

· Agitation and Fidgeting: Increased physical restlessness or fidgeting may signal pain, especially if out of character for the child.

Considerations for Caregivers:

Assessing pain in children with cognitive or communication impairments requires a keen understanding of their baseline behaviors and routines. Subtle changes in behavior, body language, or facial expressions should be closely monitored, as these may serve as critical indicators of pain that are otherwise difficult for the child to convey. A consistent approach to observation and documentation helps ensure that pain is recognized and managed effectively, even in children with limited communication abilities.

1. The Non-Communicating Children's Pain Checklist (NCCPC).

The Non-Communicating Children's Pain Checklist (NCCPC) is used to assess pain in children who cannot speak or clearly express discomfort. It relies on observing behaviors across categories, each scored from 0 (not observed) to 3 (very frequent/intense). The total score indicates pain level: 0–6: Mild/No pain, 7–12: Moderate pain and 13–18: Severe pain This tool helps caregivers and healthcare providers recognize pain through behavior when verbal communication isn’t possible.²³

Table-7: The Non-Communicating Children's Pain Checklist

Behavioral Category	Observation Points	Scoring
Vocal	Moaning, groaning, or whimpering	0-3 points
	Crying (ranging from mild to intense)
	Screaming or yelling
Social	Seeking comfort (wants to be held, cuddled)	0-3 points
	Being difficult to console or comfort
Facial Expressions	Grimacing, wrinkled forehead, clenched teeth	0-3 points
	Wide eyes, increased eye movements
Activity	Physical tension, stiff or spastic movements	0-3 points
	Thrashing, jerking movements
Body and Limbs	Guarding or protecting painful area	0-3 points
	Flinching or withdrawal when touched
Physiological Indicators	Increased sweating or flushing	0-3 points
	Changes in vital signs (e.g., heart rate, respiration)
Overall Score Interpretation	Total each category score (out of max score 18)	Interpretation of severity

2. The r-FLACC scale:

The r-FLACC scale is a behavioral pain assessment tool used for non-verbal children or those with cognitive impairments, from infancy to adolescence. It allows for individualized pain assessment by incorporating caregiver input about unique pain behaviors, such as specific facial expressions, movements, or vocalizations. Caregivers help identify these behaviors, which are added to standard scoring. The tool is quick, easy to use, and improves accuracy by personalizing pain cues. To use, caregivers are interviewed, the child is observed for 1–5 minutes, each category is scored from 0–2, and a total score out of 10 is calculated.

Table: 8: Revised- FLACC Scale

Categories	0	1	2
Face	No particular expression or smile.	Occasional grimace or frown, withdrawn, disinterested, sad, appears worried.	Frequent to constant quivering chin, clenched jaw, distressed looking face, expression of fright/panic.
Legs	Normal position or relaxed; usual tone and motion to limbs.	Uneasy, restless, tense, occasional tremors.	Kicking or legs drawn up, marked increase in spasticity, constant tremors, jerking.
Activity	Lying quietly, normal position, moves easily, regular, rhythmic respirations.	Squirming, shifting back and forth, tense/guarded movements, mildly agitated, shallow/splinting respirations, intermittent sighs.	Arched, rigid or jerking, severe agitation, head banging, shivering, breath holding, gasping, severe splinting.
Cry	No cry (awake or asleep).	Moans or whimpers, occasional complaint, occasional verbal outbursts, constant grunting.	Crying steadily, screams or sobs, frequent complaints, repeated outbursts, constant grunting.
Consolability	Content, relaxed.	Reassured by occasional touching, hugging, or being talked to; distractible.	Difficult to console or comfort, pushing caregiver away, resisting care or comfort measures.

Score and interpretation: 0:

Relaxed, comfortable, 1-3: Mild discomfort, 4-6: Moderate pain & 7-10: Severe pain²³

CONCLUSION:

Effective pain assessment in children requires a comprehensive, age-appropriate, and individualized approach. Children vary significantly in their ability to understand and express pain, necessitating the use of diverse tools and methods tailored to their developmental level. Behavioral cues, physiological changes, and verbal expressions all provide valuable insight into a child’s pain experience. Incorporating parent or caregiver input is especially crucial when evaluating children with communication or cognitive impairments. Nurses play a pivotal role in recognizing subtle signs of distress and advocating for timely and adequate pain management. Regular and systematic pain assessments—before, during, and after interventions—help ensure that pain is effectively controlled and that analgesic regimens are optimized. Understanding the child’s emotional state, family dynamics, and cultural background further enriches the assessment process. Ultimately, accurate pain assessment not only alleviates suffering but also fosters trust, supports emotional well-being, and improves overall outcomes. By prioritizing pain assessment as an integral component of pediatric care, healthcare providers can uphold children’s rights to pain relief and promote a more compassionate, family-centered healthcare environment. This holistic approach underscores the importance of viewing pain management as a fundamental aspect of quality nursing care in children.

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Received on 01.07.2025 Revised on 04.08.2025

Accepted on 03.09.2025 Published on 27.10.2025

Available online from November 08, 2025

Int. J. Nursing Education and Research. 2025;13(4):285-293.

DOI: 10.52711/2454-2660.2025.00057

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Item	1	2	3	4	5
Alertness	Deeply asleep	Lightly asleep	Drowsy	Fully awake and alert	Hyperalert
Calmness	Calm	Slightly anxious	Anxious	Very anxious	Panicky
Physical movement	Occasional	Slight	Frequent	Vigorous movement	Vigorous movement torso and head
Facial tension	Totally relaxed	No facial tension	Some muscles	Throughout the facial muscle	Contorted/grimace
Heart rate	Below baseline	At baseline	>15% above baseline, infrequent	>15% above baseline, frequent	>15% above baseline, consistent
Blood pressure	Below baseline	At baseline	>15% above baseline, infrequent	>15% above baseline, frequent	>15% above baseline, consistent