Pain Assessment and Intensity in Hospitalized Children in Canada


      Numerous acute pediatric pain assessment measures exist; however, pain assessment is not consistently performed in hospitalized children. The objective of this study was to determine the nature and frequency of acute pain assessment in Canadian pediatric hospitals and factors influencing it. Pain assessment practices and pain intensity scores documented during a 24-hour period were collected from 3,822 children aged 0 to 18 years hospitalized on 32 inpatient units in 8 Canadian pediatric hospitals. Pain assessment was documented at least once within the 24 hours for 2,615/3,822 (68.4%) children; 1,097 (28.7%) with a pain measure alone, 1,006 (26.3%) using pain narratives alone, and 512 (13.4%) with both a measure and narrative. Twenty-eight percent of assessments were conducted with validated measures. The mean standardized pain intensity score was 2.6/10 (SD 2.8); however, 33% of the children had either moderate (4–6/10) or severe (7–10/10) pain intensity recorded. Children who were older, ventilated, or hospitalized in surgical units were more likely to have a pain assessment score documented. Considerable variability in the nature and frequency of documented pain assessment in Canadian pediatric hospitals was found. These inconsistent practices and significant pain intensity in one-third of children warrant further research and practice change.


      This article presents current pediatric pain assessment practices and data on pain intensity in children in Canadian pediatric hospitals. These results highlight the variability in pain assessment practices and the prevalence of significant pain in hospitalized children, highlighting the need to effectively manage pain in this population.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Agency for Health Care and Research. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. US Department of Health and Human Services. AHCPR Pub. No. 92-0032. Rockville, MD. February 1992 (Quick Reference Guide for Clinicians. AHCPR Pub. No. 02-0019)

        • American Academy of Pediatrics Committee on Fetus and Newborn, American Academy of Pediatrics Section on Surgery, Canadian Paediatric Society Fetus and Newborn Committee
        Prevention and management of pain in the neonate: An update.
        Pediatrics. 2006; 118: 2231-2241
        • American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Task Force on Pain in Infants Children and Adolescents
        The assessment and management of acute pain in infants, children, and adolescents.
        Pediatrics. 2001; 108: 793-797
      2. Anand K.J.S. Stevens B.J. McGrath P.J. Pain in Neonates and Infants. Elsevier, Edinburgh, UK2007
        • Beyer J.E.
        • Denyes M.J.
        • Villarruel A.M.
        The creation, validation, and continuing development of the Oucher: A measure of pain intensity in children.
        J Pediatr Nurs. 1992; 7: 335-346
        • Bieri D.
        • Reeve R.
        • Champion G.
        • Addicoat L.
        • Ziegler J.
        The faces pain scale for the self-assessment of the severity of pain experienced by children: Development, initial validation, and preliminary investigation for ratio scale properties.
        Pain. 1990; 41: 139-150
        • Blauer T.
        • Gerstmann D.
        A simultaneous comparison of three neonatal pain scales during common NICU procedures.
        Clin J Pain. 1998; 14: 39-47
        • Breau L.
        The science of pain measurement and the frustration of clinical pain assessment: Does an individualized numerical rating scale bridge the gap for children with intellectual disabilities?.
        Pain. 2010; 150: 213-224
        • Breau L.M.
        • Finley G.A.
        • McGrath P.J.
        • Camfield C.S.
        Validation of the Non-communicating Children’s Pain Checklist—Postoperative Version.
        Anesthesiology. 2002; 96: 528-535
        • Cohen L.L.
        • Lemanek K.
        • Blount R.L.
        • Dahlquist L.M.
        • Lim C.S.
        • Palermo T.M.
        • McKenna K.D.
        • Weiss K.E.
        Evidence-based assessment of pediatric pain.
        J Pediatr Psychol. 2008; 33: 939-955
        • Cummings E.A.
        • Reid G.J.
        • Finley G.A.
        • McGrath P.J.
        • Ritchie J.A.
        Prevalence and source of pain in pediatric inpatients.
        Pain. 1996; 68: 25-31
        • Duhn L.J.
        • Medves J.M.
        A systematic integrative review of infant pain assessment tools.
        Adv Neonatal Care. 2004; 4: 126-140
        • Franck L.S.
        • Bruce E.
        Putting pain assessment into practice: Why is it so painful?.
        Pain Res Manag. 2009; 14: 13-20
        • Gharavi B.
        • Schott C.
        • Nelle M.
        • Reiter G.
        • Linderkamp O.
        Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland.
        Pediatr Int. 2007; 49: 652-658
        • Goodenough B.
        • Thomas W.
        • Champion G.D.
        • Perrott D.
        • Taplin J.E.
        • von Baeyer C.L.
        • Ziegler J.B.
        Unravelling age effects and sex differences in needle pain: Ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents.
        Pain. 1999; 80: 179-190
        • Harrison D.
        Implementation matters: Pain assessment: Not yet normalized practice. Special Interest Group on Pain in Childhood, International Association for the Study of Pain.
        The SIG > PIC News. 2009; 1: 4-6
        • Harrison D.
        • Loughnan P.
        • Johnston L.
        Pain assessment and procedural pain management practices in neonatal units in Australia.
        J Paediatr Child Health. 2006; 42: 6-9
        • Harrison D.
        • Loughnan P.
        • Manias E.
        • Johnston L.
        Utilization of analgesics, sedatives, and pain scores in infants with a prolonged hospitalization: A prospective descriptive cohort study.
        Int J Nurs Stud. 2009; 46: 624-632
        • Hechler T.
        • Chalkiadis G.A.
        • Hasan C.
        • Kosfelder J.
        • Meyerhoff U.
        • Vocks S.
        • Zernikow B.
        Sex differences in pain intensity in adolescents suffering from cancer: Differences in pain memories?.
        J Pain. 2009; 10: 586-593
        • Hester N.
        • Foster R.
        • Kristensen K.
        Measurement of pain in children: Generalizability and validity of the pain ladder and Pieces of Hurt tool.
        Adv Pain Res Ther. 1990; 15: 79-84
        • Hicks C.
        • von Baeyer C.
        • Spafford P.
        • van Korlaar I.
        • Goodenough B.
        The faces pain scale-revised: Toward a common metric in pediatric pain measurement.
        Pain. 2001; 93: 173-183
        • Holsti L.
        • Grunau R.
        • Shany E.
        Assessing pain in preterm infants in the neonatal intensive care unit: Moving to a “brain-oriented” approach.
        Pain Manag. 2011; 1: 171-179
        • Hubbard A.E.
        • Ahern J.
        • Fleischer N.L.
        • Van der Laan M.
        • Lippman S.A.
        • Jewell N.
        • Bruckner T.
        • Satariano W.A.
        To GEE or not to GEE: Comparing population average and mixed models for estimating the associations between neighborhood risk factors and health.
        Epidemiology. 2010; 21: 467-474
        • Hummel P.
        • van Dijk M.
        Pain assessment: Current status and challenges.
        Semin Fetal Neonatal Med. 2006; 11: 237-245
        • Jensen M.P.
        • Karoly P.
        • Braver S.
        The measurement of clinical pain intensity: A comparison of six methods.
        Pain. 1986; 27: 117-126
      3. Joint Commission on Accreditation of Healthcare Organizations. Improving the quality of pain management through measurement and action. Available at: Accessed December 23, 2011

        • Jongudomkarn D.
        • Angsupakorn N.
        • Siripul P.
        The development and validation of the Khon Kaen University Pediatric Pain Assessment Tool for school-aged Isaan children in Thailand.
        J Transcult Nurs. 2008; 19: 213-222
        • Lago P.
        • Guadagni A.
        • Merazzi D.
        • Ancora G.
        • Bellieni C.V.
        • Cavazza A.
        • Pain Study Group of the Italian Society of Neonatology
        Pain management in the neonatal intensive care unit: A national survey in Italy.
        Paediatr Anaesth. 2005; 15: 925-931
        • Lawrence J.
        • Alcock D.
        • McGrath P.
        • Kay J.
        • MacMurray S.B.
        • Dulberg C.
        The development of a tool to assess neonatal pain.
        Neonatal Netw. 1993; 12: 59-66
        • Merkel S.I.
        • Voepel-Lewis T.
        • Shayevitz J.R.
        • Malviya S.
        The FLACC: A behavioral scale for scoring postoperative pain in young children.
        Pediatr Nurs. 1997; 23: 293-297
        • Myers C.D.
        • Tsao J.C.I.
        • Glover D.A.
        • Kim S.C.
        • Turk N.
        • Zeltzer L.K.
        Sex, gender, and age: Contributions to laboratory pain responding in children and adolescents.
        J Pain. 2006; 7: 556-564
        • Rashotte J.
        • Yamada J.
        • Harrison D.
        • Coburn G.
        • Abbott L.
        • Cohen J.
        • Stevens B.
        A qualitative analysis of health professionals' acute pain assessment narratives about hospitalized children.
        Pain Res Manage. 2011; 15: 2
        • Reyes S.
        Nursing assessment of infant pain.
        J Perinat Neonatal Nurs. 2003; 17: 291-303
        • Rohrmeister K.
        • Kretzer V.
        • Berger A.
        • Haiden N.
        • Kohlhauser C.
        • Pollak A.
        Pain and stress management in the Neonatal Intensive Care Unit: A national survey in Austria.
        Wien Klin Wochenschr. 2003; 115: 715-719
        • Scott P.
        • Ansell B.
        • Huskisson E.
        Measurement of pain in juvenile chronic polyarthritis.
        Ann Rheum Dis. 1977; 36: 186-187
      4. Special Interest Group Pain in Childhood, International Association for the Study of Pain. Children’s Pain Matters! Priority on Pain in Infants, Children, and Adolescents: International Association for the Study of Pain. Available at: Accessed December 23, 2011

        • Stevens B.
        • Johnston C.
        • Petryshen P.
        • Taddio A.
        Premature Infant Pain Profile: Development and initial validation.
        Clin J Pain. 1996; 12: 13-22
        • Stevens B.J.
        • Abbott L.K.
        • Yamada J.
        • Harrison D.
        • Stinson J.
        • Taddio A.
        • Barwick M.
        • Latimer M.
        • Scott S.D.
        • Rashotte J.
        • Campbell F.
        • Finley G.A.
        CIHR Team in Children’s Pain: Epidemiology and management of painful procedures in children in Canadian hospitals.
        CMAJ. 2011; 183: E403-E410
        • Stinson J.N.
        • Kavanagh T.
        • Yamada J.
        • Gill N.
        • Stevens B.J.
        Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents.
        Pain. 2006; 125: 143-157
        • Taylor E.M.
        • Boyer K.
        • Campbell F.A.
        Pain in hospitalized children: A prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital.
        Pain Res Manag. 2008; 13: 25-32
        • Taylor B.J.
        • Robbins J.M.
        • Gold J.I.
        • Logsdon T.R.
        • Bird T.M.
        • Anand K.J.
        Assessing postoperative pain in neonates: A multicenter observational study.
        Pediatrics. 2006; 118: e992-e1000
        • Tomlinson D.
        • von Baeyer C.L.
        • Stinson J.N.
        • Sung L.
        A systematic review of Faces Scales for the self-report of pain intensity in children.
        Pediatrics. 2011; 126: 1168-1198
        • Vierhaus M.
        • Lohaus A.
        • Schmitz A.K.
        Sex, gender, coping, and self-efficacy: Mediation of sex differences in pain perception in children and adolescents.
        Eur J Pain. 2011; 15: e1-e8
        • von Baeyer C.L.
        • Spagrud L.J.
        Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years.
        Pain. 2007; 127: 140-150
        • von Baeyer C.L.
        • Spagrud L.J.
        • McCormick J.C.
        • Choo E.
        • Neville K.
        • Connelly M.A.
        Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children’s self-reports of pain intensity.
        Pain. 2009; 143: 223-227
        • Wong D.
        • Baker C.
        Pain in children: Comparison of assessment scales.
        Pediatr Nurs. 1988; 14: 9-17