FLACC Behavioral Pain Scale

The FLACC is designed and validated for children ages 2 months to 7 years. For children 8+ years, use self-report pain scales (0-10 Numeric Rating Scale, Wong-Baker Faces Pain Rating Scale if visual analog capability is limited). Exception: FLACC can be used in children up to 20 years with severe developmental delay or cognitive impairment who cannot self-report; behavioral criteria remain valid, though baseline behavior patterns require individual consideration.

FLACC is less reliable in sleeping or deeply sedated children because pain behaviors (movement, crying, facial expression) are suppressed by sleep or sedation. Assess FLACC during periods of wakefulness or light sedation. For deeply sedated patients, use validated pain scales for sedated populations (e.g., CPOT—Critical-Care Pain Observation Tool) or physiological measures (heart rate, blood pressure) as complementary assessment.

Scores 0-3 suggest mild or no pain, though score interpretation depends on baseline. If the child's baseline resting FLACC is 0 and during a procedure increases to 2-3, this indicates a pain response (change of 2-3 points is meaningful). If the child has developmental delay and baseline is 2-3, change in score is more clinically relevant than absolute score. Always compare current score to baseline.

Inconsistent scoring occurs without standardization. Train all caregivers using the FLACC training materials with video examples that show behavioral criteria (0, 1, 2 for each domain). Have caregivers practice simultaneous scoring of the same patient interactions until inter-rater reliability is demonstrated. Document baseline FLACC behavior for each patient to contextualize future scores.