Acute pain: How to assess in infants and toddlers

What causes acute pain in infants and toddlers?

In infants and toddlers, common causes of acute pain include:

• teething
• a bump or fall
• ear infections
• vaccinations by needle
• heel lances to obtain a blood sample
• procedures such as inserting a catheter (thin tube) or doing a lumbar puncture

​As a rule, anything that causes pain in older children or adults (such as inserting a needle or catheter) will also cause pain in your infant or toddler. So if your young child is having a procedure that you would find painful, they are likely experiencing at least as much pain as you would experience.

Indeed, certain procedures may be more painful for young children because their brains cannot yet help them cope with pain, for example by using distraction. Never discount your young child's pain-related distress even if they have an injury or procedure that you would not find painful.

Assessing acute pain at home

Because your young child cannot speak yet, you can only tell how much pain they are experiencing through the painful situation and their behaviour. In this case, the context means thinking about whether the procedure would be painful for an older child or could be painful for a young child even if not painful for someone older. Based on this information, you would then watch for any changes in your child's behaviour.

Behavioural signs of acute pain include:

• irritability
• sharp changes in facial expressions (for example grimacing with eyes shut and brow bulging)
• crying or whimpering
• flailing or thrashing arms or legs
• changes in their feeding, playing and/or sleeping routines
• rigidness or limpness
• changes in breathing
• changes in how they interact with people and things around them

Assessing acute pain in medical settings

In the hospital, your child's health-care team uses a range of tools to determine how much pain an infant is feeling.

In the NICU setting, one of the most common tools for assessing pain in infants is the Premature Infant Pain Profile-Revised (PIPP-R). This tool rates many of the behaviours that a child might display at home as well as physiological signs (signs inside the body), such as your infant's:

• heart rate
  
• oxygen saturation (how much oxygen is in their blood)
  
• breathing rate

For older infants and children aged up to two, health-care providers usually use the Faces, Legs, Activity, Cry and Consolability (FLACC) scale. This tool looks at several of the behaviours described above.

In medical settings, your child's health-care team plays an important role in clarifying the level and cause of pain, but feel free to share your opinions and concerns about your infant's pain with them.

Websites

Comforting Your Baby in Intensive Care
http://familynursing.ucsf.edu/comforting-your-baby-intensive-care

Videos

Bringin' up Baby: Soothing the Pain (3 mins 50 secs)
Psychological and physical strategies for parents to reduce vaccination pain in healthy infants

Reduce the pain of vaccination in babies (13 mins 08 secs)
Tips for parents on helping healthy infants get through vaccinations

Easing your baby's pain: A mother's story (3 mins 07 secs)
Three ways to instantly reduce your infant's pain in the NICU

The Power of a Parent's Touch (2 mins 40 secs)
How breastfeeding and skin-to-skin contact can help when an infant is experiencing a painful procedure

Content developed by Rebecca Pillai Riddell, PhD, CPsych, OUCH Lab, York University, Toronto, in collaboration with:
Lorraine Bird, MScN, CNS, Fiona Campbell, BSc, MD, FRCA, Bonnie Stevens, RN, PhD, FAAN, FCAHS, Anna Taddio, BScPhm, PhD
Hospital for Sick Children

References

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International Association for the Study of Pain (2010) Fact Sheets on various topics of pain prevention, management, and treatment. https://www.iasp-pain.org/resources/fact-sheets/ [Accessed July 3, 2024]

Mathew, P.J., & Mathew, J.L. (2003). Assessment and management of pain in infants. Postgraduate Medical Journal, 79(934), 438-443.

McGrath, P.J. (1985). CHEOPS: a behavioral scale for rating postoperative pain in children. Adv Pain Res Ther, 9, 395.

Merkel, S., Voepel-Lewis, T., & Malviya, S. (2002). Pain Assessment in Infants and Young Children: The FLACC Scale: A behavioral tool to measure pain in young children. AJN The American Journal of Nursing, 102(10), 55-58.

Ohlsson, A., & Shah, P.S. (2015). Paracetamol (acetaminophen) for prevention or treatment of pain in newborns. Cochrane Database Syst Rev, 6(6).

Pillai Riddell, R., Lisi, D., Campbell, L. (2013).  Pain Assessment in Neonates. In Encyclopedia of Pain, 2^nd edition.

Pillai Riddell, R.R, Racine, N.M., Gennis H.G., Turcotte, K., Uman, L.S., Horton, R.E., Ahola Kohut, S., Hillgrove Stuart, J., Stevens, B., & Lisi, D.M. (2015). Non-pharmacological management of infant and young child procedural pain. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD006275

Pillai Riddell, R., O'Neill, M., Campbell, L., Taddio, A., Greenberg, S., Garfield, H. (2018). The ABCDs of Pain Management: A Double-Blind Randomized Controlled Trial for a Brief Educational Video for Parents of Young Children undergoing Vaccination. Journal of Pediatric Psychology. Volume 43, Issue 3, 1 April 2018, Pages 224-233, https://doi.org/10.1093/jpepsy/jsx122

Pillai Riddell, R.R., Racine, N.M., Gennis, H.G., Turcotte, K., Uman, L.S., Horton, R.E., ... & Lisi, D.M. (2015). Non‐pharmacological management of infant and young child procedural pain. The Cochrane Library.

Stevens, B., Yamada, J., Campbell-Yeo, M. Gibbins, S., Harrison D., Dionne, K., Taddio, A., McNar C Willan, A., Ballantyne, M., Widger, K., Sidani, S., Estabrooks, C., Synnes, A., Squires J., Victor, C., and Riahi, S. (2018). The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial. BMC Pediatr. 2018; 18: 85.

Stevens, B.J., Gibbins, S., Yamada, J., Dionne, K., Lee, G., Johnston, C., & Taddio, A. (2014). The premature infant pain profile-revised (PIPP-R): initial validation and feasibility. The Clinical journal of pain, 30(3), 238-243.

Stevens, B.J., Abbott, L.K., Yamada, J., Harrison, D., Stinson, J., Taddio, A., & Campbell, F. (2011). Epidemiology and management of painful procedures in children in Canadian hospitals. Canadian Medical Association Journal, 183(7), E403-E410.

Stevens, B., Yamada, J., Lee, G.Y., & Ohlsson, A. (2013). Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev, 1(1).

Taddio, A., McMurtry, C.M., Shah, V., Riddell, R.P., Chambers, C.T., Noel, M., & Lang, E. (2015). Reducing pain during vaccine injections: clinical practice guideline. Canadian Medical Association Journal, 187(13), 975-982.