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FLACC Scores


A frequent challenge in pediatrics is assessing pain in children who are non-verbal. Part of this population is unable to report the location and degree of their pain because of chronological age, i.e.. an infant or toddler. Another significant group is the population of children with cognitive impairment that is severe enough to impair their expressive language. This population includes but is not limited to children with severe cerebral palsy, developmental delay, or mental retardation.

The FLACC score has been validated for measuring postoperative pain in children with mild to severe cognitive impairment. It has also been validated for the assessment of pain secondary to surgery, trauma, cancer or other painful diseases for all pre-verbal children (including infants).

Categories for scoring include Face, Legs, Activity, Cry, and Consolability, hence the term, FLACC. Total points assigned for each category may be from zero to ten.  The numeric rating scale may be categorized into no pain, mild pain, moderate pain, and severe pain based on the 0 (representing no pain) -10 (severe pain) self-report scale.


The FLACC scale was developed by Sandra Merkel, MS, RN, Terri Voepel-Lewis, MS, RN, and Shobha Malviya, MD, at C. S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI.  Permission for use of the scale must be obtained from the Health System. 



Hicks CL et al The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain, 2003;93:173-183.

Manworren RCB, Hynan LS Clinical Validation of FLACC: Preverbal patient pain scale. Pediatric Nursing, 2003;29:140-146.

Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 293–297. 

Voepel-Lewis T et al The Reliability and validity of the face, legs, activity, cry, consolability observational tool as a measure of pain in children with cognitive impairment, Anest Analg 2002;195: 1224-1229.

Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel S (2010). "Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients". Am. J. Crit. Care19 (1): 55–61.  http://ajcc.aacnjournals.org/content/19/1/55

Chapter 8 in Pain in Infants, Children, and Adolescents, 2nd edition edited by Schechter, Berde and Yaster, and published in 2003 was a valuable source of information and references for this webpage.