Pain assessment is essential to enable effective pain management. It also provides the foundations for further care. Pain management in infants and children is complex. This is due to factors such as their level of cognition, their ability to communicate, prior experience, fear and severity of their illness. Children with cognitive impairment, neonates and infants require additional consideration of assessment of their pain.

There are numerous pain assessment tools available to assist with the accurate assessment of the child’s pain level. Self-reporting is the gold standard, however, not all children are able to communicate verbally. Physiological signs and behaviour must be considered for those children who are unable to articulate their pain. Pain assessment must be holistic and involve the parents/carers.

A systematic approach using the QUESTT model should be used:

• Q = question the child about their pain and how they are feeling.
  
• U = use an age-appropriate pain assessment tool.
  
• E = evaluate their behaviour and physiological signs.
  
• S = secure the involvement of parents/carers.
  
• T = take the cause of the pain into account, what procedures has the child had?
  
• T = take action: give treatment and evaluate.

The correct tool must be identified and used if pain is to be assessed accurately. Pain assessment tools are either behavioural tools or self-report tools. The tool should be appropriate to the age, development and level of understanding of the child. Children who are cognitively impaired and neonates/infants will require a tool that measures physiological indicators as well as their behaviour.

Behaviour is a very useful measure of pain in children who are pre- or non-verbal. To assess a child’s behaviour, the nurse will need to stand close to the child and observe their behaviour in accordance with the cues on the assessment tool. Some of these behaviours may be reported by parents/carers. The behaviours that child may exhibit are:

• restlessness
  
• guarding the area affected
  
• unusual posture
  
• crying, screaming
  
• pulling at the affected area
  
• more clingy than usual
  
• head banging
  
• biting fingers
  
• irritability
  
• not feeding, decreased appetite
  
• anorexia
  
• stiffness and reluctance to move
  
• pulling away
  
• lack of interest in toys
  
• lethargy
  
• interrupted sleep pattern
  
• rocking
  
• arching back
  
• clenching hands
  
• toe flexion.

Examples of behavioural pain assessment tools are:

• FLACC
  
• CRIES
  
• the Paediatric Pain Profile (PPP)
  
• the Liverpool Infant Distress Scale (LIDS)

Physiological assessment involves both measuring vital signs and also noting the child’s appearance. Heart rate, blood pressure, respiratory rate, blood glucose and oxygen saturations should be measured and documented. The child’s colour should be noted and their skin touched to feel for sweat. Physiological indicators of pain are identified in the table in the Figure.

Self-reporting is the gold standard. This should be the preferred choice for children aged 4 years and upwards. The best-known self-reported pain assessment tools are visual analogue or number scales. Explanation of the relevant assessment tool is required if the assessment is to be accurate.