Pediatric pain assessment presents unique challenges to the medical practitioner not encountered with adult populations. Although infants and children experience pain through similar physiological processes as adults, their experiences cannot be measured with comparable assessment tools. The ability or willingness to communicate the child's experience of pain may often be limited by his/her age, developmental level, cognitive ability, previous pain experiences, and various ethnic/cultural influences. Furthermore, children may not know the meaning of "pain" and will often confuse fear and anxiety with pain which in turn may

N. Vadivelu et al. (eds.), Essentials of Pain Management,

DOI 10.1007/978-0-387-87579-8_30, © Springer Science+Business Media, LLC 2011

Table 30.1 Developmental Stages in the Pediatric Pain Patient.



Abilities and attributes

Pain expressions


No verbal skills to describe pain

Physical movements and responses: bodily arching,

Completely dependent on clinicians to assess and

rigidity, thrashing, and drawing knees to chest

interpret behavioral exhibition of pain

Facial expressions: tightly closed eyes, furrowed

brow, mouth open, and squarish

Vocalization: intense, loud cry, and inconsolable


Poor oral intake

Poor sleep

Toddler/Preschooler Minimal verbal skills

Physical movements and responses: uncooperative,

Unable to abstract, quantify, or symbolize; literal,

physical resistance, thrashing arms and legs, and

magical thinking


Can report presence of pain, but unable to score

May be physically aggressive toward individual they

and describe

believe to be responsible for the pain

Does not understand cause and effect, may

Vocalization: intense cry, verbally aggressive

interpret pain as a punishment

May regress or withdraw

Vulnerable to secondary gains

Poor oral intake

Poor sleep

Clingy to parent, caregiver,

requests hugs, and kisses

School age

Can verbalize pain

Physical movements and responses: muscle rigidity,

Able to localize and provide some description,

body stiffness, and clenched fists

cannot use adult assessment tools

Facial expressions: furrowed brow, closed eyes, and

Beginning to understand abstract thought, not as

gritted teeth

literal, but not as sophisticated as adolescents and

Poor sleep, nightmares


Stalling behaviors

Understands rank and order

Increase body awareness and fearful of bodily harm

May exaggerate or provide inaccurate descriptions

Influenced by ethnic culture


Appropriate primary source for information

Muscle tension

Able to use adult assessment tools

Deny pain in presence of peers

Can abstract, quantify, qualify, and problem solve

Changes in activity, appetite, and sleep

Lack of life experiences and maturity

Regressive behavior

Influenced by ethnic culture

amplify the pain experience. Children may not cognitively understand that the pain can be treated. Given such obstacles, clinicians must have a keen awareness of the stages of pediatric growth and development to individualize pain assessment techniques and tools specific to each childhood stage (Table 30.1).

Components of a Pain History

A thorough pain assessment includes a comprehensive pain-focused history and physical examination. The QUESTT approach (Baker and Wong 1987) is commonly utilized as a global guide for pain assessment and evaluation:

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