What it is
FLACC is a behavioural (observational) pain assessment for children who cannot reliably self-report pain — typically infants and toddlers, and any non-verbal or cognitively impaired patient. The observer scores five behaviours, each from 0 to 2, for a total of 0–10. It was developed and validated for postoperative pain and has since been validated in critical-care and procedural settings.
The five domains
The acronym F-L-A-C-C names the observed behaviours:
| Domain | 0 | 1 | 2 |
|---|---|---|---|
| Face | No expression or smile | Occasional grimace/frown, withdrawn | Frequent or constant frown, clenched jaw |
| Legs | Normal 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 (awake or asleep) | Moans, whimpers, occasional complaint | Crying steadily, screams or sobs |
| Consolability | Content, relaxed | Reassured by touching/talking | Difficult to console |
Interpreting the total
- 0 — relaxed and comfortable.
- 1–3 — mild discomfort.
- 4–6 — moderate pain.
- 7–10 — severe pain.
The total is meant to drive a reassessment loop: score, treat, re-score after the analgesic’s expected onset. A persistent or rising score after intervention is itself a finding.
When to use it
Use FLACC when self-report is not feasible — validated roughly from 2 months to 7 years, and widely used beyond that age in non-verbal or developmentally disabled children. Once a child can use a self-report tool reliably (e.g. Wong-Baker faces, or a numeric scale in older children), self-report takes precedence — pain is what the patient says it is.
Worked example
A 10-month-old, two hours post-herniotomy: frequent frown (Face 2), legs drawn up (Legs 2), squirming (Activity 1), crying steadily (Cry 2), reassured briefly by the parent (Consolability 1) = 8/10, severe pain. After a weight-based analgesic dose, re-scored at 30 minutes: occasional grimace (1), relaxed legs (0), lying quietly (0), no cry (0), content (0) = 1/10. The drop documents an effective response.
Pitfalls and caveats
- It is an observed behaviour score, not a measurement of nociception. A quiet, withdrawn child in severe pain may under-score; sedation, exhaustion or “shutting down” can mask pain.
- Distress is not specific to pain — hunger, fear, a full bladder and unfamiliar surroundings all raise the score. Interpret in context.
- A revised FLACC exists for children with cognitive impairment, adding individualised behaviours supplied by carers; the generic version can under-detect pain in this group.
- Score the trend, not just the absolute. One number in isolation is far less useful than a documented before/after around an intervention.
Run it: FLACC Pain Scale
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.