PPP Stage 4

PPP – Stage 4 Development

In the fourth stage of the work we wanted to see

  • what sort of pain scores children would have on the Paediatric Pain Profile (PPP) when they had pain, and
  • whether scores would be different when the child had pain and when they didn’t.

we also wanted to know

  • whether the tool was sensitive enough to pick up changes in the amount of pain a child had after they were given a pain killer and
  • if parents and professionals would have similar scores to each other if they observed the same child over the same period of time.

We recruited 140 families from several health care settings in the UK. Some children were on the waiting lists to come in to hospital for surgery, whilst some attended children’s hospices or other centres for short breaks.

Baseline assessments

110 parents described at least one pain and 59 described two different pains that the children had. We found that when children were at their best their average PPP score was 11 out of a possible score of 60, with 90% of children having scores between 4 and 19. When the child had what was reported to be their most troublesome pain the average PPP score was 31, with 90% of children having scores between 19 and 45. We found that these scores went up in line with the parents’ global impression of the severity of the child’s pain.

Agreement between observers

We had 111 pairs of observations where two different people had observed the same child over the same 5 minutes and independently used the PPP scale to score the child’s behaviour. Whilst we found that agreement on some of the individual behaviours was only moderate, agreement for the total score was very good. The difference in scores between observers was not statistically significant. When we looked at just the pairs of observers that consisted of a parent and a professional, results were very similar. It didn’t seem to make any difference whether the professional thought they knew the child well or not. Using the tool they could still get scores similar to the parent’s score.

Post-operative assessments

Thirty of the children went on to have surgery and in this case the PPP was used to monitor the child’s behaviour before the operation and at intervals for five days after. We had expected that children would have most pain in the first day or two after surgery but this was not always the case. For some of the children their most severe pain seemed to occur some days after surgery, possibly at a time when their regular pain killers were being reduced.

Assessments after short acting analgesics

In another group of 34 children we monitored their behaviour before and for four hours after they had a single dose of an analgesic (a pain killer). Here we found that children’s PPP score was much higher before the analgesic was given than at each assessment after this.


We have written a paper to describe this stage in the development of the Paediatric Pain Profile. The paper is published in Developmental Medicine and Child Neurology. This is the reference:

Hunt, A., Goldman, A., Seers, K., Crichton, N., Mastroyannopoulou, K., Moffat, V., Oulton, K., Brady, M., 2004. Clinical validation of the Paediatric Pain Profile. Developmental Medicine and Child Neurology. 46 (1), 9-18.

The abstract is available by clicking on the abstract link below.

Abstract Link

Poster San Diego World Congress in Pain 2002

Link to Poster San Diego World Congress in Pain 2002



As a result of this study in Stage 4 and the previous studies in Stages 1, 2 and 3, we feel that the PPP is a valid and reliable scale for recording the pain behaviour of children with severe disabilities and for monitoring the effectiveness of methods used to relieve the children’s pain. The PPP is now available for use by parents and health care professionals and can be downloaded from this website.

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