Children's Hospital of Eastern Ontario Pain Scale

Original Editor - Kapil Narale

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Introduction[edit | edit source]

The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) is a post-operative observational pain rating scale. [1][2] This scale is easy to administer [1][2] [3], and is designed for young children from ages 1-7. [1]

Administering the Scale[edit | edit source]

The scale should be administered every 3 hours, 15-20 minutes after intravenous analgesics are delivered, and 30-45 minutes after oral or rectal analgesics are delivered. [1]

The CHEOPS Scale[edit | edit source]

Here is an Outline of the CHEOPS scale. [1] As can be seen on the left column, there are six different behavioural characteristics that are assessed on the CHEOPS scale. [2]

There is also a link to a PDF version in the Resources section below.

Behavioural Characteristic Criteria Score Definition
Cry no cry +1 Child is not crying.
moaning +2 Child is moaning or quietly vocalizing silent cry.
crying +2 Child is crying, but the cry is gentle or whimpering.
scream +3 Child is in a full-lunged cry; sobbing; may be scored with complaint or without complaint.
Facial smiling 0 Score only if definite positive facial expression.
composed +1 Neutral facial expression.
grimace +2 Score only if definite negative facial expression.
Child Verbal positive 0 Child makes any positive statements or talks about other things without complaint.
none +1 Child not talking.
other complaints +1 Child complains, but not about pain, e.g., ‘I want to see mommy’ or ‘I am thirsty’.
pain complaints +2 Child complains about pain
both complaints +2 Child complains about pain and about other things, e.g., ‘It hurts’ and ‘I want my mommy’.
Torso neutral +1 Body (not limbs) is at rest; torso is inactive.
shifting +2 Body is in motion in a shifting or serpentine fashion.
tense +2 Body is arched or rigid.
shivering +2 Body is shuddering or shaking involuntarily.
upright +2 Child is in a vertical or upright position.
restrained +2 Body is restrained.
Touch not touching +1 Child is not touching or grabbing at wound.
reach +2 Child is reaching for but not touching wound.
touch +2 Child is gently touching wound or wound area.
grab +2 Child is gently touching wound or wound area.
restrained +2 Child is grabbing vigorously at wound area.
Legs neutral +1 Legs may be in any position but are relaxed; includes gentle swimming or separate-like movements.
squirm/kicking +2 Definitive uneasy or restless movements in the legs and/or striking out with foot or feet.
drawn up/tense +2 Legs tensed and/or pulled up tightly to body and kept there.
standing +2 Standing, crouching or kneeling.
restrained +2 Child’s legs are being held down.

As can be seen from the table, the minimum score is 4 and the maximum score is 13. A score ≥ 5 should be considered sufficient to administer an analgesic to the child, where a score of ≥ 8 makes it a requirement to administer an analgesic to the child. [1]

The responses are assessed in period of 5 seconds to observe the child's behavior, and then 25 seconds are allotted to record the response and score. [2]

Development and Validation[edit | edit source]

The scale was developed preceding consultations with experienced Postanesthesia Care Unit (PACU) Nurses. [2]

The first validation study, conducted by McGrath et al (1985), postoperatively, showed reliability in the CHEOPS scale. Validity was also indicated from the CHEOPS scale by comparing CHEOPS scores to the Visual Analogue Scale (VAS) pain score, comprising of similar behavioural qualities. This demonstrated a high correlation between the scores. The decrease in pain response upon analgesic application does weaken the support for validity, but is a factor taken into account. [2]

In another study, when the CHEOPS scale was compared to other pain rating scales, such as the Objective Pain Scale (OPS), used with the youngest age group (6 months to 3 years), Faces Pain Scale added for slightly older children (3 years to 6.5 years), and the self report VAS were added for the older children (6.5 years to 12 years). There was a high correlation between the various scales. All scales are seen to be valid for postoperative pain measurement for children from 6 months to 12 years. [2]

Another study by Suraseranivongse et al, comparing various pain scales within children 1-5 year old, shows that there was high validity with discriminating pain in the CHEOPS scale, in pre- and post-surgery administrations. In this case, the application of the CHEOPS scale was recommended for pain assessment in the immediate post-operative phase, for children aged 1-5 years.

Contrarily, a study by Beyer et al, found that CHEOPS scores were low after children were discharged from PACU, which correlated overtime with poor self-reports of pain. For this reason, CHEOPS may be only valid immediately post-surgery. [2]

Willis et al, note that the CHEOPS scale is the gold standard for a preverbal pain assessment. However, due to the short time window for observation and analysis, and recording of the observation, with various behaviors to assess, it can be burdensome to administer. [2]

Tarbell et al note that due to the strong correlation between the CHEOPS scale and the observer VAS scale, it may be more practical to use the VAS scale. [2]

Limitations[edit | edit source]

Since this scale is designed to be administered in the children population without any neurological conditions, it is not applicable to be administered in in the children population with any cognitive impairments. The CHEOPS scale is not suitable for these types of patients, since the level of cognitive impairment markedly impacts pain behavior more than that can be measured by the CHEOPS scale. [3]

There is moderate correlation between the CHEOPS scale, and other scales which are targeted towards children with cognitive impairments, such as NCCPC-PV (Non-Communicating Children's Pain Checklist - Postoperative Version) and DESS (Echelle Douleur Enfant San Salvador). [3]

Despite the CHEOPS scale having good validity and reliability for post-operative pain conditions, it has not been validated for assessing acute procedural pain, although it has been used, in studies, to assess procedural pain. [2]

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Zielinski Jakub, Morawska-Kochman Monika, Zatonski Tomasz. 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. Advances in Clinical and Experimental Medicine. 2020:29(3):1-10.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Crellin Dianne, Sullivan Thomas P, Babl Franz E, O'Sullivan Ronan, Hutchinson Adrian. [ Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting.] Pediatric Anesthesia. 2007: 17:720–733
  3. 3.0 3.1 3.2 Massaro Marta, Ronfani Luca, Ferrara Giovanna, Badina Laura, Giorgi Rita, D'Osualdo Flavio, Taddio Andrea, Barbie Egidio. [ A comparison of three scales for measuring pain in children with cognitive impairment.] Foundation Acta Pædiatrica. 2014: 103:495-500.