II. Indications
- Acute pain assessment in preverbal children
III. Criteria
- Face
- Score 0: No expression or smile
- Score 1: Occasional grimace or frown; appears withdrawn, disinterested
- Score 2: Frequent to constant quivering chin, clenched jaw
- Legs
- Score 0: Normal position or relaxed
- Score 1: Uneasy, restless or tense
- Score 2: Kicking or legs drawn up
- Activity
- Score 0: Lies quietly in normal position and moves easily
- Score 1: Squirming or shifting back and forth, tense
- Score 2: Arched, rigid or jerking
- Cry
- Score 0: No cry (awake or asleep)
- Score 1: Moans or whimpers; occassional complaint
- Score 2: Crying steadily, screams or sobs, frequent complaints
- Consolability
- Score 0: Content and relaxed
- Score 1: Distractable, reassured by occasional touching, hugging or being talked to
- Score 2: Difficult to console
IV. Interpretation
- Total the score from each of the 5 criteria, resulting in a score from 0-10