Pain assessment in infants and young children

This last week has been hard on all of us.  And very very confusing.

Our poor baby cut his first teeth.  You know how when you read an article about teething it mentions all these associated symptoms like diarrhea and diaper rash and fussiness and even potentially low grade fever?  Then it usually goes on to say that those symptoms may not be associated with teething at all so check with your doctor because there may be something else going on?

Clearly, there were teeth cutting through the gum.  I could feel and see them.  I could also see (and feel) an increase in drool production.  I thought the more frequent loose stools were related to that.  They weren’t really watery.  Then there was the diaper rash. Our first ever.  We felt like bad parents.  It wasn’t just red…it was blistering.  We cringed ever time we looked at it or had to clean it. But clearly the diaper rash was from pooping 10 times a day, right? And our son didn’t feel like eating because his gums hurt, right?  And those little red bumps on his hands were from chewing them, right?


It’s now become obvious that he has hand, foot and mouth disease.  HFMD is going around his daycare right now so it seems a safe bet.  Rashes in the genital region are common in HFMD which alleviates some of our diaper-rash guilt.

The treatment for HFMD is symptomatic and supportive: hydration, pain and fever management and time.  But this begs the question…

How can you tell if your pre-verbal child is in pain?

Contrary to my UT post, I have been treating my son with over-the-counter analgesics for the last few days.  I am an anesthesiologist.  Taking away pain is a huge part of my identity and when I think about my son being in pain and unable to tell me about it, I feel physically ill.

Pain – The Fifth Vital Sign

In 1995, the president of the American Pain Society, Dr James Campbell, described pain as “the fifth vital sign.”  Pain is the number one reason why people seek medical care and yet it is often overlooked and poorly treated.  When nursing was just starting to develop as a profession, it was realized that regular measurement of patients’ vital signs (heart rate, respiratory rate, blood pressure and temperature and, once it was available in the ’80s, pulse oximetry reading) was able to identify patients whose condition was deteriorating before they, well, collapsed.  Dr Campbell felt that if pain was formally assessed in a standardized manner every time the vitals were assessed, then we would be well on our way to identifying pain in a timely manner and be able to treat it appropriately.  If you’ve ever been a patient in a hospital, you might have experienced this.  After having your vitals taken, the nurse asks you to rate your pain from 0-10 (a simple numeric scale).  Your rating is charted on a special pain assessment form.  If you rate > 4 in my hospital, the nurse is obligated to offer you some pain medication.  Whether or not you take it is up to you.

When I was in medical school, I was taught that children younger than 4 couldn’t be relied on to tell you where it hurt, not even by pointing.  At young ages many of them just aren’t able to use words to express what they are feeling.  Often they will point to their tummy.  Everything is a tummy ache.  An ear infection is a tummy ache.  A sore throat is a tummy ache.  Appendicitis is a tummy ache.  A headache is a tummy ache.

However, children as young as 3 or 4 can use developmentally appropriate self-reporting pain tools.  They may be able to “colour the pain” on a picture of a person to show you where it hurts even if they can’t express it in words.

In children this age, we commonly use the Faces scale or a simple visual-analog scale (VAS) (easy to find using google), both of which can also be used at home

Preschoolers and young children in pain may view it as a punishment.  They need lots of verbal and physical reassurance as well as analgesics when they are in pain.

Developmentally, toddlers and infants don’t yet have the tools to “tell” us when they are in pain or to rate its severity for us.  We have to rely on their behaviours and, in the hospital, vital signs.  Toddlers in pain may have trouble sleeping.  They may “guard” the painful body part.  They may exhibit aggressive or regressive, withdrawn behaviour.  They may scream and cry.  Infants cry and may be inconsolable.  They may be hypersensitive or irritable.  They often flail, arch their backs or appear rigid.  They may draw their knees up to their chest.  They also have difficulty sleeping.  They may refuse to eat.

In the hospital we use the FLACC or RILEY pain scales which have been validated for young children for both medical and surgical pain (again, I suggest google if you want details).

When my son was in the throes of HFMD he easily scored a 5 or 6 on the FLACC scale and a 6 on the Riley scale.  A dose of baby acetaminophen later and he scored zero.

Now I have HFMD and, based on what I am feeling, I am very very glad that I gave my son some simple over-the-counter analgesics!


  1. Hope your household feels better soon….

  2. Ohhh, so sorry. HFMD is terrible. Teething can really suck too; we’re in the middle of getting lateral upper incisors in, and we have lots of misery 😦

    One tip I wanted to share; I learned the other day that not all children’s acetaminophen is created equal. We recently transitioned from infant Tylenol (which W had no problem with, and swallowed without a fuss) to children’s acetaminophen (the infant formula is no longer being made, and is hard to find). Because I’m sort of crunchy, I bought a non-Tylenol brand (Little Fevers, to be exact) that was dye- and HFCS-free. It’s still sweetened, but isn’t as thick and syrupy (nor as horrid a color) as on-brand Tylenol. W seemed to hate it, though; she screamed and cried (and had to be held down) when we gave it to her. We couldn’t figure out what the problem was, particularly because she’d never had an objection to acetaminophen before. I finally tasted the stuff (bad mommy! should have done so from the start!) and it’s horribly foul. I threw it away and bought Tylenol brand, which is thick and syrupy and similar in flavor to the infant stuff. She takes it without a problem. Definitely learned my lesson; from now on, I will ALWAYS taste medicine before I give it to her (unless there’s no choice of brands out there, in which case there’s nothing to be done, of course).

    I also learned recently that for prescription meds for which there isn’t a choice of brands/flavors, many pharmacies will add flavoring for you!! Win!

    Hope your little guy is on the mend (and you too!)

    1. Great tip!

      I am using tylenol too – just didn’t want to really endorse a brand and get accused of being a shill for big pharma! The white grape flavour seems enjoyable to my little guy and is clear so it won’t stain. He likes the flavour of infant advil too.

      At the pharmacy, you can often get a choice of flavours…strawberry, banana and others. At the hospital we often hide bad tasting drugs (like midazolam for preop sedation in kids) in root beer or dr pepper. Not at all crunchy but it gets it down!

      1. Got a tip from a friend that Target benadryl is nasty, while brand-name and Walgreens benadryl are ok.

        And yeah, I totally agree that departing from the “crunchy” in favor of getting the medicine into the kid is the way to go. W has a super-sensitive gag reflex, and if I give her a med she hates, she can actually throw up. That’s the LAST thing I need when she’s sick and dehydrated.

  3. Can I also say that if you have a baby that vomits medication there are paracetamol suppositories. I’m not a medical person at all and I am easily squicked out by that stuff but when my baby is sick, feverish and in pain I’ll do it. A bit of vaseline and about 3 seconds while his nappy is off and it’s done.

    1. Lucky you! I am not sure we have acetaminophen suppositories in a small enough dose for infants in North America. Something to check with your pharmacist…

  4. Michelle · · Reply

    I’m so sorry. My first had an asymptomatic HFM (I had it bad, he was very mild) and I thought we were done. Then we caught a very bad one when he was 12 months old. He was very ill, viral rash, screaming and dehydrated. Ended up spending a night at the hospital (after days of trying to nurse at home, fever, and several visits to the doctor where they couldn’t tell what was wrong and said ‘he just wasn’t that sick’!!). I couldn’t even get medicine in him, he refused anything by mouth.

    I feel your pain, Coxsackie viruses are the pits. Hope you’re better very, very soon.

  5. Mohammad Fanguy · · Reply

    Acetaminophen is the most popular painkiller in the US. It is best known by the brand name Tylenol but is sold under 97 different brand names. It is known as paracetamol in many parts of the world. It is also sold in combination with other drugs in more than 100 products.During cold and flu season, people who take acetaminophen for arthritis are at risk for acetaminophen poisoning. Taking just twice the recommended dose of acetaminophen can cause acute liver failure. Unfortunately, this has already happened to an alarming number of people because it isn’t hard to do. Two years ago, more than 56,000 people visited the emergency room due to accidental acetaminophen overdoses and 100 people died from unintentionally taking too much. Worse yet, the numbers appear to be growing..

    My current web site

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