Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Background: Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. Methods: We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). Results: Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. Conclusions: There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.