Challenges and ways for pain assessment of children in the primary health care

Hisham Fayiz Alkhuzaie, Yaqoub Yousef Alhabib, Aysar Farhan Alanazi, Mahmoud Ibrahim Ali, Abdullah Ali Alqahtani, Sulafa Khaled Noorelahi, Ibrahim Ghaleb Daiwali, Fatimah Mohammed Alawadh, Mohammed Emad Kashmiri, Salman Mesfer Alyaseen, Mohsen Mohammed Alyaseen, Ali Abdulmajid Alsulaiman, Hamed Mohammed AlQarni


Pain assessment and management have shown great advances in recent decades regarding the treatment protocols and the various assessment approaches that have been developed and validated to specific for pediatric patients. In this literature review, we aim to shed more light on the assessment of pain in pediatric patients and the challenges that healthcare workers might face during the process in primary healthcare centers. In neonates, the crying, require O2 to reach a saturations more than 95%, increasing vitals, expressionless, and sleepless score shows the greatest advantage over other scores (COMFORT and distress for mechanically ventilated neonates), while in infants the face, leg, activity, cancelability, and cry scale shows promising results. In older children, self-reporting by the visual analogue scale should be standardized whenever possible or facial, and behavioral assessment should be used. Assessment of pain in patients with cognitive and intellectual disabilities might be challenging, and therefore, it should be interpreted carefully not to be misdiagnosed, in addition to trying to obtain relevant information from a well-trained accompanying caregiver. Further investigations are needed, however, to standardize these scores and to spread awareness among clinicians and caregivers about the importance of appropriate pain assessment.


Pain, Scale, Challenge, Pediatric, Children

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O'Rourke D. The measurement of pain in infants, children, and adolescents: from policy to practice. Phys Ther. 2004;84(6):560-70.

Harris J, Ramelet AS, van Dijk M. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med. 2016; 42(6):972-86.

Gerik SM. Pain management in children: developmental considerations and mind-body therapies. South Med J. 2005;98(3):295-302.

Kahsay H. Assessment and treatment of pain in pediatric patients. Curr Pediatr Res. 2017;21:148-57.

Twycross A, Roderique L. Review of pain content in three-year preregistration pediatric nursing courses in the United Kingdom. Pain Manag Nurs. 2013;14 (4):247-58.

McGrath PJ, Stevens BJ, Walker SM, Zempsky WT. Oxford textbook of paediatric pain. United Kingdom: Oxford University Press; 2013.

Anand KJ, Stevens BJ, McGrath PJ. Pain in neonates and infants: pain research and clinical management series. Amsterdam: Elsevier Health Sciences; 2007.

The assessment and management of acute pain in infants, children, and adolescents. Pediatr. 2001;108 (3):793-7.

Ferland CE, Vega E, Ingelmo PM. Acute pain management in children: challenges and recent improvements. Curr Opin Anaesthesiol. 2018;31(3): 327-32.

Canbulat Şahiner N, Türkmen AS. Complementary Paediatrics. London: Intech open; 2012.

Chiaretti A, Pierri F, Valentini P, Russo I, Gargiullo L, Riccardi R. Current practice and recent advances in pediatric pain management. Eur Rev Med Pharmacol Sci. 2013;17(Suppl 1):112-26.

Ramstad K, Jahnsen R, Skjeldal OH, Diseth TH. Characteristics of recurrent musculoskeletal pain in children with cerebral palsy aged 8 to 18 years. Dev Med Child Neurol. 2011;53(11):1013-8.

van der Slot WMA, Benner JL, Brunton L, Engel JM, Gallien P, Hilberink SR, et al. Pain in adults with cerebral palsy: A systematic review and meta-analysis of individual participant data. Ann Phys Rehabil Med. 2020;S1877-0657(20):30034-8.

McGrath PA, Seifert CE, Speechley KN, Booth JC, Stitt L, Gibson MC. A new analogue scale for assessing children's pain: an initial validation study. Pain. 1996;64(3):435-43.

Dagnan D, Ruddick L. The use of analogue scales and personal questionnaires for interviewing people with learning disabilities. Clin Psychol Forum. 1995: 21-4.

Chibnall JT, Tait RC. Pain assessment in cognitively impaired and unimpaired older adults: a comparison of four scales. Pain. 2001;92(1-2):173-86.

Defrin R, Lotan M, Pick CG. The evaluation of acute pain in individuals with cognitive impairment: a differential effect of the level of impairment. Pain. 2006;124(3):312-20.

Defrin R, Pick CG, Peretz C, Carmeli E. A quantitative somatosensory testing of pain threshold in individuals with mental retardation. Pain. 2004; 108(1-2):58-66.

Barney CC, Tervo R, Wilcox GL, Symons FJ. A Case-Controlled Investigation of Tactile Reactivity in Young Children With and Without Global Developmental Delay. Am J Intellect Dev Disabil. 2017;122(5):409-21.

Barney CC, Merbler AM, Simone DA, Walk D, Symons FJ. Investigating the Feasibility of a modified quantitative sensory testing approach to profile sensory function and predict pain outcomes following intrathecal baclofen implant surgery in cerebral palsy. Pain Med. 2020;21(1):109-17.

Clarke Z, Thompson A, Buchan L, Combes H. Parents’ experiences of pain and discomfort in people with learning disabilities. Br J Learn Disabil. 2007;36:84-90.

Kirsh KL. Differentiating and managing common psychiatric comorbidities seen in chronic pain patients. J Pain Palliat Care Pharmacother. 2010;24 (1):39-47.

Breau LM, McGrath PJ, Camfield C, Rosmus C, Finley GA. Preliminary validation of an observational pain checklist for persons with cognitive impairments and inability to communicate verbally. Dev Med Child Neurol. 2000;42(9):609-16.

Lautenbacher S, Niewelt BG, Kunz M. Decoding pain from the facial display of patients with dementia: a comparison of professional and nonprofessional observers. Pain Med. 2013;14(4): 469-77.

Prkachin KM, Berzins S, Mercer SR. Encoding and decoding of pain expressions: a judgement study. Pain. 1994;58(2):253-9.

O'Neill MC, Pillai Riddell R, Garfield H, Greenberg S. Does caregiver behavior mediate the relationship between cultural individualism and infant pain at 12 months of age?. J Pain. 2016;17(12):1273-80.

Breau LM, MacLaren J, McGrath PJ, Camfield CS, Finley GA. Caregivers' beliefs regarding pain in children with cognitive impairment: relation between pain sensation and reaction increases with severity of impairment. Clin J pain. 2003;19(6):335-44.

Craig KD, Korol CT, Pillai RR. Challenges of judging pain in vulnerable infants. Clin Perinatol. 2002;29(3):445-57.

Breau LM, McGrath PJ, Camfield CS, Finley GA. Psychometric properties of the non-communicating children's pain checklist-revised. Pain. 2002;99(1-2):349-57.

Chang J, Versloot J, Fashler SR, McCrystal KN, Craig KD. Pain assessment in children: validity of facial expression items in observational pain scales. Clin J pain. 2015;31(3):189-97.

Sheu E, Versloot J, Nader R, Kerr D, Craig KD. Pain in the elderly: validity of facial expression components of observational measures. Clin J pain. 2011;27(7):593-601.

Barney CC, Andersen RD, Defrin R, Genik LM, McGuire BE, Symons FJ. Challenges in pain assessment and management among individuals with intellectual and developmental disabilities. Pain Rep. 2020;5(4):e821.

Gai N, Naser B, Hanley J, Peliowski A, Hayes J, Aoyama K. A practical guide to acute pain management in children. J Anesth. 2020;34(3):421-33.

Dantas L, Dantas T, Santana-Filho V, Azevedo-Santos I, DeSantana J. Pain assessment during blood collection from sedated and mechanically ventilated children. Rev Bras Ter Intensiva. 2016;28.

Wong C, Lau E, Palozzi L, Campbell F. Pain management in children: Pain assessment tools and a brief review of nonpharmacological and pharmacological treatment options. Can Pharm J. 2012;145(5):222-5.

Solodiuk J, Curley MA. Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS). J Pediatr Nur. 2003;18(4):295-9.

Zhu LM, Stinson J, Palozzi L. Improvements in pain outcomes in a Canadian pediatric teaching hospital following implementation of a multifaceted knowledge translation initiative. Pain Res Manag. 2012;17(3):173-9.

Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nur. 2011;12(4):230-50.

Witt N, Coynor S, Edwards C, Bradshaw H. A Guide to Pain Assessment and Management in the Neonate. Curr Emerg Hosp Med Rep. 2016;4:1-10.

Prevention and management of pain and stress in the neonate. American academy of pediatrics. committee on fetus and newborn. committee on drugs. section on anesthesiology. section on surgery. canadian paediatric society. Fetus and Newborn Committee. Pediatr. 2000;105(2):454-61.

Linhares M, Oliveira N, Doca F, Martinez F, Carlotti A, Finley A. Assessment and management of pediatric pain based on the opinions of health professionals. Psychol Neurosci. 2014;7:43-53.

Ramira ML, Instone S, Clark MJ. Pediatric Pain Management: An Evidence-Based Approach. Pediatr Nur. 2016;42(1):39-46.

Hurley-Wallace A, Wood C, Franck LS, Howard RF, Liossi C. Paediatric pain education for health care professionals. Pain Rep. 2018;4(1):e701.