Toddler-Preschooler Postoperative Pain Scale Research Articles

Randomized Controlled Trial of Scrotal versus Inguinal Orchidopexy on Postoperative Pain.

To compare the impact of orchidopexy approach (scrotal vs inguinal) on analgesic requirements, postoperative pain scores and complication rates. A superiority randomized controlled trial including boys 10 to 95 months of age at surgery, diagnosed with palpable undescended testis, was conducted. Patients with nonpalpable or bilateral undescended testis, previous inguinal surgery on the ipsilateral side and concurrent procedures were excluded. Block randomization with 1:1 allocation ratio and a standardized anesthesia protocol were employed. The primary outcome was postoperative pain and analgesic use in-hospital and at home using the validated pain scales FLACC (Face, Legs, Activity, Cry, and Consolability Behavioural Scale), CHEOPS (Children's Hospital of Eastern Ontario Pain Scale), PPPM (Parents Postoperative Pain Measure) and TPPPS (Toddler-Preschooler Postoperative Pain Scale). Secondary outcomes included operative time, conversion and success rates, and complications. An intention to treat protocol was followed. We enrolled 173 patients, and 12 withdrew. Of the 161 patients who completed followup, 80 had scrotal orchidopexy and 81 inguinal orchidopexy. In-hospital use of ibuprofen (p=0.02) and acetaminophen (p <0.01), as well as FLACC (p <0.01) and CHEOPS (p=0.04) pain scores were slightly higher in patients who underwent orchidopexy. No difference in mean operative time and median at-home administration of analgesic was noted. The conversion rate was 24% (19/80). Of these, 13 (68%) were canalicular testes. The overall complication rate was 4% (6/161): 1 testicular atrophy, 3 re-ascents and 2 wound infections. Of these, 5 underwent scrotal orchidopexy and 1 had inguinal orchidopexy (wound infection). Even though in-hospital mean postoperative pain scores and analgesic consumption were slightly lower for scrotal orchidopexy cases, the pain levels were mild across all scales. Median at-home analgesic use and pain scores were similar for both groups, as well as operative time and complication rates. Scrotal orchidopexy is an effective alternative to inguinal orchidopexy for low-lying undescended testis, as 68% of cases that needed conversion were canalicular testes.

Comparison of Role of Different Doses of Rectal Paracetamol with Rectal Diclofenac as Pre-emptive Analgesics for Postoperative Pain Relief in Paediatric Surgeries

Background: Post operative pain is a major concern in children particularly in developing countries were opioids are not freely available. Use of opioids is associated with side effects increasing patient discomfort and delaying patient discharge from hospital. We conducted a study comparing the use of different doses of rectal paracetamol with rectal diclofenac when used as pre-emptive analgesics on postoperative pain and recovery in paediatric patients considering the relative risk of diclofenac to increase bleeding in surgeries like tonsillectomy, cleft lip and cleft palate. Methods: Study groups included 20 patients in each. Group P40 receiving 40 mg/kg rectal paracetamol, Group P20 receiving 20 mg/kg rectal paracetamol, Group D receiving rectal diclofenac 1 mg/kg. Pain scoring was done by TPPPS (Toddler Pre-schooler postoperative pain scale) time to first need of analgesia and total dose of analgesia was noted. The rates of recovery were evaluated by using “Modified Steward Coma Scale”at 5 and 10 minutes after extubation. Results: Time of first demand of analgesic was delayed in Group-P40 as compared to Group-D and Group-P20 and difference was statically significant. TPPPS of the three studied groups varied significantly at different time intervals in favour of Group-P40. Total duration of analgesia in Group- P40 was (646±9.94) min Group- D (501±10.63) min and in Group-P20 (294±23.17) min Total analgesic requirement was also low in Group P40 and the difference between groups was significant. Conclusion: Pre-emptive high dose rectal paracetamol appears to be more effective than rectal diclofenac sodium suppository for postoperative analgesia in children without additional risk of bleeding in surgeries like tonsillectomy and cleft lip and cleft palate repair. Hence, high dose rectal paracetamol can be used as an alternative to diclofenac sodium due to higher risks of bleeding with diclofenac sodium in surgeries with increased risk of bleeding.

A Novel Distraction Technique for Pain Management during Local Anesthesia Administration in Pediatric Patients

The aim of this study was to assess the effect of an active and novel distraction technique WITAUL (Writing In The Air Using Leg) on the pain behavior observed and reported by children receiving local anesthesia injections prior to dental treatment. The study was conducted on 160 children (80 in control and 80 in intervention group) between the ages of 4- 10 years. During the administration of anesthesia the children in the control group were made to relax by means of deep breathing and those in the intervention group were taught to use the WITAUL distraction technique. the behavior of the children aged 4- 5 years was noted using the Modified Toddler- Preschooler Post operative Pain Scale (TPPPS) and that of children aged above 6 years was measured using the FACES Pain Scale-Revised (FPS-R). The use of WITAUL was found to be statistically significant (p value < 0.0001) compared to the control method in serving as a distraction and hence in managing pain during local anesthesia administration. The mean Modified TPPPS scores (4- 5 year olds) for the WITAL group was 2.46 +/- 1.752 and that of the control was 5.64 +/- 2.328. The mean FPS-R scores (6 - 10 year olds) for the WITAUL group was 3 +/- 1.748 and that of the control group was 6.26 +/- 1.858. The WITAUL technique therefore appears to be a simple and effective method of distraction during local anesthesia administration in pediatric patients.

Pre-emptive Analgesia for Postoperative Pain Relief in Children – Role of Paracetamol

This prospective clinical study was carried out in the Dept. of Anaesthesia, Analgesia and Intensive Care Medicine, BSMMU, Dhaka, during the period of May 2003 to July 2003. The study was done to emphasize the importance of giving analgesics preemptively instead of waiting for the child to complain of pain and to produce smooth recovery after surgery by decreasing immediate postoperative pain in children by a simple, safe acceptable drug. The children scheduled for tonsillectomy under general anaesthesia were recruited in this study. The analgesic efficiency of rectal paracetamol in two doses, 25 mg/kg bodywt.(Gr-P25) and 50 mg/kg. bodywt. (Gr-P50) were compared with Diclofenac Sodium suppository 1mg/ kg body weight (Gr-D) given half an hour before induction of anaesthesia. Pain scoring was done by TPPPS (Toddler Pre-schooler postoperative pain scale). Heart rate and blood pressure were stable in Gr-P50 and Gr-D. Time of first demand of analgesic was delayed in Gr-P50 and Gr-D. Total paracetamol consumption in 24 hours was less in Gr-P50(181±14.25) and Gr-D (212±25) than Gr-P25(318± 26.39). Total duration of analgesia in Gr- P50 (657±9.94) mins. and in Gr- D(502±10.63) mins. and in Gr-P25(288±23.17) mins. Pre-emptive high dose rectal paracetamol appears to be more effective than diclofenac sodium suppository for postoperative analgesia in children undergoing tonsillectomy. Journal of BSA, Vol. 18, No. 1 &amp; 2, 2005 p.9-16

Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Summary Background: Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. Methods: We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). Results: Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. Conclusions: There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.

Perioperative LA in young paediatric patients

Objective To investigate if postoperative pain/discomfort and anxiety experienced by young children who had extractions under general anaesthesia (GA) were affected by perioperative injection techniques of local anaesthetic (LA). Design A single-centre, double-blind, randomised controlled trial. Setting Conducted in 2002/2003 at the Unit of Paediatric Dentistry, Eastman Dental Hospital, London. Methods Children, aged 2-6 years scheduled for extractions under GA, were randomly assigned to receive either no LA (NLA), infiltration injection (IFL) or intraligamental injection (ITR) perioperatively. All children received analgesic suppositories after induction. Outcome measures Anxiety was scored using the Venham Picture Scale. Postoperative pain was scored using the Simplified Toddler-Preschooler Postoperative Pain Scale and supplemented with the Modified Pain/Discomfort Scale. Results Eighteen children received NLA, 17 received IFL and 19 received ITR. Postoperative pain/discomfort and anxiety scores were not significantly different during the period of recovery. On the first night, the intraligamental group had significantly lower pain scores (p = 0.012). Conclusion Postoperative pain/discomfort and anxiety during the period of recovery experienced by young children who had extractions under GA appear not to be affected by perioperative injection techniques of LA. Upon discharge, intraligamental injection appears beneficial, as it is probably well tolerated by causing less soft tissue numbness initially and thus, reduces perceived pain/discomfort.

Perioperative local anaesthetic in young paediatric patients undergoing extractions under outpatient 'short-case' general anaesthesia. A double-blind randomised controlled trial

To investigate if postoperative pain/discomfort and anxiety experienced by young children who had extractions under general anaesthesia (GA) were affected by perioperative injection techniques of local anaesthetic (LA). A single-centre, double-blind, randomised controlled trial. Conducted in 2002/2003 at the Unit of Paediatric Dentistry, Eastman Dental Hospital, London. Children, aged 2-6 years scheduled for extractions under GA, were randomly assigned to receive either no LA (NLA), infiltration injection (IFL) or intraligamental injection (ITR) perioperatively. All children received analgesic suppositories after induction. Anxiety was scored using the Venham Picture Scale. Postoperative pain was scored using the Simplified Toddler-Preschooler Postoperative Pain Scale and supplemented with the Modified Pain/Discomfort Scale. Eighteen children received NLA, 17 received IFL and 19 received ITR. Postoperative pain/discomfort and anxiety scores were not significantly different during the period of recovery. On the first night, the intraligamental group had significantly lower pain scores (p = 0.012). Postoperative pain/discomfort and anxiety during the period of recovery experienced by young children who had extractions under GA appear not to be affected by perioperative injection techniques of LA. Upon discharge, intraligamental injection appears beneficial, as it is probably well tolerated by causing less soft tissue numbness initially and thus, reduces perceived pain/discomfort.

Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.

Randomized controlled trial of the intraligamental use of a local anaesthetic (lignocaine 2%) versus controls in paediatric tooth extraction

Children still experience pain upon waking following dental extraction under general anaesthesia. Local anaesthetic has been shown to reduce this pain, but needs to be administered via a method that causes minimum injury or distress to the child. This study aims to evaluate the use of intraligamental injection of local anaesthetic, under general anaesthesia prior to the extraction of the tooth, for postoperative pain control in children aged 2-5 years. A randomized, single-blind, controlled trial of intraligamental lignocaine (2% lignocaine solution with adrenaline (epinephrine) 1 : 80 000) for primary teeth extraction under general anaesthesia was performed. Pain was scored by the investigators at 5-, 15-, 30-, and 60-min time points in the first hour using the Toddler-Preschooler Postoperative Pain Scale. Eighty-six children were recruited in the study: 42 randomized in the lignocaine treatment group and 44 in the control group. There was no significant difference (P = 0.42, Mann-Whitney U-test) in the cumulative four time point median pain score over the first hour. In the lignocaine treatment group, this was 3 (interquantile range (IQR) 0-7.5) and in the control group this was 3 (IQR: 0-10). At the 5-min time point after the child returned from recovery, the pain score in the lignocaine group (0 IQR 0-1) was statistically lower than that in the control group (0 IQR 0-5) (P = 0.023). There was no difference in the 15-, 30-, or 60-min time points. Intraligamental lignocaine used for dental extraction under general anaesthesia in young children initially causes less pain after recovery, but this difference is not sustained over the first hour after dental extraction.

Pain Relief for Children after Adenotonsillectomy

Effective pain relief following adenotonsillectomy in children remains a challenge. This study evaluated the effects of intramuscular 0.5 mg/kg ketamine, 1 mg/kg tramadol or 1 mg/kg meperidine on post-operative pain and recovery in 45 children aged 1-7 years undergoing adenotonsillectomy. Anaesthesia was induced with thiopental or sevoflurane (with succinylcholine for intubation) and was maintained with sevoflurane in oxygen and nitrous oxide. Post-operative pain was scored blind using a modified Toddler-Preschooler Post-Operative Pain Scale 30, 60, 120 and 240 min after tracheal extubation. Post-operative agitation scores were also recorded. Mean post-operative pain score was significantly higher in the tramadol-treated group compared with the meperidine-treated group 120 min after extubation. At all other time-points after extubation, mean post-operative pain scores were similar for the three treatment groups. Ketamine was associated with a significantly higher mean agitation score compared with tramadol and meperidine. We conclude that the effects of ketamine, meperidine and tramadol on post-operative pain following adenotonsillectomy in children were similar.

Validating the Derbyshire Children's Hospital Pain Tool: a pilot study.

The Derbyshire Children's Hospital Paediatric Pain Chart (DPC) is the current pain assessment tool used at the Derbyshire Children's Hospital. It was originally devised as a simple pain tool for use in the clinical area, and it is applicable for use in children of all ages within the postoperative setting. The pain assessment chart encompasses pain assessment by utilizing facial expression, body movement and verbal expression. An exploratory study was performed to define its reliability and validity. The research nurse (V.P.) assessed 40 children aged 1-5 undergoing minor and intermediate surgery comparing the Toddler Preschooler Postoperative Pain Scale and the DPC. Assessments were performed preoperatively and for 4 h postoperatively. Any analgesia administered postoperatively was recorded. All the children scored 0 preoperatively with both pain scales, thus demonstrating known groups validity. There were 116 dual assessments by the research nurse using both pain scales. There was a strong correlation (r = 0.89) demonstrating convergent validity. There was a significant correlation between 182 joint assessments by the research nurse (V.P.) and the nursing staff using the DPC (Spearmans rank correlation, 0.81) and the Cronbach alpha coefficient ranged from 0.83 to 0.98. Construct validity was demonstrated by a fall in the mean pain scores from 1.8 to 0.1 following analgesia in 19 children. This exploratory study suggests the DPC holds construct, convergent and known groups validity and is a reliable pain assessment tool for children aged 1-5 years undergoing minor and intermediate surgery.

Pain assessment following general anesthesia using the toddler preschooler postoperative pain scale: A comparative study

Study objectives To evaluate the reliability of the Toddler Preschooler Postoperative Pain Scale (TPPS) following general anesthesia as a guide to analgesic administration, and to compare the validity of this scale with other observational measures of pain in children. Design Prospective, consecutive, single-blinded observational study. Setting Operative and radiology suites at a community hospital. Patients 51 ASA physical status I and II patients aged 1 to 5 years requiring general anesthesia. Interventions Patients emerging from general anesthesia following elective otolaryngology, urology, and nonpainful radiology procedures were observed. Persons caring for the children were blinded as to the purpose of the observers. The observers recorded pain scores during recovery, before and after analgesic administration and at discharge. Measurements The TPPS was used in three sequential stages. The initial stage (n = 20) examined pain scores from emergence through discharge from hospital following myringotomy, adenoidectomy, or tonsillectomy. The second stage compared these pain scores to those observed on emergence from nonpainful diagnostic radiologic procedures (n = 11) and patients receiving caudal analgesia following urological procedures (n = 8). The third stage studied the clinical utility of the TPPS in comparison to the face, legs, activity, crying, consolability (FLACC) scale and a modified COMFORT scale using simultaneous measurements (n = 12). Main results TPPS scores varied in a categorical fashion with the intensity of pain and significantly decreased following opioid administration. All three scales reliably demonstrated pain reduction following opioid administration. Initial TPPS scores tended to be lower in patients who did not require treatment for pain. Conclusions Following procedures that are likely to produce pain, TPPS, FLACC, and the COMFORT scale, modified as a purely behavioral tool, can be recommended for postoperative assessment of patients aged 1 to 5 years. The TPPS may be preferred for the discrimination between painful and nonpainful states.

Pain in young children attending an accident and emergency department

Objectives—To assess pain in young children presenting to an accident and emergency (A&E) department. To evaluate the use of the toddler-preschooler postoperative pain scale (TPPPS) and the use of analgesia...

Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies.

Many different systems for the assessment of pain in newborns and infants have been tested for validity, rarely for reliability but never for sensitivity or specificity. We aimed to determine whether the assessment of an analgesic demand in the lower age group during the postoperative period is possible by observational methods only. In an repetitive and sequential prospective process for identifying observationable behaviour and measurable physiological parameters as indicators of a postoperative analgesic demand, 584 newborns, infants and young children were studied (7 prospective studies, 4238 observations). Twenty-six items were selected as suggested by current literature and for reasons of economy and practicability. The factor analyses resulted in a two-factorial solution with the behavioural items loading on one factor and the physiological parameters on the other (principal component analyses). The physiological parameters blood pressure, respiratory rate and heart rate were found to be unreliable and had no discriminant power to detect an analgesic demand during the postoperative period (discriminant analyses, ROC-curves). In newborns and infants, nine observational items were identified as equally selective, reliable, sensitive and specific to the assessment of postoperative analgesic demand, whereas in young children only five items could be identified (discriminant analyses, ROC-curves). For economic reasons, these five items (crying, facial expression, posture of the trunk, posture of the legs, motor restlessness) were chosen as the basis of an additional pain scale ranging from 0=no pain to 10=maximal (Children's and Infants' Postoperative Pain Scale, CHIPPS). Its internal consistency yielded values for Cronbachs' alpha with 0.92 for toddlers and 0.96 for infants. The coefficient for interrater reliability was 0.93. The scale was validated constructively by the intravenous administration of metamizol, tramadol, nalbuphine, piritramide and ketamine (repeated measures analysis of variance). The Toddler-Preschooler Postoperative Pain Scale and CHIPPS equally identified painfree situations or analgesic demand in 87.4%. In cases with definite pain, the score of CHIPPS was never below 4 points. Seventy-one toddlers gave verbal comments on their pain intensity: in 29 painfree situations the CHIPPS score was 3.0 and in 29 painful situations it was 5.7. The values for sensitivity and specificity of CHIPPS were calculated to be 0.92-0.96 and 0.74-0.95, respectively (discriminant analyses). We conclude that it is possible to determine postoperative analgesic demand in the low age group of children by using an observational system such as CHIPPS alone.

BEHAVIORAL ASPECTS OF RECOVERY FROM GENERAL ANESTHESIA IN A PEDIATRIC POST-ANESTHESIA CARE UNIT

S401 Introduction: Recovery from general anesthesia can be a tumultuous time for both patients and caretakers. The etiologies of agitated behavior during recovery from anesthesia are difficult to ascertain in young children; however, the treatment for pain differs from that for anxiety or delirium. The purpose of this pilot study was to identify characteristics of emergence behavior that differentiate emergence delirium from pain in the pediatric population. Methods: We developed a pediatric emergence agitation scale (PEAS) from adult agitation scales designed for use in nursing home settings. [1,2] The tool was observational so pre-verbal children could be assessed. The variables were: restlessness, thrashing, repetitive vocalizations, screaming, restraint, altered sensorium. Each category was rated on a scale of 1-3 (none, present, severe). The Toddler-Preschooler Postoperative Pain Scale [3] was used to assess pain and allow a test of discriminative validity of these two scales. With IRB approval, 30 patients, ages 1 - 8 years old were observed as they entered the post-anesthesia care unit (PACU). Two research assistants (RAs) independently observed each of the patients for 15 min. Patient assessment took place for one-min intervals at time 0, 5, 10, and 15 min. The RAs were blinded to the type of anesthetic used. At the conclusion of the observation period, the following data was recorded: age, sex, procedure, anesthetic used, premedication, anesthetic complications, and co-morbid states (seizures, mental retardation, ADHD). The nurses assessment of the patient (agitation, pain, both, neither) was also recorded. Statistical instruments used were Kolmogorov-Smirnov 2-sample test, and Intraclass Correlation Coefficient (ICC). Results: The study sample comprised 17 males and 13 females. Mean age was 5.9 yrs (SD 2.6 yrs). Seven (23.3%) of the patients were noted by PACU nurses to be agitated, 17 (56.7%) to be caim or asleep and 2 (6.7%) to be both agitated and in pain. There were no patients noted to be in pain but not agitated. Therefore, discriminative validity of these scales could not be assessed. The interrater reliability of the PEAS tool assessed by ICC was 0.78, and of the TPPPS was 0.77 (perfect agreement = 1.0). Both scales correlated well with a nursing assessment of agitation (TPPPS p<0.01; PEAS p<0.01). Discussion: The results of this preliminary study point out several important aspects of analysis of emergence behavior in children. First, it appears to be very difficult for an observer to differentiate between pain and agitation. Yet, there are a number of relatively recent articles remarking on the relative rates of agitation or excitement in children recovering from different anesthetics. [4,5] If these studies have not employed validated measures which discriminate between pain and agitation, the results are confounded. Second, PACU nurses may base their assessment on factors such as patient response to voice, touch, parental presence or other data not measured by current scales. Future scales will need to account for emotional state of the child and response to non-pharmacologic intervention. Thirdly, the interrater reliability of the Toddler-Preschooler Postoperative Pain Scale was supported. In summary, the preliminary analysis of the PEAS tool, although limited, serves as an initial step in the differentiation of emergence agitation behaviors from pain behaviors. Refinement of the scale may lead toward more precise evaluation and treatment of undesirable recovery behaviors in children.

Brief report: behavioral correlates of postoperative pain in toddlers and preschoolers.

To investigate the association between preoperative parent and child behaviors and postoperative pain in toddlers and preschoolers. Participants were 74 pediatric patients (59 boys, 15 girls), scheduled for inguinal hernia or hydrocele repair, and their parents. Children ranged in age from 12 to 64 months (M = 33.7 months, SD = 14.7 months). Child and parent behaviors were assessed 30 minutes prior to surgery using the Behavioral Observation Scale (BOS), a modified version of the Dyadic Prestressor Interaction Scale (Melamed & Bush, 1985. Postoperative pain was assessed using an observational measure, the Toddler-Preschooler Postoperative Pain Scale (TPPPS) (Tarbell, Cohen, & Marsh, 1992). Postoperative pain was negatively related to parents' provision of surgery-relevant information during the preoperative observation period. Preoperative interventions for young children should include information about the surgery experience.

The Toddler-Preschooler postoperative pain scale: an observational scale measuring postoperative pain in children aged 1–5. Preliminary report

This study evaluates the reliability and validity of the Toddler-Preschooler Postoperative Pain Scale (TPPPS), an observational scale developed to be a clinically useful measure of postoperative pain in children aged 1–5 years. The TPPPS consists of 7 items divided among 3 pain behavior categories: (1)Vocal pain expression; (2) Facial pain expression; and (3) Bodily pain expression. These items were derived from preliminary studies by the authors and from other observational studies of children's pain behavior. Seventy-four children between the ages of 12 and 64 months seen for inguinal hermia or hydrocele repair were the subjects of the study. Subjects were observed postoperatively for six 5-min intervals, commencing with their awakening from anesthesia, using the TPPPS. Two raters independently observed 28 of the children to assess inter-rater reliability. Validity was assessed by relating TPPPS scores to the timing and type of analgesics used, visual analog and numerical scale pain ratings made by parents and nurses, and perioperative vital signs. The TPPPS was found to possess satisfactory internal reliability (Cronbachs's alpha = 0.88). Inter-rater reliability was good, with kappas for the pain behavior items ranging from 0.53 to 0.78. Preliminary evidence of the scale's validity is provided by the sensitivity of the scale to analgesic regimen, the convergence between TPPPS scores and nurse and parent ratings of postoperative pain, and the associations found between TPPPS scores and perioperative vital signs.