Child Health · Pain
FLACC Pain Scale — Assessing Child Pain
How to assess pain in a child who can't tell you. FLACC scale: Face, Legs, Activity, Cry, Consolability, scored 0-10. Treatment thresholds, safe paracetamol / ibuprofen doses, when to seek urgent help. For ages 2 months-7 years. Merkel 1997.
Last reviewed 2 June 2026
FLACC pain scale — 2 mo to 7 yr
Face · Legs · Activity · Cry · Consolability
Score all 5 items to see total.
Educational tool only — not medical advice. FLACC is validated for pre-verbal children (2 months to 7 years) and for older children with cognitive impairment. For verbal children able to self-report, use a developmentally appropriate self-report tool (Faces Pain Scale-Revised for ages 4-12, numeric rating scale for 8+).
What does this mean?
The FLACC (Face, Legs, Activity, Cry, Consolability — Merkel 1997) lets a clinician or parent score pain in a child too young to self-report. Cut-offs: 1–3 mild, 4–6 moderate, 7–10 severe. For acute pain in this age range, treatment goal is usually a sustained score < 4. Non-pharmacological measures help a lot: kangaroo/cuddle, swaddling, breastfeeding, sucrose drops (Stevens 2016 Cochrane: sucrose halves cry duration for needle procedures in infants), distraction, and parent presence. Pharmacological: weight-based paracetamol/ibuprofen first line; opioids reserved for moderate–severe surgical pain with careful monitoring. Under-treatment of children’s pain remains common — clinicians historically under-recognise it because pre-verbal kids can’t verbalise severity. Tools like FLACC reduce that gap. Use the same tool consistently across the same child so the trend is interpretable.
What is the FLACC scale?
Pain assessment for children 2 months to 7 years (and older children unable to self-report). 5 categories scored 0-2 each, total 0-10.
- Face
- Legs
- Activity
- Cry
- Consolability
Score interpretation
- 0: no pain.
- 1-3: mild — comfort + paracetamol.
- 4-6: moderate — paracetamol + ibuprofen.
- 7-10: severe — prompt strong analgesia + medical review.
Recheck after intervention (15-30 min).
Safe child analgesia
- Paracetamol: 15 mg/kg every 4-6 hours; max 60 mg/kg/24h.
- Ibuprofen: 5-10 mg/kg every 6-8 hours; max 30 mg/kg/24h.
- Combined for moderate-severe pain works well.
- Don’t use: aspirin (<16 yrs — Reye’s); OTC codeine <12 yrs.
Non-pharmacological relief
- Distraction (TV, games, bubbles).
- Comfort (cuddles, breastfeeding).
- Heat / cold packs.
- Massage.
- Deep breathing.
- Imagery / hypnotherapy (older children).
- Music.
- Parent presence.
When to take child to A&E
- Pain not responding to paracetamol + ibuprofen.
- Pain + signs of serious illness (fever, lethargy).
- Visible injury (suspected fracture).
- Headache + neurological signs.
- Chest pain.
- Severe abdominal pain (with vomiting, fever, blood).
- Testicular pain in boys (torsion emergency).
- Limb pain + can’t bear weight.
Modified FLACC for autism / developmental delay
Standard FLACC may misinterpret typical autistic behaviours. r-FLACC (revised) adjusts for individual baseline. Parents know cues best.
Vaccine pain management for babies
- Breastfeeding during injection.
- Sucrose drops for <6 months not breastfeeding.
- Distraction.
- Alternate injection sites if multiple.
- Parent holds + comforts.
Different scenarios
Scenario 1: 18-month-old post-ear infection, FLACC 5
Moderate. Paracetamol + ibuprofen alternating. Recheck 30 min — should improve.
Scenario 2: Post-surgery 4-year-old, FLACC 8
Severe. Hospital protocol — stronger analgesia. Notify nursing staff immediately.
Scenario 3: 2-year-old non-verbal autism, behaviour change
r-FLACC adjusted. Investigate cause — ear, dental, urinary, fracture. Pain often under-recognised.
Scenario 4: Baby fever + crying + FLACC 6
Paracetamol for fever + pain. Recheck. If not improving in 24h or warning signs, see GP.
Scenario 5: Newborn heel-prick blood test
Use NIPS (not FLACC). Breastfeeding or sucrose drops before; skin-to-skin during.
Care guidance — child pain
- FLACC for 2 months-7 years.
- NIPS for newborns.
- FACES / numeric for older / verbal children.
- Combine observational + self-report when possible.
- Paracetamol + ibuprofen safe + effective for most.
- Non-drug methods alongside.
- Recheck after interventions.
- Red flags → same-day medical review.
- Chronic pain — multimodal management.
- Parent intuition matters — trust it.
Sources
- Merkel S, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997.
- NICE NG193. Chronic pain in over 16s (frameworks apply to paediatrics).
- RCPCH. Position statement on the prevention and management of pain in children.
Frequently asked questions
What is the FLACC pain scale?
FLACC = FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY. Pain assessment tool for children 2 months to 7 years (and older children unable to self-report). 5 categories scored 0-2 each → TOTAL 0-10. Created by Merkel et al. 1997. Validated extensively. USED in: hospital paediatric wards, A&E, post-surgical recovery, primary care, parents at home. STRENGTHS: simple, fast, reliable across observers.
How is FLACC scored?
(1) FACE: 0 = no expression; 1 = occasional grimace, withdrawn; 2 = frequent frown, clenched jaw, quivering chin. (2) LEGS: 0 = normal position; 1 = uneasy, restless, tense; 2 = kicking or drawn up. (3) ACTIVITY: 0 = lying quietly; 1 = squirming, tense; 2 = arched, rigid, jerking. (4) CRY: 0 = no cry; 1 = moans, occasional complaint; 2 = constant crying, sobs. (5) CONSOLABILITY: 0 = content, relaxed; 1 = reassured by touch / hug / talk; 2 = inconsolable. SUM = 0-10.
What do FLACC scores mean?
0 = NO pain. 1-3 = MILD pain — may benefit from comfort + paracetamol. 4-6 = MODERATE — needs analgesia (paracetamol + ibuprofen, sometimes stronger). 7-10 = SEVERE — needs prompt strong analgesia + immediate review. THRESHOLDS guide treatment decisions. REPEAT assessment after interventions (15-30 min) to check response.
When to use FLACC?
ANY time you're unsure if child in pain + can't tell you directly: (1) PRE-VERBAL (under 2-3); (2) DEVELOPMENTAL delay; (3) NON-VERBAL conditions; (4) UNDER ANAESTHESIA recovery; (5) SEDATED on ICU; (6) AUTISM (modified FLACC-r); (7) POSTOPERATIVE; (8) ILL CHILD in A&E. AT HOME: parents can use to guide whether analgesia / GP / A&E needed. NOT for self-reporting older children (use FACES scale or 0-10 numeric for 4+).
What painkillers can I give my child?
(1) PARACETAMOL (acetaminophen) — first-line. 15 mg/kg every 4-6 hours; max 60 mg/kg/24h. (2) IBUPROFEN — second-line OR alongside paracetamol. 5-10 mg/kg every 6-8 hours; max 30 mg/kg/24h. Avoid <6 months unless prescribed. AVOID if dehydrated, kidney issues, asthma sensitive. (3) BOTH TOGETHER for moderate-severe pain — alternating doses works well. (4) DON'T USE: aspirin (Reye's syndrome <16 yrs); over-the-counter codeine (<12 yrs, restricted in older). PRESCRIPTION opioids: paediatric specialist only.
How does FLACC differ from other pain scales?
FLACC = OBSERVATIONAL (you watch child). FACES = SELF-REPORT (child points to face matching their pain). NRS / VAS = NUMERIC 0-10 (older children, adolescents). N-PASS = NEONATAL pain + sedation. NIPS = NEONATAL infant pain. CRIES = ages 0-3. PAEDIATRIC pain assessment should use APPROPRIATE scale for AGE + COMMUNICATION ABILITY. CLINICIANS often use 2 scales (observational + self-report if possible).
What about non-pain causes of distress?
BEHAVIOURAL distress can mimic pain in young children: hunger, tiredness, fear, separation anxiety, illness, fever, frustration, sensory overload. CONTEXT matters: recent fall? Recent procedure? Known illness? Recent feed/sleep? FEVER plus high FLACC: could be pain from infection. STILL TREAT distress with comfort + analgesia if uncertain — paracetamol is safe + treats both pain + fever. RECHECK after intervention.
Should I trust FLACC for autism / developmental delay?
MODIFIED FLACC (r-FLACC for revised) — adjusts for individual baseline behaviours common in some children with autism / developmental delay. ALSO known FLACC behaviour can be misleading — non-verbal autistic child may not show typical pain expression. PARENTS know individual cues best. SOMETIMES need additional clinical assessment + investigation if behavioural changes occur. CRPS / pain in autism often under-recognised — vigilance important.
Can I use FLACC at home?
YES — simple enough for parents. (1) Observe child in current state; (2) Score each category 0-2; (3) Sum total 0-10. PROVIDES objective measure to inform: give analgesia? call GP? A&E? AFTER PARACETAMOL: recheck in 30 min — score should fall. WORKS WELL for postoperative, viral illness, ear infection, suspected pain causes. RECORD scores in pain diary if ongoing.
When should I take my child to A&E for pain?
RED FLAGS regardless of FLACC: (1) Severe pain not responding to first-line analgesia (FLACC 7+ after paracetamol); (2) Pain + signs of serious illness (fever, lethargy, poor feeding, rash); (3) Pain + visible injury (suspected fracture, severe wound); (4) Headache + neurological signs; (5) Chest pain; (6) Severe abdominal pain (especially with vomiting, fever, blood in stool); (7) Testicular pain in boys (torsion emergency); (8) Limb pain + can't bear weight; (9) Recurrent severe migraines. CALL 111 / 999 / A&E.
What about chronic pain in children?
CHRONIC PAIN (>3 months) under-recognised in children. CAUSES: juvenile idiopathic arthritis, abdominal migraine, IBS, headaches, growing pains (controversial), neuropathic pain, post-viral fatigue. ASSESSMENT: holistic — physical, psychological, social factors. TREATMENT multimodal: physio, psychology (CBT), pain neuroscience education, medication selectively, family education. PAEDIATRIC PAIN clinics in tertiary centres. NICE NG193 (chronic primary pain) supports multimodal approach.
Can children develop opioid dependence?
PRESCRIPTION opioids carry risks even in children. AVOIDED in routine paediatric pain. WHEN USED: post-surgical, oncology, end-of-life, severe trauma. SHORT COURSES only; weaning plans. TOLERANCE + dependence biological — not character flaw. NHS GUIDANCE: limit opioid use; alternatives + multimodal pain management preferred. PARENTAL EDUCATION about safe storage if opioids prescribed (lock away; keep away from siblings).
What's non-pharmacological pain relief for children?
(1) DISTRACTION — TV, games, books, bubbles, video calls; (2) COMFORT — cuddles, breastfeeding (infants), comfort items; (3) HEAT / COLD packs; (4) MASSAGE; (5) DEEP BREATHING; (6) IMAGERY / hypnotherapy for older children; (7) MUSIC; (8) PARENT presence; (9) POSITIONING; (10) FOR INFANTS: skin-to-skin, sweet sucrose drops, breastfeeding during procedures (heel pricks, vaccines). COMBINE with analgesia for moderate-severe pain.
Should babies experience pain during routine vaccines?
YES — and there's good evidence-based management: (1) BREASTFEEDING during injection — reduces crying significantly; (2) SUCROSE (oral sugar solution 24%) — for infants under 6 months who can't breastfeed; (3) DISTRACTION; (4) AVOID multiple injections same site — alternate; (5) PARENT HOLDS securely + comforts; (6) TOPICAL anaesthetic cream (Emla) for some scenarios (not routine for vaccines per UK NHS). LONGER-TERM: babies who experience well-managed early procedures don't develop adverse pain responses.
How does this relate to other calculators on BumpBites?
Companion: /calculators/nips-pain neonatal scale; /calculators/baby-fever; /calculators/baby-teething (pain management); /calculators/pediatric-dose for safe medication; /calculators/vaccine-reaction; /calculators/baby-colic.