This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.
Babies and toddlers cannot rate their pain on a scale of 0 to 10, and neither can many people with cognitive impairment, after surgery or in intensive care. The FLACC scale, developed at the University of Michigan by Merkel and colleagues in 1997, scores pain from observed behavior. Its name lists the five categories: Face, Legs, Activity, Cry and Consolability.
The score
| Category | 0 | 1 | 2 |
|---|---|---|---|
| Face | no particular expression or smile | occasional grimace or frown, withdrawn | frequent to constant quivering chin, clenched jaw |
| Legs | normal position or relaxed | uneasy, restless, tense | kicking or legs drawn up |
| Activity | lying quietly, moves easily | squirming, shifting, tense | arched, rigid or jerking |
| Cry | no cry | moans or whimpers, occasional complaint | crying steadily, screams or sobs |
| Consolability | content, relaxed | reassured by touch or voice, distractible | difficult to console or comfort |
Each category scores 0 to 2, for a total of 0 to 10, the same range as the self-report scales older children and adults use.
Example
A toddler with an occasional grimace, restless legs, squirming, whimpering and who calms down when held scores 1 + 1 + 1 + 1 + 0 = 4: moderate pain.
Interpretation
| FLACC | Meaning |
|---|---|
| 0 | relaxed and comfortable |
| 1 to 3 | mild discomfort |
| 4 to 6 | moderate pain |
| 7 to 10 | severe pain or discomfort |
How to observe
Watch an awake child for 1 to 5 minutes with the legs and body uncovered, then reposition the child or touch the body to look for tension. For a sleeping child, observe for at least 5 minutes. Score again after giving pain relief, at the time the medicine should be working, to check that it helps.
Who it is for
The FLACC scale was validated in children aged 2 months to 7 years after surgery. It is also used in older children and adults who cannot communicate, with a revised version (r-FLACC) for children with cognitive disability that lets parents add the child’s own pain behaviors.
Limits
- Distress from hunger, fear or separation from parents can raise the score without pain.
- Children who are very ill or sedated may show little behavior despite pain.
- The score guides treatment but does not replace a parent’s knowledge of their child or a clinician’s judgment.
Children from about 4 years old can usually use a faces scale, and from about 8 years a numeric scale, which should then be preferred.