How to Recognize Serious Pediatric Pain

Evaluating Pain in a Child

Pain can be difficult for a child to describe. Also, a child isn't always able to recognize a sensation as pain. An older child may be able to describe tingling, cramping, or sharp sensations and may be able to tell where and when the sensation occurs. When a young child is in pain, the signs can be hard to recognize.

Signs that may mean your child is in pain include:

• Changes in usual behavior. Your child may eat less or become fussy or restless.
• Crying, grunting, or breath-holding.
• Crying that can't be comforted.
• Facial expressions, such as a furrowed brow, a wrinkled forehead, closed eyes, or an angry appearance.
• Sleep changes, such as waking often or sleeping more or less than usual. Even children in severe pain may take short naps because they are tired.
• Body movements, such as making fists, guarding a part of the body (especially while walking), kicking, clinging, or not moving.

Some children may deny that they are in pain because they are afraid of medical procedures. For example, admitting that they are in pain might mean blood tests, which may be painful themselves. Some children may try to ignore their pain rather than take medicines, which often have discomforting side effects.

Pain isn't a visible symptom, so you and your child's treatment team will need to rely on your child as the primary source of information on the status of the pain. Only your child knows if pain is present. And experts say that children rarely pretend to have pain. 

 

How to Recognize Serious Pediatric Pain

The Urgences 2026 conference, organized by the French Society of Emergency Medicine, was held in Paris in early June. To avoid overlooking serious problems, speakers at the session “When to Investigate Pain: Red Flags for Pain in Children” highlighted the warning signs to look for based on the location of pediatric pain.

Hip Pain Red Flags

As noted by Guillaume Lopin , an emergency physician and pediatrician at Toulouse University Hospital, Toulouse, France, about half of the hip pain cases in pediatric emergency departments are due to acute transient synovitis (TS). Other causes include osteoarticular infection, slipped capital femoral epiphysis, primary osteochondritis dissecans (OCD), and, less commonly, tumors, leukemia, abuse, or hemophilia.

Key Points

• Hip pain: TS only if age 3-9, WB+, monoarticular, well-appearing, favorable course.
• Hip red flags: fever, total functional loss, insomnia, chronicity, <3 y, >10 y, multi-joint.
• Abdominal pain: fixed nonperiumbilical pain, insomnia, progression, no pain-free intervals → surgical workup.
• Appendicitis: WBC/neutrophils + PAS; US for intermediate risk; avoid CT radiation.
• Chest pain: <5% cardiac; exertional/sudden/constrictive pain, abnormal exam/ECG, ↑troponin if red flags.\
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  Hip Pain Red Flags

  As noted by Guillaume Lopin , an emergency physician and pediatrician at Toulouse University Hospital, Toulouse, France, about half of the hip pain cases in pediatric emergency departments are due to acute transient synovitis (TS). Other causes include osteoarticular infection, slipped capital femoral epiphysis, primary osteochondritis dissecans (OCD), and, less commonly, tumors, leukemia, abuse, or hemophilia.

•  TS should be considered only if all criteria are met: age between 3 and 9 years, typical symptoms and physical examination findings, the ability to bear weight on the affected leg, preserved overall condition, monoarticular involvement, and a favorable prognosis.
• The red flags are as follows: 

• High fever may signal a true medical emergency, including septic arthritis, which typically presents with severe pain, marked loss of function, and joint effusion. A moderate fever may point to osteomyelitis, which usually causes less intense pain and less marked functional limitation, with no effusion and a normal initial x-ray.
• In children younger than 3 years, obtaining a reliable history and performing a thorough physical examination can be difficult, and the initial signs are often nonspecific. In this age group, the condition may represent juvenile idiopathic arthritis (JIA), an unreported injury, or abuse; less commonly, it may be congenital dislocation or hemophilia. In children older than 10 years, a stress fracture should be considered and investigated.
• With total functional impairment or hyperalgesia, septic arthritis should be considered, along with unstable effusion, fracture in children younger than 3 years, abuse, or a spontaneous pathologic fracture. In cases of pain severe enough to cause insomnia, consider osteoarthritis, acute leukemia, a bone tumor, or intra-abdominal infection such as psoitis.
• With chronicity, consider OCD, stable slipped capital femoral epiphysis.
• If another joint is affected, consider viral arthritis, reactive arthritis, or JIA, and consult a pediatric rheumatologist.

In all cases, clinicians should avoid defaulting to easy explanation such as somatization or referred pain, including tendinitis, growing pains, functional pain, or an adolescent crisis, Lopin concluded.

Abdominal Pain Red Flags

Romain Guedj , MD, PhD, a pediatrician in the Department of Emergency Pediatrics, Trousseau University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France, reassured clinicians, saying not to hesitate to administer level 2 or 3 analgesics as this will not interfere with the clinical examination.

He then outlined the potential surgical causes, including intestinal obstruction, appendicitis or peritonitis, testicular or ovarian torsion, and an abdominal mass, possibly a tumor.

“The pain is typically nonperiumbilical, fixed in location, causes insomnia, worsens over time, and is not associated withpain-free intervals. We would then proceed with laboratory testing and, if indicated, ultrasound,” Guedj said.

Although appendicitis is the most common pediatric surgical emergency, it can be difficult to diagnose. The location of pain depends on the position of the cecum, and clinical findings such as fever, localized tenderness, psoitis, or pain when hopping on one foot are not always highly sensitive or specific.

In laboratory tests, white blood cells — and in particular neutrophils — are highly specific. The pediatrician recommends calculating the Pediatric Appendicitis Score and performing an ultrasound in cases of intermediate risk. Avoid CT scans in children because they expose them to radiation.

In most cases, no definitive diagnosis can be made. The pediatrician therefore advises telling parents that there are no alarming signs at the time of the visit, that the cause of the child’s pain is not yet clear, but that this is common in cases of abdominal pain and often resolves on its own. Parents should also be instructed to return for reevaluation if the pain worsens, keeps the child awake at night, persists, or if other symptoms develop.

The underlying cause may also be medical, involving the digestive system, liver, kidneys, urinary tract, or genital organs. It may likewise reflect an infection, such as an ear, nose, and throat or pulmonary infection; rheumatic purpura; or an endocrine disorder, including diabetic ketoacidosis or acute renal failure.

Chest Pain Red Flags

Common causes of chest pain in pediatric emergency departments include asthma attacks, parietal pain, and chest trauma: fewer than 5% of pediatric chest pain cases are of cardiac origin, according to Alexis Louvel , an emergency medicine physician at Rouen University Hospital Center, Rouen, France.

These cases may involve coronary artery anomalies, which can be difficult to diagnose but typically present with exertional pain, aortic dissection, or pneumothorax, which causes sudden, severe pain. Other possibilities include myocarditis, in which patients experience constricting pain, or pulmonary embolism, where a risk factor is identified in 95% of the cases.

The red flags are as follows:

• During the medical history, clinicians should note pain or discomfort with exertion, sudden-onset pain that reaches maximal intensity immediately, constrictive pain, pain severe enough to disrupt sleep, or a viral or postviral context.
• During the physical examination, although specificity is limited, clinicians should look for unexplained tachycardia, hypotension, low oxygen saturation, asymmetric vesicular breath sounds, a pericardial friction rub, a new-onset murmur — in which case, the parents should be questioned and the medical record reviewed — and hepatomegaly.
• On testing, an abnormal ECG.
• In laboratory testing, a positive troponin result should be considered, but only if one of the warning signs listed above is present.

Finally, for headaches in children presenting to the emergency department, the French National Authority for Health guideline on Headaches in Children and Adolescents: Relevance of Imaging remains the preferred reference. Headaches due to a serious underlying medical condition are rare — fewer than 2% are linked to a brain tumor — and are almost always associated with a clinical abnormality.

This story was translated from Medscape’s French edition.