October 2011 | Volume 19 | Number 6 EMERGENCY NURSE 32

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BETWEEN APRIL 2009 and March 2010, 2.2 million
children under 11 years of age presented to hospital
emergency departments (EDs) in the UK. This figure
represents 14 per cent of all such presentations
during the same period (Health and Social Care
Information Centre 2011).
More than one third of these children presented
with recorded ED diagnoses of dislocation,
fracture, joint injury, amputation, laceration,
sprain, ligament injury, soft tissue inflammation,
contusion or abrasion.
In all of these conditions, pain is likely to be the
main symptom. Most of these children would have
been in pain when they presented to EDs, therefore,
yet the literature indicates that pain assessment
and management in children in EDs is suboptimal,
and that children experience unnecessary pain and
suffering as a result (Van Hulle Vincent and Denyes
2004, Rajasagaram et al 2009, RCN 2009).
Weng et al (2010) suggest that pain in children
is sometimes overlooked in EDs because emergency
nurses have poor pain assessment skills, while
McCaffery and Robinson (2002) say that many
nurses underestimate the complexity of pain
assessment and management, and fail to treat acute
pain adequately. This problem could be rectified, say
Bauman and McManus (2005), if pain was regarded
as the fifth vital sign, a suggestion supported by
RCN (2009) guidelines on acute pain in children.
Nilsson et al (2008) say that childrens reports
of pain should be acknowledged within the
pain-assessment process but, as Kortesluoma
and Nikkonen (2004) point out, many healthcare
professionals fail to do this.
Correspondence
v.melby@ulster.ac.uk
Date of acceptance
September 15 2011
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
www.emergencynurse.co.uk
Abstract
Evidence suggests that children who are in pain
and who present to emergency departments receive
sub-optimal pain assessment and relief. Many
factors contribute to this unacceptable quality of
care, including emergency nurses lack of knowledge
about the appropriate pain assessment tools.
This article refers to a literature review and case
study to discuss childrens pain assessment tools.
It concludes that an education programme for
emergency nurses could be provided to augment
their awareness of best practice pain assessment
and management guidelines.
Keywords
Children, pain assessment, analgesia, best practice
Acute pain relief in children:
use of rating scales and analgesia
Vidar Melby and colleagues review different pain
assessment tools and choices of analgesia for
children who present to emergency departments
Assessing childrens pain can be complicated by their anxiety or stress
M
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EMERGENCY NURSE October 2011 | Volume 19 | Number 6 33
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Asking children to assess their own pain can be
difficult because children cannot always verbalise
what they experience (Weng et al 2010). Many
children imagine the worst possible outcomes of
treatments and become increasingly anxious about
being admitted to hospital. They may then exhibit
excessive pain behaviour because they are so
afraid or pretend that they are not in pain to avoid
admission (Machester Triage Group 2005).
Many children become anxious when exposed to
unfamiliar environments and people, particularly
people in uniforms, or to needles or parental distress
(College of Emergency Medicine (CEM) 2010). These
reactions can further complicate pain assessment
and management.
A case study that concerns the presentation to an
ED of a child in acute pain is shown right.
Pain assessment tools
Pain management is most effective when accurate
pain assessments have been carried out (Mackintosh
2007). There are several pain assessment tools
available but none has been identified in the
literature as the best to use in all circumstances.
Many nurses are uncertain about which pain
assessment tool to use (Cohen et al 2008), therefore,
and some do not use any of them in their day-to-day
practice (Simons and Roberson 2002).
Simons and Macdonald (2004) asked
100 childrens nurses which pain-rating tool they
preferred to use. They found that 61 participants
had no preference, indicating that the use of such
tools by childrens nurses is inconsistent. Among the
39 participants who stated a preference, the most
popular tool, chosen by one third of participants,
was the Wong-Baker (1988) FACES rating scale
(Figure 1, page 34) followed by McGrath et als (1985)
Childrens Hospital of Eastern Ontario pain scale
(CHEOPS) (Table 1, page 34) and Merkel et als (1997)
Faces, Legs, Activity, Cry and Consolability (FLACC)
pain scale (Table 2, page 35).
The Wong-Baker FACES rating scale is a
self-assessment tool. Nurses who use it ask children
to point to the face on the scale that best represents
how they feel about their pain (Wong-Baker 1988).
The CHEOPS and the FLACC scale are
observational tools, however. Nurses who use
the CHEOPS assess how children cry, their facial
expressions, their ability to verbalise, how they move
their torsos and how they move their legs, while
those who use the FLACC scale assess childrens
facial expressions, respiration rate, activity, cry
and their openness to being consoled. In both
cases, nurses provide scores of between zero and
two for each of the five assessments they have
Case study
A nine-year-old boy, accompanied
by his mother, presented to the
emergency department (ED).
They were taken into a childrens
triage room, which is decorated
for children and includes toys, and
additional comfort was provided by
the nurses to reduce the boys anxiety
(Tak and van Bon 2006).
The mother said that the boy had
fallen from a tyre swing onto his
outstretched hand.
On examining the boy, the triage nurse
observed that he had gross deformity
to his left arm, with tenderness around
the distal tip of the radius and ulna.
The boy was triaged in the
orange category for serious but
non-life-threatening injuries. Vital signs
were assessed and found to be within
normal ranges. A child protection
assessment was also carried out with
no risks being identified.
He was clearly in severe pain and his
arm had to be immobilised. Effective
pain relief was needed immediately,
therefore, to ensure that his arm
could be immobilised without causing
additional pain.
Immobilisation of his arm would
provide alignment and support for the
bone to unite and heal (Harris 2009),
and would relieve his pain. No pain
assessment tool was used, however.
It was explained to the boy and
his mother that pharmacological
pain relief was the next step in the
management plan and that this would
be administered intranasally. Providing
information to children and their
families about forthcoming procedures
can reduce anxiety and stress
(Pritchard 2009).
The boy was given 2.86mg of
intranasal diamorphine, the maximum
dose in relation to his weight, within
ten minutes of triage. This meets
the College of Emergency Medicines
(CEM) (2010) recommended standard
that children with moderate-to-severe
pain should receive appropriate
analgesia within 20 minutes of arriving
at the ED.
Although the boy said his arm was
still sore and he was obviously still
in pain, the plaster back slab had
to be applied to immobilise his arm
before the drug had started to work.
After immobilisation, the boy seemed
more settled and comfortable. His vital
signs were monitored throughout the
care process.
After the diamorphine had taken
effect, the boys arm was X-rayed
and fractures of the ulna and radius
were confirmed. He was then
transferred to hospital by ambulance
for specialist orthopaedic management.
On presenting at the ED, the boy had
been a priority for assessment because
he was a child and his injury had
posed a risk of vascular compromise
with visible gross deformity.
The care provided corresponds
with what is suggested in the
literature, namely that children receive
inadequate pain assessment and
relief when they attend EDs.
The care cannot be described as
entirely evidence based because,
although the boy received appropriate
analgesia, his pain had not been
assessed using a pain rating tool.
Furthermore, although distraction
methods were used, he could also
have been given nitrous oxide and
oxygen, which is an important holding
measure for pain relief (CEM 2010)
and may have reduced his distress
during immobilisation.
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made to produce scores of between zero and ten
(McGrath et al 1985, Merkel et al 1997).
After undertaking a systematic review of pain
assessment tools, von Baeyer and Spagrud (2007)
recommended the use of the CHEOPS to assess pain
associated with those medical investigations that
cause brief pain.
Meanwhile, Shavit et al (2008), in a quantitative
study of pain assessment tools, state that pain
scores obtained by ENs from children using
self-reporting tools, such as the Wong-Baker FACES
rating scale, were consistently higher than those
obtained by ENs using observational tools, such
as the CHEOPS and FLACC scale. However, the
researchers did not take into account the ages or sex
of the children involved in their study, the injuries
the children had sustained, or the consistency of
pain they experienced, all of which could have
influenced the researchers findings.
Knowledge of the types of injury children have
sustained is crucial in assessing pain severity
(Oakley et al 2006). Pain is also indicated by,
for example, elevated pulse or respiration rate,
so the monitoring of vital signs is also important
(Chummun 2009).
Nurses can also identify if children are in pain
by observing whether they cry or grimace, or by
how they hold their injured limbs, and by asking
childrens parents or carers whether the children
are behaving unusually (Maurice et al 2002).
It should be recalled, however, that assessing pain in
children can be complicated by their anxiety, fear or
stress of being in an ED (Moor 2001).
The ideal assessment tool is age-appropriate and
incorporates both nurses observations of childrens
behaviour and childrens reports of pain (Nilsson et al
2008). Accordingly, the CEM (2010) has developed
a hybrid childrens pain assessment tool (Table 3,
page 36) that comprises a face scale similar to that
in the Wong-Baker FACES rating scale and nurses
observations of childrens behaviour similar to those
in the CHEOPS and FLACC scale, but to four levels
of pain intensity. It also provides examples of the
kinds of injury that can cause the pain reported
and observed. The CEM (2010) recommends its tool
for use in children in all types of pain.
Pain management options
Young (2005) argues that pain in children should
be managed quickly and effectively to avoid
short- and long-term physical and emotional harm.
Adriansson et al (2004) go further, suggesting that,
because children may be unable to understand the
rationale for treatment or to amend their behaviour
to alleviate pain, they are uniquely vulnerable.
The CEM (2010) has described ways in which
childrens pain can be managed and reduced. These
include the adoption of psychological strategies,
Table 1 Childrens Hospital of Eastern Ontario pain scale
Score
0 1 2
C
a
t
e
g
o
r
y
Cry No cry Crying, moaning Scream
Facial expression Smiling Composed Grimace
Ability to verbalise Positive None or makes other
complaints
Pain complaints
Movement of torso Neutral Shifting, tense,
upright
Restrained
Movement of legs Neutral Kicking, squirming,
legs are drawn up
Restrained
Scores for each of the five categories are added together to produce a total score
of between zero and ten
(Adapted from McGrath et al 1985)
Figure 1 Wong-Baker FACES rating scale
Face scale
Description Does not hurt Hurts a little Hurts a little more Hurts even more Hurts a lot Hurts the most
Score 0 1 2 3 4 5
(Adapted from Wong and Baker 1988)
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EMERGENCY NURSE October 2011 | Volume 19 | Number 6 35
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such as providing child-friendly environments,
distracting children with toys, cuddling and
reassuring them, and using non-pharmacological
treatment interventions such as limb immobilisation.
The best practice for treating children in severe
pain, as judged by the CEM (2010) childrens pain
assessment tool, is to administer intravenous
or intranasal opioids such as diamorphine
(Kidd et al 2009). In children with clinical fractures,
for example, intranasal diamorphine provides safe
and effective relief of moderate to severe pain
(Kendall et al 2001).
The intranasal route is preferable to the
intravenous route or cannulation because it is less
invasive, and so less stressful for children and their
parents (Gahir and Ransom 2006). Moreover, the
nasal mucosa can be accessed easily and can absorb
lipophilic compounds, such as diamorphine, rapidly
(Costantino et al 2007, Hadley et al 2010).
Some authors urge caution when administering
opioids in children. Maurice et al (2002), for
example, claim that the introduction of opioids
at an early age can lead to addiction later in life,
while the British National Formulary for Children
(Paediatric Formulary Committee 2011) states
that there is insufficient evidence about the safety
and effectiveness of intranasal diamorphine
to warrant its use.
However, in a randomised controlled trial
comparing intranasal with oral diamorphine in
247 children with acute traumatic injuries who had
attended an ED, Marzouk et al (2008) found that,
20 minutes after administration, the pain scores
of those who received intranasal diamorphine
were 50 per cent lower than those who received
oral morphine.
Diamorphine is estimated to be twice as potent
as morphine (Paediatric Formulary Committee 2011),
Table 2 Faces, Legs, Activity, Cry and Consolability pain scale
Score
0 1 2
C
a
t
e
g
o
r
y
Facial
expression
Unwrinkled brow
Unclenched jaw
Blank or content expression
Distressed appearance
Has a troubled or worried expression
Has a wrinkled brow
Corners of mouth are turned down
Has an alarmed or fearful expression
Has open eyes and a pleading expression
Has a clenched jaw
Has a scowling or stern expression
Respiration Normal and unlaboured
Barely audible
Increased
Loud
Difficult
Strained
Gas exchange appears to be difficult
Episodic bursts of rapid breaths
Gasping
Loud and strained
Activity Lies quietly
Lies in an open position
Moves easily or is flaccid
Has relaxed muscles
Appears to be at rest
Squirming and appearing uneasy
Fidgeting
Clenching fists
Appearing discontented
Appearing slightly restless
Arched or rigid
Jerking or writhing
Forceful touching
Tugging or rubbing body parts
Appears to be trying to get away from pain
Legs are drawn up or arms are flailing
Cry Quiet Moans or whimpers
Expresses pain
Makes hushed, low sounds
Crying
Makes loud, guttural moaning
Makes unpleasant noises
Screams or yells
Openness to
consolation
Contented Reassured by the sound of a loved one
Reassured by soft touching and caressing
Can be comforted through distraction
Is inconsolable
Cannot be comforted through distraction
Scores for each of the five categories are added together to produce a total score between zero and ten
(Adapted from Merkel et al 1997)
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Adriansson C, Suserud BO, Bergbom I (2004)
The use of topical anaesthesia at childrens
minor lacerations: an experimental study.
Accident and Emergency Nursing. 12, 2, 74-84.
Baker CM, Wong DL (1987) QUEST: a process
of pain assessment in children. Orthopaedic
Nursing. 6, 1, 11-21.
Bauman BH, McManus JG Jr (2005) Pediatric
pain management in the emergency
department. Emergency Medicine Clinics
of North America. 23, 2, 393-414.
Chummun H (2009) Hypertension:
a contemporary approach to nursing care.
British Journal of Nursing. 18, 13, 784-789.
Cohen LL, Lemanek K, Blount RL et al
(2008) Evidence-based assessment of pediatric
pain. Journal of Pediatric Psychology.
33, 9, 939-955.
College of Emergency Medicine (2010)
Guideline for the Management of Pain in
Children. CEM, London.
Costantino HR, Illum L, Brandt G et al (2007)
Intranasal delivery: physicochemical and
therapeutic aspects. International Journal
of Pharmaceutics. 337, 1, 1-24.
Gahir KK, Ransom PA (2006) Intranasal
diamorphine integrated care pathway for
paediatric analgesia in the accident and
emergency department. Emergency Medicine
Journal. 23, 12, 959.
Hadley G, Maconochie I, Jackson A (2010)
A survey of intranasal medication use in
the paediatric emergency setting in England
and Wales. Emergency Medicine Journal.
27, 7, 553-554.
Harris C (2009) Principles of fracture
management. In Mooney M, Ireson C (Eds)
Occupational Therapy in Orthopaedics and
Trauma. Wiley-Blackwell, London.
Health and Social Care Information
Centre (2011) A&E Attendances in England:
Experimental Statistics 2009-10.
http://tiny.cc/1exbr (Last accessed:
September 20 2011.)
Kendall JM, Reeves BC, Latter VS et al (2001)
Multicentre randomised controlled trial of
nasal diamorphine for analgesia in children and
teenagers with clinical fractures. British Medical
Journal. 322, 7281, 261-265.
Kidd S, Brennan S, Stephen R et al (2009)
Comparison of morphine concentration-time
profiles following intravenous and intranasal
diamorphine in children. Archives of Disease
in Childhood. 94, 12, 974-978.
Kortesluoma RL, Nikkonen M (2004) I had this
horrible pain: the sources and causes of pain
experiences in 4- to 11-year-old hospitalized
children. Journal of Child Health Care.
8, 3, 210-231.
Mackintosh C (2007) Assessment and
management of patients with post-operative
pain. Nursing Standard. 22, 5, 49-55.
Manchester Triage Group (2005) Emergency
Triage. Wiley-Blackwell, London.
Marzouk O, Bell C, Grice J et al (2008)
A randomized controlled trial to compare
intranasal diamorphine with oral morphine
in children with acute pain from trauma.
Annals of Emergency Medicine. 51, 4, 480-480.
Maurice SC, ODonnell JJ, Beattie TF (2002)
Emergency analgesia in the paediatric
population: part I. Current practice and
perspectives. Emergency Medicine Journal.
19, 1, 4-7.
References
Table 3 College of Emergency Medicine tool for assessing acute pain in children in emergency departments
Score range
0 1-3 4-6 7-10
S
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l
f
-
a
s
s
e
s
s
m
e
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t

w
i
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f
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s

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o
n
s

o
f

c
h
i
l
d

s

b
e
h
a
v
i
o
u
r
No pain Mild pain Moderate pain Severe pain
Normally active
Happy expression
Movement normal
Rubs affected areas
Neutral expression
Can talk normally
Movement slightly decreased
Protects affected areas
Grimaces
Complains of pain
Cries but is consolable
Movement decreased
Protects affected areas
Frightened expression
Quiet or complains of much pain
Cries and is inconsolable
Movement greatly decreased
E
x
a
m
p
l
e
s

o
f

i
n
j
u
r
y
Bump on the head Abrasion
Small laceration
Ankle or knee sprain
Clavicle or finger fracture
Sore throat
Small burn or scald
Fingertip injury
Forearm, elbow or ankle fracture
Mild appendicitis
Large burn or scald
Fingertip injury
Fracture of long bone or dislocation
Severe appendicitis
Sickle cell crisis
Nurses make judgements of pain intensity based on childrens self-assessments and their own observations of childrens behaviour
and presenting problems, listening closely to what the children and their parents or guardians say
(Adapted from College of Emergency Medicine 2010)
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EMERGENCY NURSE October 2011 | Volume 19 | Number 6 37
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however, so vigilant monitoring of children who
receive it is important.
Conclusion and recommendations
Children are more vulnerable than adults, and their
pain should be reduced as quickly as possible while
avoiding stressful situations and invasive procedures
as much as possible.
Factors that contribute to sub-standard quality
of care of children include poor nurse assessment
skills, failure to use available pain-assessment
tools, and a failure to use pharmacological and
non-pharmacological interventions creatively.
Another such factor is a failure to listen to the
children concerned. In all pain assessments, childrens
opinions should be valued and age-appropriate pain
scoring tools should be used to measure the type
and intensity of their pain. The literature suggests
that, for use in EDs, the CHEOPS or the CEM hybrid
assessment tools are the most appropriate when
dealing with briefly painful events.
Pain should be regarded as the fifth vital sign
and it is essential that assessment continues after
initial baseline measurements so that the efficacy
of pharmacological and non-pharmacological
interventions can be evaluated. Evidence suggests
that intranasal diamorphine offers the best
pharmacological management of moderate-to-severe
pain in children.
Emergency nurses must ensure that pain
assessment, management interventions and
care evaluations are documented accurately and
comprehensively so that they can produce evidence
that best practice has been followed.
To this end, education programmes that address
emergency nurses knowledge and skills deficits in
childrens acute pain assessment and management
are useful. Such programmes should cover the
physiology of pain, the range of pain assessment
tools and analgesia available, the importance of
making accurate assessments, and how to ask
children about their pain.
Baker and Wong (1987) offer a helpful pneumonic,
QUEST, that summarises guidelines for nurse
assessment and management of pain in children:
Question the child.
Use pain rating scales.
Evaluate the childs behaviour and physiological
changes.
Secure the involvement of parents.
Take the causes of pain into account, take action
and evaluate results.
Conflict of interest
None declared
Vidar Melby is a senior lecturer
in nursing at the University of
Ulster, Derry
Charlene McBride is a nursing
student at the University of
Ulster, Coleraine
Alexandra McAfee is a nurse pain
specialist at the Belfast Health
and Social Care Trust
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