Scoring: SCCM 2022 recommendations
| Domain |
Recommended tool(s) |
Strength / evidence |
| Self-report, ≥6 years, able to communicate |
VAS, Numeric Rating Scale, Oucher, Wong-Baker FACES |
Conditional, low [3] |
| Noncommunicative critically ill patient |
FLACC or COMFORT-B |
Strong, moderate [3] |
| Postoperative pain assessment |
Observational tools rather than vital signs alone |
Strong, moderate [3] |
| Sedation depth, mechanically ventilated |
COMFORT-B or State Behavioral Scale (SBS) |
Strong, moderate [3] |
| Sedation depth, mechanically ventilated |
Richmond Agitation-Sedation Scale (RASS) |
Conditional, low [3] |
| Iatrogenic withdrawal (opioid or benzodiazepine) |
WAT-1 or Sophia Observation Scale (SOS) |
Strong, moderate [3] |
| Withdrawal screening onset |
Begin after 3–5 days when higher opioid/benzodiazepine doses are used |
Conditional, moderate [3] |
Caution. Vital signs alone reflect a physiologic stress response and do not correlate reliably with self-reported pain. SCCM recommends observational tools over vital signs for postoperative pain assessment in critically ill children [3].
Scale selection by age
The figure below (2019 JAMA Pediatrics systematic review) maps validated pain and sedation scales to age group (preterm infants, term infants, toddlers) and clinical context (acute, prolonged, postoperative, sedation). Only scales meeting criteria for construct validity, internal consistency, interrater reliability, and defined cutoff points are included [4].
!Figure 3 Overview of Relevant Scales With Cutoff
| Age group |
Recommended scales |
Key features |
| Preterm neonates |
PIPP-R, N-PASS, NFCS |
Includes gestational age adjustment; validated for procedural and prolonged pain |
| Term neonates (postoperative) |
CRIES, PIPP-R, N-PASS |
CRIES validated specifically for postoperative pain |
| Infants/toddlers (2 mo–3 yr) |
FLACC, COMFORT-B |
Behavioral observation; FLACC most widely used |
| Preschool (4–5 yr) |
FPS-R, simplified scales, FLACC |
Self-report emerging; behavioral backup recommended |
| School-age (6–12 yr) |
NRS-11, FPS-R, CAS, VAS |
Self-report gold standard; NRS-11 most widely used |
| Adolescents (≥12 yr) |
NRS-11, VAS |
Adult-type scales appropriate |
| Cognitively impaired |
Revised FLACC, PPP |
Modified behavioral scales with individualized descriptors |
| Sedated/ventilated |
COMFORT-B, FLACC |
COMFORT-B for sedation depth; FLACC for pain |
| Withdrawal assessment |
WAT-1, SOS |
Score ≥3 indicates withdrawal; assess q12h or more frequently |
Caution. A frightened or fatigued young child who does not follow commands is not thereby demonstrating brain injury or pain. Interpret behavioral non-response in the context of developmental stage and clinical state.
Neonates
The American Academy of Pediatrics recommends five neonatal pain scales: NFCS, PIPP, N-PASS, BIIP, and APN/DAN.
| Scale |
Population / use |
Structure |
| PIPP/PIPP-R (Premature Infant Pain Profile-Revised) |
Procedural pain, preterm and term neonates |
Gestational age, behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, nasolabial furrow. Good content, concurrent, and construct validity and interrater reliability [4] |
| N-PASS (Neonatal Pain, Agitation and Sedation Scale) |
Prolonged pain, sedation, acute procedural pain; 23–40 weeks gestational age |
5 criteria (crying-irritability, behavioral state, facial expression, extremity tone, vital signs), scored 0–2 for pain/agitation and 0 to −2 for sedation [4] |
| CRIES (Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness) |
Postoperative neonatal pain |
10-point scale, 5 domains each scored 0–2; correlates well with PIPP for the first 72 hours after surgery in term and preterm infants [6,7] |
A 2025 Cochrane systematic review identified 65 neonatal pain rating scales, with PIPP/PIPP-R, N-PASS, and COMFORT-neo among the most extensively validated [5].
Open the CRIES Calculator →
Preverbal children: FLACC
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is the most widely used behavioral pain scale for children who cannot self-report [4,9].
- Age range: approximately 2 months to 7 years [4]
- Scoring: five domains, each scored 0–2, total 0–10
- Postoperative pain: strong evidence supports FLACC in critically ill children [9]
- Procedural pain: interrater reliability 0.92, intrarater reliability 0.87, sensitivity 94.9% and specificity 73.5% at a cutoff of 2 [11]
- Emergency department: high interrater reliability confirmed in children 6 months to 5 years with acute pain [12]
- Cognitive impairment: the revised FLACC was developed and validated for nonverbal and cognitively impaired children [9]
A 2023 systematic review concluded FLACC can be used for observational pediatric pain measurement, though further evidence is needed to strengthen the recommendation [13].
Open the FLACC Calculator →
Self-report scales
Below 6 years. A 2019 systematic review found no self-report measure could be recommended for children younger than 6 years [1].
| Scale |
Age range |
Structure / performance |
| Faces Pain Scale-Revised (FPS-R) |
≥4–5 years |
6 faces, scored 0–10; correlation r=0.93 with VAS; strong cross-cultural validity, construct validity, responsiveness [15] |
| Wong-Baker FACES |
≥4–5 years |
6 faces, smiling to crying, scored 0–10; preferred by children when given a choice, but smiling/crying anchors may confound pain intensity with affect [14] |
| Simplified 2-step scale |
4 years |
Yes/no for pain presence, then mild/moderate/severe; improved discrimination of pain vs. no pain compared with standard FPS-R [16] |
| Pain Block |
4–7 years |
Concrete ordinal scale for children who struggle with faces scales; correlation 0.82 with FPS-R [17] |
≥6 years. NRS-11 (0–10), FPS-R (6 faces, 0–10), Color Analogue Scale (graduated color intensity), and Visual Analogue Scale (100 mm line, children ≥8 years can generally comply) are strongly recommended for acute pain [3]. Only weak recommendations exist for self-report in postoperative and chronic pain due to limited evidence [3].
Clinical pearl. For a 5-year-old who cannot reliably rate a 6-face scale, use the simplified 2-step approach (pain present yes/no, then mild/moderate/severe) rather than defaulting to a purely behavioral score [16].
Sedation: COMFORT-B
The COMFORT-B scale assesses both pain and sedation in critically ill children. It removed the vital-sign items from the original COMFORT scale because of reliability concerns during critical illness [18].
| Parameter |
Detail |
| Domains |
Alertness, calmness, respiratory response, crying, physical movement, muscle tone, facial tension (behavioral items only) [18] |
| Scoring |
Each domain rated 1–5; total score 6–30 [18] |
| Oversedation |
≤10 [18] |
| Undersedation |
≥23 [18] |
| Light sedation |
17–22 [18] |
| Moderate sedation |
11–16 [18] |
| Deep sedation |
6–10 [18] |
SCCM recommends COMFORT-B or SBS (strong, moderate evidence) and suggests RASS (conditional, low evidence) for sedation depth in mechanically ventilated children [3].
Open the COMFORT-B Calculator →
Withdrawal: WAT-1
The Withdrawal Assessment Tool-1 (WAT-1) is validated for monitoring iatrogenic withdrawal in pediatric ICU patients.
- Structure: 11-item, 12-point scale assessing motor-related symptoms and behavioral state [20]
- Scoring: score ≥3 is consistent with the presence of withdrawal [20]
- Validation: 126 children (median age 1.6 years), 21 centers, exposed to ≥5 days of opioids [20]
- Psychometric properties: high-quality evidence for reliability, structural validity, criterion validity, and feasibility [21]
- Limitation: cannot differentiate opioid from benzodiazepine withdrawal [20]
SCCM recommends WAT-1 or SOS (strong, moderate evidence) and suggests screening after a shorter interval (3–5 days) when higher opioid or benzodiazepine doses are used (conditional, moderate evidence) [3]. The 2025 AAP clinical report recommends providers familiarize themselves with WAT-1 or SOS to detect early withdrawal signs so treatment can be initiated promptly [22].
Open the WAT-1 Calculator →
Special populations
- Cognitive impairment. Use the revised FLACC with individualized behavioral descriptors [9].
- Neuromuscular blockade. No pain or sedation tool has been validated in patients receiving NMBAs. Vital sign changes may indicate acute pain and should be addressed even without a validated score.
- Palliative care. FPS-R is recommended for self-assessment; FLACC/revised FLACC and the Paediatric Pain Profile (PPP) are recommended for observational assessment [8].
Protocol thresholds and documentation
- Specify which scale applies to each age group and clinical context.
- Define an action threshold (e.g., FLACC ≥4 triggers reassessment and consideration of intervention).
- Train staff to a consistent scoring standard; interrater reliability depends on standardized training.
- Use the same scale across serial assessments in a given patient to enable trending.
- Reassess after analgesic intervention; pain scores should decrease, and persistent elevation warrants reassessment.
Clinical pearl. Set and document a numeric action threshold (e.g., FLACC ≥4) in the protocol itself, not left to individual judgment, so that reassessment and intervention are triggered consistently across shifts.
References
- Birnie KA, Hundert AS, Lalloo C, Nguyen C, Stinson JN. Recommendations for Selection of Self-Report Pain Intensity Measures in Children and Adolescents: A Systematic Review and Quality Assessment of Measurement Properties. Pain. 2019;160(1):5-18.
- Krauss BS, Calligaris L, Green SM, Barbi E. Current Concepts in Management of Pain in Children in the Emergency Department. Lancet. 2016;387(10013):83-92.
- Smith HAB, Besunder JB, Betters KA, et al. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med. 2022;23(2):e74-e110.
- Giordano V, Edobor J, Deindl P, et al. Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development: A Systematic Review. JAMA Pediatr. 2019;173(12):1186-1197.
- Färnqvist K, Olsson E, Garratt A, et al. Clinical Rating Scales for Assessing Pain in Newborn Infants. Cochrane Database Syst Rev. 2025;4:MR000064.
- Krechel SW, Bildner J. CRIES: A New Neonatal Postoperative Pain Measurement Score. Initial Testing of Validity and Reliability. Paediatr Anaesth. 1995;5(1):53-61.
- McNair C, Ballantyne M, Dionne K, Stephens D, Stevens B. Postoperative Pain Assessment in the Neonatal Intensive Care Unit. Arch Dis Child Fetal Neonatal Ed. 2004;89(6):F537-41.
- Chan AY, Ge M, Harrop E, et al. Pain Assessment Tools in Paediatric Palliative Care: A Systematic Review of Psychometric Properties and Recommendations for Clinical Practice. Palliat Med. 2022;36(1):30-43.
- Crellin DJ, Harrison D, Santamaria N, Babl FE. Systematic Review of the Face, Legs, Activity, Cry and Consolability Scale for Assessing Pain in Infants and Children: Is It Reliable, Valid, and Feasible for Use? Pain. 2015;156(11):2132-2151.
- Best Practices Guidelines For Acute Pain Management In Trauma Patients. Bernard A, Oyler DR, Anglen JO, et al. American College of Surgeons (2020).
- Crellin DJ, Harrison D, Santamaria N, Huque H, Babl FE. The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain. J Pain. 2018;19(8):862-872.
- Kochman A, Howell J, Sheridan M, et al. Reliability of the Faces, Legs, Activity, Cry, and Consolability Scale in Assessing Acute Pain in the Pediatric Emergency Department. Pediatr Emerg Care. 2017;33(1):14-17.
- Peng T, Qu S, Du Z, et al. A Systematic Review of the Measurement Properties of Face, Legs, Activity, Cry and Consolability Scale for Pediatric Pain Assessment. J Pain Res. 2023;16:1185-1196.
- Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A Systematic Review of Faces Scales for the Self-Report of Pain Intensity in Children. Pediatrics. 2010;126(5):e1168-98.
- Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: Toward a Common Metric in Pediatric Pain Measurement. Pain. 2001;93(2):173-183.
- Emmott AS, West N, Zhou G, et al. Validity of Simplified Versus Standard Self-Report Measures of Pain Intensity in Preschool-Aged Children Undergoing Venipuncture. J Pain. 2017;18(5):564-573.
- Jung JH, Lee JH, Kim DK, et al. Validation of the "Pain Block" Concrete Ordinal Scale for Children Aged 4 to 7 Years. Pain. 2018;159(4):656-662.
- Ista E, van Dijk M, Tibboel D, de Hoog M. Assessment of Sedation Levels in Pediatric Intensive Care Patients Can Be Improved by Using the COMFORT "Behavior" Scale. Pediatr Crit Care Med. 2005;6(1):58-63.
- Miatello J, Palacios-Cuesta A, Radell P, et al. Inhaled Isoflurane for Sedation of Mechanically Ventilated Children in Intensive Care (IsoCOMFORT): A Multicentre, Randomised, Active-Control, Assessor-Masked, Non-Inferiority Phase 3 Trial. Lancet Respir Med. 2025;13(10):897-910.
- Franck LS, Scoppettuolo LA, Wypij D, Curley MAQ. Validity and Generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for Monitoring Iatrogenic Withdrawal Syndrome in Pediatric Patients. Pain. 2012;153(1):142-148.
- Zaccagnini M, Ataman R, Nonoyama ML. The Withdrawal Assessment Tool to Identify Iatrogenic Withdrawal Symptoms in Critically Ill Paediatric Patients: A COSMIN Systematic Review of Measurement Properties. J Eval Clin Pract. 2021;27(4):976-988.
- Adler AC, Siegel LB, Wilder RT, Good J. Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children: Clinical Report. Pediatrics. 2025;e2025073169.