II. Indications

  1. Acute pain assessment in preverbal children

III. Criteria

  1. Face
    1. Score 0: No expression or smile
    2. Score 1: Occasional grimace or frown; appears withdrawn, disinterested
    3. Score 2: Frequent to constant quivering chin, clenched jaw
  2. Legs
    1. Score 0: Normal position or relaxed
    2. Score 1: Uneasy, restless or tense
    3. Score 2: Kicking or legs drawn up
  3. Activity
    1. Score 0: Lies quietly in normal position and moves easily
    2. Score 1: Squirming or shifting back and forth, tense
    3. Score 2: Arched, rigid or jerking
  4. Cry
    1. Score 0: No cry (awake or asleep)
    2. Score 1: Moans or whimpers; occassional complaint
    3. Score 2: Crying steadily, screams or sobs, frequent complaints
  5. Consolability
    1. Score 0: Content and relaxed
    2. Score 1: Distractable, reassured by occasional touching, hugging or being talked to
    3. Score 2: Difficult to console

IV. Interpretation

  1. Total the score from each of the 5 criteria, resulting in a score from 0-10

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