title: The use of the faces, legs, activity, cry and consolability scale to assess procedural pain and distress in young children.
abstract: BACKGROUND
  Young children frequently undergo diagnostic and therapeutic procedures in the emergency department (ED). Although developed and validated for postoperative pain, Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scores have been recommended and used for the assessment of procedural pain as well. We set out to assess if FLACC scores can differentiate pain and distress and establish a hierarchy of FLACC scores experienced during common ED procedures.
  
  
  METHODS
  Prospective observational study at an urban tertiary children's hospital ED. We aimed to recruit 30 children each aged 6 to 42 months undergoing intravenous cannula (IV) insertion, nasogastric tube (NGT) insertion, metered dose inhaler (MDI) use and oxygen saturation (SpO(2)) measurement. Based on videotapes, 2 independent observers assessed pain and distress using FLACC scores during all procedural phases.
  
  
  RESULTS
  A total of 125 patients were recruited and filmed for IV (33), NGT (30), MDI (34), and SpO2 (28). Median FLACC scores were as follows: NGT, 10 (interquartile range [IQR] 8.75-10); IV, 6.5 (IQR, 4.5-9.75); MDI, 6.5 (IQR, 0-9); and SpO(2), 0 (IQR, 0-0.5). The FLACC scores increased during each of the 3 phases, before the procedure, during restraint, and during the procedure. Procedural distress decreased with age except for NGT insertions, which remained very high irrespective of age.
  
  
  CONCLUSIONS
  FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children. This study identified substantial levels of pain and distress in young children by FLACC during commonly performed ED procedures, with nasogastric tube insertion having very high and intravenous cannulation/venepuncture and MDI having high FLACC scores.
authors.affiliation: Emergency Department, Royal Children's Hospital, Victoria, Australia.
authors.forename: Franz E
authors.initials: FE
authors.lastname: Babl
authors.forename: Dianne
authors.initials: D
authors.lastname: Crellin
authors.forename: Joyce
authors.initials: J
authors.lastname: Cheng
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Sullivan
authors.forename: Ronan
authors.initials: R
authors.lastname: O'Sullivan
authors.forename: Adrian
authors.initials: A
authors.lastname: Hutchinson
mesh_terms: D000367:Age Factors; D002404:Catheterization / Q000009:adverse effects; D002652:Child Behavior; D002675:Child, Preschool; D003448:Crying; D004636:Emergency Service, Hospital; D019066:Facies; D005260:Female; D006801:Humans; D007223:Infant; D018730:Infant Behavior; D007441:Intubation, Gastrointestinal / Q000009:adverse effects; D007866:Leg / Q000502:physiology; D008297:Male; D036501:Metered Dose Inhalers / Q000009:adverse effects; D009043:Motor Activity; D009068:Movement; D010092:Oximetry / Q000009:adverse effects; D010146:Pain / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D010147:Pain Measurement / Q000379:methods*; D018962:Phlebotomy / Q000009:adverse effects; D011446:Prospective Studies; D012149:Restraint, Physical; D014743:Videotape Recording