A comparison of pain assessment by physicians, parents and children in an outpatient setting

Emerg Med J. 2017 Mar;34(3):138-144. doi: 10.1136/emermed-2016-205825. Epub 2016 Oct 25.


Introduction: Our objective was to compare pain assessments by patients, parents and physicians in children with different medical conditions, and analyse how this affected the physicians' administration of pain relief.

Patients and methods: This cross-sectional study involved 243 children aged 3-15 years treated at Bergen Accident and Emergency Department (ED) in 2011. The child patient's pain intensity was measured using age-adapted scales while parents and physicians did independent numeric rating scale (NRS) assessments.

Results: Physicians assessed the child's mean pain to be NRS=3.2 (SD 2.0), parents: NRS=4.8 (SD 2.2) and children: NRS=5.5 (SD 2.4). The overall child-parent agreement was moderate (Cohen's weighted κ=0.55), but low between child-physician (κ=0.12) and parent-physician (κ=0.17). Physicians significantly underestimated pain in all paediatric patients ≥3 years old and in all categories of medical conditions. However, the difference in pain assessment between child and physician was significantly lower for fractures (NRS=1.2; 95% CI 0.5 to 2.0) compared to wounds (NRS=3.4; CI 2.2 to 4.5; p=0.001), infections (NRS=3.1; CI 2.2 to 4.0; p=0.002) and soft tissue injuries (NRS=2.4; CI 1.9 to 2.9; p=0.007). The physicians' pain assessment improved with increasing levels of pain, but only 42.1% of children with severe pain (NRS≥7) received pain relief.

Conclusions: Paediatric pain was significantly underestimated by ED physicians. In the absence of a self-report from the child, parents' evaluation should be listened to. Despite improved pain assessments in children with fractures and when pain was perceived to be severe, it is worrying that barely half of the children with severe pain received analgesics in the ED.

Keywords: clinical assessment; emergency department management; fractures and dislocations; paediatrics, paediatric injury; pain management.

MeSH terms

  • Adolescent
  • Analgesics / therapeutic use
  • Child
  • Child, Preschool
  • Cross-Sectional Studies
  • Emergency Service, Hospital / organization & administration
  • Female
  • Humans
  • Male
  • Norway
  • Outpatients / psychology
  • Pain Management / methods
  • Pain Management / standards
  • Pain Measurement / standards*
  • Parents / psychology*
  • Perception*
  • Physicians / psychology*
  • Physicians / standards
  • Self Report / standards*
  • Surveys and Questionnaires
  • Workforce


  • Analgesics