The measurement properties of observational pain assessment scales in pediatric opstoperative patients: a systematic review_Chinese Journal of Evidence-Based Medicine

Authors：

WANG Yingwen ^1,2 , FU Weijia ¹ , QI Shaodan ¹ , ZHANG Yurong ¹ , WANG Beibei ¹ , ZHANG Yanhong ¹ ,  GU Ying ¹ ,  ZHANG Xiaobo ³

1. Nursing Department of Children’s Hospital of Fudan University, Shanghai 201102, P. R. China;
2. Education and Training Department of Children’s Hospital of Fudan University, Shanghai 201102, P. R. China;
3. Respiratory Department of Children’s Hospital of Fudan University, Shanghai 201102, P. R. China;

Corresponding?author：

GU Ying, Email: guying0128@aliyun.com; ZHANG Xiaobo, Email: zhangxiaobo0307@163.com

Keywords：

Children; Postoperative; Pain assessment; Scale; Measurement properties; Systematic review; COSMIN

DOI：

10.7507/1672-2531.202506114

Video：

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Objective To systematically review the measurement properties of observational pain assessment scales for pediatric patients after surgery. Methods The PubMed, Embase, CINAHL, PsycArticles, and SinoMed databases were electronically searched to collect studies related to the objectives from inception to April 13, 2024. Two reviewers independently screened literature, extracted data and assessed the risk of bias of the included studies. And the quality of measurement properties was rated using updated criteria for good measurement properties to determine recommendation levels. Results A total of 26 studies were finally included involving 12 observational pain assessment scales for pediatric patients after surgery. None reported measurement error or cross-cultural validity. The overall content validity of all 12 scales was evaluated by reviewers, with measurement properties rated as sufficient or inconsistent. For internal consistency, due to insufficient or uncertain content validity, the evidence quality was low. Eight scales calculated internal consistency, among which CHEOPS, CHIPPS, COMFORT, FLACC, and NCCPC-PV scales had sufficient measurement properties with evidence quality of low or above, receiving Grade A recommendations. Conclusion Compared with other scales, CHEOPS, CHIPPS, COMFORT, FLACC, and NCCPC-PV scales demonstrated good measurement property evaluation with acceptable evidence quality and can be recommended for use. Other scales still require further improvement in measurement property validation.

Citation： WANG Yingwen, FU Weijia, QI Shaodan, ZHANG Yurong, WANG Beibei, ZHANG Yanhong, GU Ying, ZHANG Xiaobo. The measurement properties of observational pain assessment scales in pediatric opstoperative patients: a systematic review. Chinese Journal of Evidence-Based Medicine, 2026, 26(1): 47-54. doi: 10.7507/1672-2531.202506114 Copy

1.	Raja SN, Carr DB, Cohen M, et al. The revised international association for the study of pain definition of pain: concepts, challenges, and compromises. Pain, 2020, 161(9): 1976-1982.
2.	Mekonnen ZA, Melesse DY, Kassahun HG, et al. Prevalence and contributing factors associated with postoperative pain in pediatric patients: a cross-sectional follow-up study. Perioper Care Oper Room Manag, 2021, 23: 100159.
3.	Ghai B, Makkar JK, Wig J. Postoperative pain assessment in preverbal children and children with cognitive impairment. Paediatr Anaesth, 2008, 18(6): 462-477.
4.	Fuller AM, Bharde S, Sikandar S. The mechanisms and management of persistent postsurgical pain. Front Pain Res (Lausanne), 2023, 4: 1154597.
5.	Howard RF. Current status of pain management in children. JAMA, 2003, 290(18): 2464-2469.
6.	Macintyre PE, Quinlan J, Levy N, et al. Current issues in the use of opioids for the management of postoperative pain: a review. JAMA Surg, 2022, 157(2): 158-166.
7.	Registered Nurses’ Association of Ontario. Assessment and management of pain (3rd edition).
8.	JBI Evidence Summary. Child pain and distress: observational/behavioral or physiological approaches during medical procedures. 2021.
9.	JBI Evidence Summary. Verbal children in hospital: pain assessment. The JBI EBP Database. 2021.
10.	JBI Evidence Summary. Child pain and distress: self-report during medical procedures. The JBI EBP Database. 2021.
11.	King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain, 2011, 152(12): 2729-2738.
12.	Ostojic K, Paget S, Kyriagis M, et al. Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference, and management. Arch Phys Med Rehabil, 2020, 101(2): 213-219.
13.	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.
14.	Thapar N, Benninga MA, Crowell MD, et al. Paediatric functional abdominal pain disorders. Nat Rev Dis Primers, 2020, 6(1): 89.
15.	Tutelman PR, Chambers CT, Stinson JN, et al. Pain in children with cancer: prevalence, characteristics, and parent management. Clin J Pain, 2018, 34(3): 198-206.
16.	Stevens B, Pillai Riddell R, Oberlander TE, et al. Assessment of pain in neonates and infants. Amsterdam: Elsevier, 2007: 76-91.
17.	Andersen RD, Langius-Ekl?f A, Nakstad B, et al. The measurement properties of pediatric observational pain scales: a systematic review of reviews. Int J Nurs Stud, 2017, 73: 93-101.
18.	Pizzinato A, Liguoro I, Pusiol A, et al. Detection and assessment of postoperative pain in children with cognitive impairment: a systematic literature review and meta-analysis. Eur J Pain, 2022, 26(5): 965-979.
19.	Zieliński J, Morawska-Kochman M, Zatoński T. Pain assessment and management in children in the postoperative period: a review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children. Adv Clin Exp Med, 2020, 29(3): 365-374.
20.	von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain, 2007, 127(1-2): 140-150.
21.	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.
22.	Crellin DJ, Harrison D, Santamaria N, et al. 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.
23.	Prinsen CAC, Mokkink LB, Bouter LM, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res, 2018, 27(5): 1147-1157.
24.	Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res, 2010, 19(4): 539-549.
25.	Terwee CB, Prinsen CAC, Chiarotto A, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Qual Life Res, 2018, 27(5): 1159-1170.
26.	Mokkink LB, Elsman EBM, Terwee CB. COSMIN guideline for systematic reviews of patient-reported outcome measures version 2. 0. Qual Life Res, 2024, 33(11): 2929-2939.
27.	Elsman EBM, Mokkink LB, Terwee CB, et al. Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN for OMIs 2024. Qual Life Res, 2024, 33(8): 2029-2046.
28.	Terwee CB, Jansma EP, Riphagen II, et al. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res, 2009, 18(8): 1115-1123.
29.	Prinsen CA, Vohra S, Rose MR, et al. How to select outcome measurement instruments for outcomes included in a "Core Outcome Set" - a practical guideline. Trials, 2016, 17(1): 449.
30.	Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol, 2007, 60(1): 34-42.
31.	Alhazzani W, Guyatt G. An overview of the GRADE approach and a peek at the future. Med J Aust, 2018, 209(7): 291-292.
32.	Loeser JD, Melzack R. Pain: an overview. Lancet, 1999, 353(9164): 1607-1609.
33.	Sullivan MD. Opioid overprescribing or underprescribing after surgery. Mayo Clin Proc, 2021, 96(5): 1108-1110.
34.	Lee KKH, Siddiqui S, Heller G, et al. The prevalence and predictors of discharge opioid overprescribing in opioid-na?ve patients after breast, gynecologic, and head and neck cancer surgery: a prospective cohort study. Can J Anaesth, 2025, 72(1): 132-141.

1. Raja SN, Carr DB, Cohen M, et al. The revised international association for the study of pain definition of pain: concepts, challenges, and compromises. Pain, 2020, 161(9): 1976-1982.
2. Mekonnen ZA, Melesse DY, Kassahun HG, et al. Prevalence and contributing factors associated with postoperative pain in pediatric patients: a cross-sectional follow-up study. Perioper Care Oper Room Manag, 2021, 23: 100159.
3. Ghai B, Makkar JK, Wig J. Postoperative pain assessment in preverbal children and children with cognitive impairment. Paediatr Anaesth, 2008, 18(6): 462-477.
4. Fuller AM, Bharde S, Sikandar S. The mechanisms and management of persistent postsurgical pain. Front Pain Res (Lausanne), 2023, 4: 1154597.
5. Howard RF. Current status of pain management in children. JAMA, 2003, 290(18): 2464-2469.
6. Macintyre PE, Quinlan J, Levy N, et al. Current issues in the use of opioids for the management of postoperative pain: a review. JAMA Surg, 2022, 157(2): 158-166.
7. Registered Nurses’ Association of Ontario. Assessment and management of pain (3rd edition).
8. JBI Evidence Summary. Child pain and distress: observational/behavioral or physiological approaches during medical procedures. 2021.
9. JBI Evidence Summary. Verbal children in hospital: pain assessment. The JBI EBP Database. 2021.
10. JBI Evidence Summary. Child pain and distress: self-report during medical procedures. The JBI EBP Database. 2021.
11. King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain, 2011, 152(12): 2729-2738.
12. Ostojic K, Paget S, Kyriagis M, et al. Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference, and management. Arch Phys Med Rehabil, 2020, 101(2): 213-219.
13. 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.
14. Thapar N, Benninga MA, Crowell MD, et al. Paediatric functional abdominal pain disorders. Nat Rev Dis Primers, 2020, 6(1): 89.
15. Tutelman PR, Chambers CT, Stinson JN, et al. Pain in children with cancer: prevalence, characteristics, and parent management. Clin J Pain, 2018, 34(3): 198-206.
16. Stevens B, Pillai Riddell R, Oberlander TE, et al. Assessment of pain in neonates and infants. Amsterdam: Elsevier, 2007: 76-91.
17. Andersen RD, Langius-Ekl?f A, Nakstad B, et al. The measurement properties of pediatric observational pain scales: a systematic review of reviews. Int J Nurs Stud, 2017, 73: 93-101.
18. Pizzinato A, Liguoro I, Pusiol A, et al. Detection and assessment of postoperative pain in children with cognitive impairment: a systematic literature review and meta-analysis. Eur J Pain, 2022, 26(5): 965-979.
19. Zieliński J, Morawska-Kochman M, Zatoński T. Pain assessment and management in children in the postoperative period: a review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children. Adv Clin Exp Med, 2020, 29(3): 365-374.
20. von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain, 2007, 127(1-2): 140-150.
21. 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.
22. Crellin DJ, Harrison D, Santamaria N, et al. 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.
23. Prinsen CAC, Mokkink LB, Bouter LM, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res, 2018, 27(5): 1147-1157.
24. Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res, 2010, 19(4): 539-549.
25. Terwee CB, Prinsen CAC, Chiarotto A, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Qual Life Res, 2018, 27(5): 1159-1170.
26. Mokkink LB, Elsman EBM, Terwee CB. COSMIN guideline for systematic reviews of patient-reported outcome measures version 2. 0. Qual Life Res, 2024, 33(11): 2929-2939.
27. Elsman EBM, Mokkink LB, Terwee CB, et al. Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN for OMIs 2024. Qual Life Res, 2024, 33(8): 2029-2046.
28. Terwee CB, Jansma EP, Riphagen II, et al. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res, 2009, 18(8): 1115-1123.
29. Prinsen CA, Vohra S, Rose MR, et al. How to select outcome measurement instruments for outcomes included in a "Core Outcome Set" - a practical guideline. Trials, 2016, 17(1): 449.
30. Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol, 2007, 60(1): 34-42.
31. Alhazzani W, Guyatt G. An overview of the GRADE approach and a peek at the future. Med J Aust, 2018, 209(7): 291-292.
32. Loeser JD, Melzack R. Pain: an overview. Lancet, 1999, 353(9164): 1607-1609.
33. Sullivan MD. Opioid overprescribing or underprescribing after surgery. Mayo Clin Proc, 2021, 96(5): 1108-1110.
34. Lee KKH, Siddiqui S, Heller G, et al. The prevalence and predictors of discharge opioid overprescribing in opioid-na?ve patients after breast, gynecologic, and head and neck cancer surgery: a prospective cohort study. Can J Anaesth, 2025, 72(1): 132-141.

Chinese Journal of Evidence-Based Medicine

The measurement properties of observational pain assessment scales in pediatric opstoperative patients: a systematic review

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