Do we assess all relevant behaviours in children with cognitive impairments using the revised Face, Leg, Cry, Consolability (r-FLACC) Scale? - A Qualitative Study.

For pain assessment in cognitive impaired children, the r-FLACC (revised-Face, Legs, Activity, Cry and Consolability) scale can be used simply and effectively postoperatively in clinical practice. The aim of this study was to analyse, whether all relevant behaviours for pain assessment in cognitive impaired children are covered by the r-FLACC. In this single-centre retrospective study, we analysed all r-FLACC tools from children/adolescents with cognitive impairment who underwent surgery at our department between February 2011 and December 2024. The objective was to find out what pain behaviours in children with cognitive impairment are not included in the r-FLACC questionnaire. The study included 531 observations from 345 patients (female: 45.5%; median age 9.8 years, age range 2.6-18 years). All specific behaviours within the r-FLACC categories were selected. A total of 1.514 pain-related behaviours were added to the existing r-FLACC categories. Of these behaviours, 444 were already mentioned in the r-FLACC as pain behaviours (207 in the same category and 237 in a higher or lower category). Of the remaining 1070 behaviours, 915 could be grouped into 10 categories that address extend the existing r-FLACC categories. The remaining 155 cases were put into four new categories: aggressive behaviour, physiological reaction, specific behaviour and posture. CONCLUSIONS: The current version of the r-FLACC covers most of the pain-related behaviours in cognitive impaired children/adolescents. Additional behaviours related to 'Facial expression', 'Sound/communication' and 'Movement' might be added to the existing categories. The behaviour of aggression, which has not yet been mentioned in the r-FLACC, could be included as a new dimension in a modified r-FLACC. WHAT IS KNOWN: • While some children with cognitive impairment are able to name their pain, others cannot and are unable to quantify the severity with words. • A suitable reliable instrument to assess pain in cognitive impairemt patients is the r-FLACC (revised- Face, Legs, Activity, Cry and Consolability). WHAT IS NEW: • Ten new categories that extend the existing r-FLACC categories were found. • Three new categories could be identified: Aggressive behaviour, physiological reaction, posture.