Highlights
- •The FLACC scale was reliable and sensitive to procedural pain in young children.
- •The FLACC scale may not be specific for procedural pain assessment.
- •The circumstances of procedures interfered with application of the FLACC scale.
Abstract
The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most
commonly and widely used behavioral observation pain scales. The aim of this study
was to test the psychometric and practical properties of the FLACC scale to quantify
procedural pain in infants and young children. Twenty-six clinicians independently
applied the FLACC scale to segments of video collected from 100 children aged 6 to
42 months undergoing a procedure. Video segments were scored by 4 reviewers. Inter-
and intrarater reliability coefficients were high (.92 and .87, respectively). Linear
mixed modeling confirmed scale responsiveness (differences in difference between FLACC
scores across phases for painful versus nonpainful procedures was 4.2, 95% confidence
interval = 3.67-4.81). Sensitivity and specificity were 94.9% and 73.5%, respectively,
at a cutoff of 2. However, the mean difference across phases for children with baseline
scores >3 was much lower than for children with scores <3, P = .0001. Correlations between FLACC and Visual Analog Scale observer pain and distress
were good (r = .74 and r = .89, respectively). This study supports the reliability
and sensitivity of the FLACC scale for procedural pain assessment. However, the circumstances
of procedures interfered with application of the scale and the findings question the
capacity of the scale to differentiate between pain- and nonpain-related distress.
Perspective
This article provides evidence that the FLACC scale is reliable and sensitive to pain
for procedural pain assessment. Concerns remain about specificity and scale design.
Identification of a scale valid for this purpose is needed to provide a platform for
improved procedural pain management in infants and young children.
Key words
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Article info
Publication history
Published online: March 15, 2018
Accepted:
February 22,
2018
Received in revised form:
December 31,
2017
Received:
September 7,
2017
Footnotes
Funding and other material support provided by a Murdoch Children's Research Institute clinical research grant.
The authors have no conflicts of interest to declare.
Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com.
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© 2018 by the American Pain Society
