FLACC Scores

FLACC Score

A frequent challenge in pediatrics is assessing pain in children who are non-

verbal. Part of this population is unable to report the location and degree of their
pain because of chronological age, i.e. an infant or toddler. Another significant
group is the population of children with cognitive impairment that is severe
enough to impair their expressive language. This population includes but is not
limited to children with severe cerebral palsy, developmental delay, or mental
retardation.

The FLACC score has been validated for measuring postoperative pain in children
with mild to severe cognitive impairment. It has also been validated for the
assessment of pain secondary to surgery, trauma, cancer or other painful diseases
for all pre-verbal children (including infants).

In the diagram below are the categories for scoring. Zero, one or two points is
assigned to each of the five categories shown in the table: Face, Legs, Activity,
Cry, and Consolability (hence the term, FLACC). Total points assigned may be
from zero to ten.

As discussed above, the numeric rating scale may be categorized into no pain,
mild pain, moderate pain, and severe pain based on the 0-10 self report scale. The
categories guide analgesic selection when the score is obtained by self-report. In
contrast, the total FLACC score (0-10) cannot be converted to these descriptive
groupings. The score should be contextualized to the particular patient, the clinical
setting and his/her primary caregiver's perception of the child's behavior. A patient
with developmental delay may need an opioid for pain relief but have a FLACC
score that is less than seven.

CATEGORIES SCORING
0 1 2
No particular Occasional grimace or Frequent to
FACE expression or frown, withdrawn, constant quivering
smile disinterested. chin, clenched jaw.
Normal position Kicking, or legs
LEGS Uneasy, restless, tense.
or relaxed. drawn up.
Lying quietly,
Squirming, shifting Arched, rigid or
ACTIVITY normal position
back and forth, tense. jerking.
moves easily.
CRY No cry, (awake Moans or whimpers; Crying steadily,
or asleep) occasional complaint screams or sobs,
frequent
 complaints.
Reassured by occasional
touching hugging or Difficulty to
CONSOLABILITY Content, relaxed.
being talked to, console or comfort
distractable.

References:

Hicks CL et al The Faces Pain Scale-Revised: toward a common metric in

pediatric pain measurement. Pain, 2003;93:173-183.

Manworren RCB, Hynan LS Clincal Validation of FLACC: Preverbal patient pain

scale. Pediatric Nursing, 2003;29:140-146.

Voepel-Lewis T et al The Reliability and validity of the face, legs, activity, cry,
consolability observational tool as a measure of pain in children with cognitive
impairment, Anest Analg 2002;195: 1224-1229.

Pediatric Pain Assessment

Pediatric Pain Assessment

John M Saroyan

William S Schechter

Proper pain assessment is the cornerstone for proper pain treatment. Below we
have listed commonly used age and developmental stage specific guidelines for
pediatric pain assessment.

Physiologic Measures Many times on rounds clinicians are overheard saying,

“The heart rate and blood pressure are normal, how could this patient have 8 out
of ten pain?” Actually, a child, teenager or adult may experience severe pain and
not have a change in their heart rate or blood pressure. These measures may be the
only currently useful index of pain in the intraoperative setting but are non-
specific and must be analyzed in context.

~3-7 years old: Faces Pain Scale – Revised (FPS-R) In the child who is
developmentally able, self-report is the gold standard. Fortunately, instruments
exist for children ~3-7 years old to aid in their self-report. Many readers are
probably familiar with the Wong-Baker FACES scale (Wong-Baker, shown). The
FACES pain scale has been revised so that the scale is from zero to ten rather than
zero to five as in the Wong-Baker measure or zero to six as in the Bieri Faces Pain
scale (not shown). The affective qualities including the smile and tears have been
removed. When using the Faces Pain Scale Revised, you no longer have to
include a statement such as “You can experience the worst pain and not be
crying.”

Wong-Baker

Face Pain Scale-Revised

Instruction for Faces Pain Scale-Revised "These faces show how much
something can hurt. This face [point to left-most face] shows no pain. The faces
show more and more pain [point to each from left to right] up to this one [point to
right-most face] – it shows very much pain. Point to the face that shows how
much you hurt [right now]."

Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so ’0’ = ’no pain’
and ’10’ = ’very much pain.’ Do not use words like ’happy’ and ’sad’. This scale
is intended to measure how children feel inside, not how their face looks. (Once
again, say "hurt" or "pain," whichever seems right for a particular child.)

The Faces Pain Scale-Revised is not a scale that our pediatric pain management
service is using on a daily basis yet. When we initiate an educational initiative in
pediatric pain management later this year, medical student, residents, fellows and
nurse practitioners will be taught how to administer the Faces Pain Scale-Revised.

~8years or greater: Numeric rating scale for pain This is the method that
almost everybody is probably familiar with. The provider asks, "On a scale of
zero to ten, where zero means no pain and ten equals the worst possible pain, what
is your current pain level?"
Common mistakes include the interviewer saying, “On a scale from ONE to ten”
or “and ten equals the worst pain THAT YOU EVER HAD”. In the first example,
the error is stating that one is the low end of the scale. As the second example
shows, it is important not to put the highest end of the scale in terms of past
experience. Remember that for children it often useful to substitute the terms
“ouch” or “hurt” for the word “pain”.

The numeric rating scale may be categorized into no pain (0), mild pain (1-3),
moderate pain (4-6), and severe pain, (7-10). These categories have been used in
the past to indicate whether an opioid is indicated. Children with acute pain and
some forms of chronic pain that is greater than six are frequently treated with an
opioid.