Faces Pain Scale (Wong-Baker)
- Fysiobasen
- Sep 16
- 3 min read
The Faces Pain Scale (FPS) is a self-report tool designed to measure a child’s personal perception of pain. The most widely used version is the Wong-Baker Faces Pain Scale, consisting of six illustrated faces expressing increasing levels of discomfort – from a smiling face (0) to a crying face (10)¹.
Its purpose is to provide a simple and intuitive method for children to communicate pain intensity, without requiring advanced verbal or numerical understanding. It is particularly useful for children aged 3 years and older, when verbal descriptions of pain may be limited².
Target Group and Use
The scale is suitable for children from the age of three, as children at this stage can recognize facial expressions and relate them to their own emotions³.
Procedure:
The child is shown a series of faces ranging from smiling to crying.
They are asked to point to the face that best represents how much pain they feel.
The chosen face corresponds to a number on the scale from 0 to 10, in increments of 2 (0–2–4–6–8–10).
No additional explanation should be necessary⁴.
The scale requires little instruction and can be administered by healthcare professionals, parents, or caregivers. It is especially valuable in acute pain assessment, postoperative monitoring, or daily pain tracking in pediatric settings.
Advantages
Non-verbal: Ideal for children with limited language or communication skills.
Intuitive: Facial expressions reduce cognitive load.
Time-efficient: Quick to use in emergency departments or pre-hospital care.
Flexible: Usable by both clinicians and caregivers.
Children often prefer face-based pain scales over numbers or words and demonstrate consistent choices when relating a face to their pain experience¹.
Limitations and Challenges
Despite its simplicity, several limitations exist:
Children under 10 may confuse emotions such as fear, anxiety, or sadness with pain⁵.
Garra et al. (2013): Some children selected the crying face post-surgery even when reporting mild pain, showing emotional reactions may bias interpretation².
Some children choose the smiling face despite significant discomfort, possibly due to misunderstanding or reluctance to complain².
Parents and healthcare providers may misinterpret children’s selections – studies show discrepancies between caregiver and child reports when using the same scale⁵.
➡️ Key point: FPS must be used as the child’s self-report, not interpreted by adults.
Scoring System
0: No pain (smiling face)
2–4–6–8: Increasing levels of pain intensity (progressively distressed expressions)
10: Worst pain imaginable (crying face with tears)⁴
The FPS is an ordinal tool – scores reflect increasing intensity but should not be treated as linear or interval data⁴.
Validity and Clinical Utility
The Faces Pain Scale is validated for both acute and chronic pain in children¹. Studies show strong correlation with the Visual Analogue Scale (VAS) in children over 5 years³.
Consistency: Stable results across repeated use.
Ease of use: Practical in fast-paced clinical settings.
Sensitivity to change: Detects shifts in pain before and after treatment.
By giving children an accessible way to self-report, FPS supports timely pain relief and improved participation in care.
Clinical Recommendations
❌ Do not use with children who have severe cognitive impairments – observational tools such as FLACC may be more appropriate.
❌ Do not interpret the chosen face as a “social expression.” Always ask the child what the face means to them.
❌ Do not allow caregivers to override the child’s choice – FPS is designed as a self-report only.
When in doubt, FPS should be combined with behavioral observation to strengthen interpretation and guide clinical decision-making.
Summary
The Wong-Baker Faces Pain Scale is a valid and intuitive method for self-reported pain in children as young as 3 years¹.
It reduces cognitive demands and encourages active participation in care².
Must be used strictly as the child’s own report – not adult interpretation⁵.
✅ Used correctly, FPS is a highly effective tool for assessing pediatric pain in acute, postoperative, and chronic care settings.
Sources:
Bieri Daiva, Reeve Robert A, Champion G. David, Addicoat Louise, Ziegler John B. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial Validation, and preliminary investigation for ratio scale properties. Pain. 1990:41:139-150.
Garra Gregory, Singer Adam J, Domingo Anna, Thode Henry C. The Wong-Baker Pain FACES Scale Measures Pain, Not Fear. Pediatric Emergency Care. 2013:29(1):17-20.
Garra Gergory, Singer Adam J, Taira Breena R, Chohan Jasmin, Cardoz Hiran, Chisena Ernest, Thode Henry C. Validation of the Wong-Baker FACES Pain Rating Scale in Pediatric Emergency Department Patients. Academic Emergency Medicine. 2010:17(1):50-54.
Zielinski Jakub, Morawska-Kochman Monika, Zatonski Tomasz. Pain assessment and management in children in the postoperative period: A review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children. Advances in Clinical and Experimental Medicine. 2020:29(3):1-10.
Lawson Simone L, Hogg Melanie M, Moore Charity G, Anderson William E, Osipoff Paul S, Runyon Michael S, Reynolds Stacy L. Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale–Revised. Pediatric Emergency Care. 2021:37(12):e950-e954.
