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Do children with high 
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Review of Pediatric Observational Sedation and Pain Scales

Dr. BurgerBecky Burger, MD
Section Editor

In pediatric sedation research many validated sedation scales have been used.  Unlike self-report scales such as the FACES or numerical scale that ask patients to rate their pain, observational scales measure a patient’s behavior, vital signs, response to pain or a combination of these. 

The majority of the observational scales originated in anesthesia or critical care settings and aim to assess deep sedation. 

This is a review of the most commonly used observational pediatric pain and sedation scales for sedation and pain research.

Pain Scales

  1. CHEOPS – Children’s Hospital of Eastern Ontario Pain Scale: This pain scale measures six behaviors (cry, facial, verbal, torso, touch and legs).  The scale ranges from four to thirteen with some studies citing a score greater than four and other studies greater than six indicating pain.  This scale was originally validated for children between one and seven years old and subsequently has been studied in children between four months and seventeen years old.  CHEOPS was developed to measure post-operative pain and has since been applied in multiple other settings including pain during laceration repair and fracture reduction in the emergency department.  CHEOPS has high inter-rater and test-retest reliability.  (McGrath PJ, Johnson G, Goodman JT, et al. CHEOPS: a behavior scale for rating postoperative pain in children. In: Fields HL, Dubner R, Carvero F, et al, eds. Advances in Pain Research and Therapy. New York, NY: Raven Press; 1985:395–402.)
  2. FLACC – Face, Legs, Arms, Cry, Consolability.  This pain scale measures the five behaviors stated in its name.  The scale ranges from zero to ten with higher scores indicating more pain.  FLACC was originally validated for children between four and eighteen years old and has subsequently been studied in children zero to eighteen years of age.  FLACC has been primarily used in studies of post-operative pain and minor non-invasive procedures.  FLACC has high inter-rater reliability. (Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S.  The FLACC: a Behavioral Scale for Scoring Postoperative Pain in Young Children.  Pediatric Nursing Journal.  1997 May-June; 23(3): 293-7.)
  3. COMFORT Scale – This scale uses eight categories of behaviors and vital signs to measure pain including alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension.  Each category is measured on a scale of one to five, for a total score of eight to forty, with higher scores indicating greater pain.  This scale is validated in children up to seventeen years old.  The COMFORT scale has good inter-rater reliability and internal consistency.  (Ambuel B, Hamlett KW, Marx CM, Blumer JL.  Assessing Distress in Pediatric Intensive Care Environments: The COMFORT Scale.  Journal of Pediatric Psychology.  1992; 17(1): 95-109.)
  4. OSBD-r – Observational Scale of Behavioral Distress-Revised:  This scale was originally developed in 1983 by Jay, Ozolins, Elliott and Caldwell to include eleven behaviors and was revised in 1987 by Elliott, Jay and Woody to include eight behaviors (information seeking, cry, scream, restraint, verbal response, emotional support, verbal pain, and flail).  The score ranges from zero to 23.5 (each behavior is multiplied by a pre-assigned value based on the intensity of distress - cry and information seeking are weighted at 1.5; emotional support at 2; verbal resistance and verbal pain at 2.5; and scream, restraint and flail at 4).  Higher OSBD-r scores indicate greater distress.  OSBD-r was originally validated in patients between two and twenty years old to measure distress during bone marrow aspiration and lumbar punctures and has since been used to measure pain and sedation during other procedures including those in the emergency department.  OSBD-r has high inter-rater reliability. (Elliott CH, Jay SM, Woody P.  An Observational Scale for Measuring Children’s Distress during Medical Procedures.  Journal of Pediatric Psychology.  1987 Dec; 12(4): 543-51.)

Sedation Scales

  1. UMSS – University of Michigan Sedation Scale: This sedation scale ranges from zero to four with higher numbers indicating deeper sedation.  UMSS is a well-validated score approved for children between six months and twelve years of age.  It has been used to assess levels of sedation in multiple settings as well as discharge readiness after sedation.  Studies have shown excellent correlation between UMSS score and Bispectral Index (BIS monitor). (Malviya S, Voepel-Lewis T, Tait AR, et al.  Depth of Sedation in Children Undergoing Computed Tomography: Validity and Reliability of the University of Michigan Sedation Scale (UMSS).  British Journal of Anaesthesia.  2002; 88.2: 241-5.)
  2. AVPU – Alert, Voice, Pain, Unresponsive: This sedation scale has four levels – alert, responsive to voice, responsive to pain and unresponsive.  This scale is a simplification of the Glasgow Coma Scale and is used frequently by pre-hospital personnel.  There is very limited published data about the validation, inter-rater reliability and approved ages for this scale.
  3. Ramsay Sedation Score: This sedation scale ranges from one to six with higher values indicating deeper sedation.  Dr. Ramsay and Dr. Simpson designed this scale in 1974 to measure sedation on thirty patients between the ages of eight and seventy-five years old in the intensive care unit.  It has since been used to measure sedation during minor painful or diagnostic procedures.  Good correlation has been shown between Ramsay Score and BIS monitor. (Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R.  Controlled Sedation with Alphaxalone-Alphadolone.  British Medical Journal. 1974; 2:656–659.)

These scales have all been used in sedation literature in a variety of settings.  Despite their name, the pain scales are often used to measure levels of sedation.  The observation of distress or pain is not the same as sedation or anxiety.  The scales that measure sedation are not specific enough to discern differences in mild to moderate sedation. 

More studies need to be conducted to differentiate levels of sedation during minor sedation, such as levels achieved with intranasal midazolam or inhaled nitrous oxide. 

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