Postoperative pain expression in preschool children: Validation of the child facial coding system

Objective: The purposes of the study were threefold: (a+) to determine whether a measurement system based on facial expression would be useful in the assessment of postoperative pain in young children; (b) to examine construct validity in terms of structure, consistency, and dynamics of the facial display; and (c) to evaluate concurrent validity in terms of associations with global judgments of the children's pain. Patients: One hundred children between the ages of 13 and 74 months were videotaped for a maximum of 1 hour after arrival in the postanesthesia care unit (PACU) at British Columbia's Children's Hospital. Outcome Measures: Videotapes were edited into 20-second blocks, randomly selected from each 2-minute time period taped during the hour following surgery, and coded for the presence or absence of 13 facial actions in the Child Facial Coding System (CFCS). Results: Facial expressions were characterized primarily by the following constellation of actions: open lips, lowered brows, a deepened nasolabial furrow, mouth stretched wide in both horizontal and vertical directions, eyes squeezed shut or squinted, and raised cheeks. A principal components analysis indicated that these actions comprised a single factor, accounting for 55% of the variance in CFCS actions. Facial action summary scores were correlated with a visual analog rating of global pain, confirming that the CFCS has convergent validity. Facial action summary scores, i.e., pain displays, were at their lowest immediately after admittance to the PACU and just before the child's release from the PACU. Conclusions: The present study demonstrated that the CFCS serves as a valid measurement tool for persistent pain in children.