Background and Goal of Study:
The Face, Leg, Activity, Cry, Consolability scale (FLACC) and the Colored Analogue Scale
(CAS) are both recommended tools in pediatric postoperative pain assessment. Nurses often
report lower pain intensity scores compared to children and parents (1). This might impair
good pain management. Aim: to further investigate differences in-hospital pain assessment
between nurses, children and parents after adenotonsillectomy.
Materials and Methods:
After IRB approval, a prospective cohort study was carried out investigating intra-hospital pain
after adenotonsillectomy in daytime surgery. Inclusion: eligible were children between 6 and
12 years old, ASA 1&2. Exclusion: known mental retardation.
Instruments: a. the FLACC-scale scored by 2 independently nurses (1 permanent research
nurse) at 2h and 4h postoperative; b. a CAS consists of two extremes, ‘no pain’ (white color)
and ‘most pain’ (red color), on which both the child and parent slide a marker on a vertical line
to indicate the child’s pain at 2h and 4h postoperative (0 indicating no pain and 10 very much
pain). Statistics: 1. agreement between nurses FLACC scores using intraclass correlation
coefficient (ICC); 2. ICC between child/parental CAS scores; 3. discriminant validity:
McNemar test after dichotomizing pain scores into 2 groups (non to mild pain vs. moderate to
severe pain) using cut-off values of respectively ≥3 on the FLACC and ≥3 on the
child/parental CAS ratings.
Results and Discussion:
This study included 57 children (64 % girls) with mean age of 108 (months), SD±25.7. ICC
between FLACC scores at 2h were: r =.72; P=.000 and at 4h: r = .33; P =.07). ICC between
child/parental CAS at 2h: r=.72; P=.000 and at 4h r=.63; P=.001. After dichotomizing scores
at 2h [FLACC2h: n=2 had moderate to severe pain vs. CASchild2h: n=32; P<.0001] and at 4h
[FLACC4h: n= 3 had moderate to severe pain vs. CASChild4h: n=32; P <.0001]. FLACC
scores compared to parental CAS at 2h [CASparent2h: n=46 had moderate to severe pain;
P<.0001] and at 4h [CASparent4h: n=34 had moderate to severe pain; P<.0001].
Conclusions:
Nurses pain intensity scores are systematically lower compared to child and parental
assessment. No differences were found between nurses FLACC ratings. Furthermore there
were no differences between child and parental CAS ratings.

06 / Postoperative observational FLACC scores by nurses do not reliably reflect children’s and parental Colored Analogue Scale ratings of children’s pain