Pain in young children attending the accident and emergency department

• children
• pain

Editor,—We read with interest the article by Macarthy et al.¹ We too have experienced difficulties assessing and scoring children's pain in the accident and emergency (A&E) setting. We feel that while subjective assessment has been shown to be the gold standard of pain assessment in some settings, for example, postoperative pain, the unexpected nature and anxiety associated with an attendance at the A&E department makes this type of scoring invalid.

We have been working on developing an observational score for the assessment of pain in children presenting to the A&E department. We know from experience of auditing analgesic use in A&E that children who have a pain score allocated receive more analgesia in a more timely fashion than those who do not.

Our pain score is loosely based on both the TPPS² and CHEOPS³ score and relies on observations of various parameters in five categories (1) cry/vocal expression, (2) colour, (3) facial expression, (4) posture, (5) movement. Each score receives a value of 0, 1 or 2 to give a maximum total of 10 (similar to the mechanism of a Apgar score).

This score has been validated by medical students (Davis and Rostron⁴) in the department and has shown to have good inter-rater reliability (Spearman's rank correlation 0.82) and to have also significant constructive validity when compared with patients who presented with non-painful conditions. We feel that this score can be extended from the age of one year right through the paediatric population and not be just restricted to under fives, as we have experienced problems with subjective pain scoring in all age groups presenting to the department.

We endorse the suggestion that exploration of such pain scores in the A&E department should be actively pursued and intend to further validate our Alder Hey score against the modified TPS score as the author suggests.