The Toddler-Preschooler Postoperative Pain Scale (TPPPS) can be used to evaluate the pain experienced by a small child during and following a medical or surgical procedure.

Criteria for use:

(1) child 1-5 years old

(2) must occur during or after a potentially painful medical procedure or surgery

(3) child must be awake


Expressions of pain which are observed:

(1) verbal (3)

(2) facial (3)

(3) bodily movements (1)


Pain Expression



verbal pain complaint and/or cry




groan, moan, grunt


open mouth with lips pulled back at corners


squint, closed eyes


furrowed forehead, brow bulging


restless motor behavior and/or rubbing-touching painful area



• verbal pain complaint: any word, phrase, or statement that refers to pain, hurt or discomfort; it must be a statement and not a question.

• cry: tears in eyes and/or running down face and/or making sobbing sounds; this should not include crying initiated by separation from parents, unless the child is undergoing a potentially painful procedure.

• scream: acute, loud, high-pitched cry

• groan, moan, grunt: deep, low-pitched sounds; may be drawn out (moan) or abrupt (grunt)

• open mouth with lips pulled back at corners: open mouth with lips pulled back at corners, with a downward pull on the jaw

• squint, closed eyes: eyelids taut, stiff, closed or nearly closed with wrinkling of the skin at the lateral aspect of the eyes

• furrowed forehead: creasing or furrows above the eyebrows

• brow bulging: bulging between the eyebrows

• restless motor behavior: unrestrained motor activity with the body and/or head never still; may appear random or lack goal directions

• rubbing-touching painful area: touching, rubbing, massaging body part where the medical or surgical procedure was performed


Scoring Behavior


if behavior present during a 5 minute observation period


if behavior absent during a 5 minute observation period



pain score =

= SUM(number of behaviors present)



• minimum score: 0

• maximum score: 7

• According to Table V (page 278), the low pain group had a mean score of < 1.17; the moderate pain group had a mean score of 1.18 - 3.00; the high pain group had a mean score of 3.01 to 5.33.

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