Parental Perspectives on Using the FLACC Scale for Postoperative Pain at Home After Orchiopexy

We refer to the article “The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial” published in Pediatric Anesthesia in September 2024 1. We report a supplementary analysis focusing on (1) parental perspectives on home-based use of the Face, Legs, Activity, Cry, Consolability (FLACC) scale for postoperative pain assessment and (2) agreement between FLACC and Numeric Rating Scale (NRS) scores. The plan to conduct this analysis was made a priori. Ethics approval was obtained from the Danish Data Protection Agency (ID: 1–16–02-609-20), Central Denmark Region Committees on Health Research Ethics (ID: 1–10–72-202-20), and Danish Health and Medicines Authority (ID: 2020080651). The study was conducted in accordance with the Declaration of Helsinki. Parents provided written informed consent at inclusion. The authors list follows the ICMJE authorship guidelines. Pain assessment presents a challenge in very young children, as self-report, the gold standard for pain assessment, necessitates cognitive and communicative abilities 2. Following day surgery, responsibility for pain assessment is largely transferred to parents—a task that parents often find difficult 3. This underscores the importance of providing parents with pain assessment tools that can enhance their confidence. To our knowledge, no studies have investigated parental perspectives on home-based use of the FLACC scale. The study was designed as a prospective observational study. The inclusion criteria were parents of children under 5 years scheduled for orchiopexy at Aarhus University Hospital between December 2020 and January 2024. Before discharge, parents received a written plan for at-home pain management. This plan consisted of acetaminophen (50 mg/kg/day in three to four daily doses), naproxen (5 mg/kg/day twice daily) for the first 2 days and rescue morphine (0.2 mg/kg) reserved for breakthrough pain. Parents assessed their child's pain using the NRS, followed by the FLACC scale, at four time points after discharge: the evening of the day of surgery, and the morning, midday, and evening of postoperative day 1. On the evening of postoperative day 1, parents completed a paper-based questionnaire (four items), addressing their perspectives on using the FLACC scale at home. All children were male (100.0%) with a mean age of 26.7 months ±3.9. After discharge, 12 children were administered a single dose of morphine on the day of surgery, while 6 children were administered a single dose of morphine on postoperative day 1. All parents returned the scoring sheet and questionnaire (response rate 100%). All parents found the FLACC scale either easy (proportion = 0.90, 95% CI: 0.79–0.96) or feasible (proportion = 0.10, 95% CI: 0.04–0.21) to use (Table 1A). The majority considered it useful (proportion = 0.85, 95% CI: 0.73–0.92), reported increased confidence in assessing and managing pain (proportion = 0.60, 95% CI: 0.47–0.72), and indicated willingness to use it again in the event of future surgery (proportion = 0.77, 95% CI: 0.64–0.86). In total, 239 out of 240 possible pairs of NRS and FLACC scores were obtained. The average NRS and FLACC scores were 1.4 ± 1.4 and 1.0 ± 1.7, respectively. The absolute differences ranged from 0 to ±4. In 61% (95% CI: 55%–68%) of paired samples, the absolute difference was 0, while 21% (95% CI: 16%–27%) exhibited a difference of ±1 (Table 1B). A difference of ±2 occurred in 15% of paired samples (95% CI: 11%–21%). The intraclass correlation coefficient (ICC) was 0.84 (95% CI: 0.79–0.87, p < 0.001) indicating good and significant agreement. Spearman's ρ was 0.71 (95% CI: 0.63–0.79, p < 0.001) indicating positive, moderately strong, and significant correlation. Most parents found the FLACC scale easy to use, useful, and confidence-enhancing when assessing and managing their child's postoperative pain at home. Parent-reported NRS and FLACC scores showed good agreement. Prior research has similarly reported good agreement between parent-reported NRS and FLACC scores (ICC 0.84), suggesting that the NRS provides an evaluation comparable to a formalized observational tool 4. While the NRS may be sufficient, the FLACC scale appears to offer support and reassurance rather than superior measurement accuracy. Larger studies are needed to determine which method best reflects children's actual pain and whether FLACC use improves home-based pain management. This work was supported by Novo Nordisk Fonden, NNF18C0052692, and The Foundation of Dr. Med. Edgar Schnohr and Wife Gilberte Schnohr. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.