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Behavioral Observational Pain Scale (BOPS) for Post-Op Pediatric Pain

The Behavioral Observational Pain Scale (BOPS) for Post-Op Pediatric Pain is used to assess pain in pediatric patients aged 1 to 7 years who are unable to self-report their pain accurately.
Facial expression
Positive/Neutral facial expression, calm, composed 0
Negative facial expression, concerned 1
Negative facial expression, warped face, grimace 2
Verbalization (saying something out loud)
General conversation, crow, laugh 0
Totally silent, weeping and/or complaining but not because of pain 1
Screaming, Crying, and/or complaining about pain 2
Body positioning
Idle, laying, relaxing with all extremities or walking, sitting 0
Uneasy movements, shifting fashion and/or touching wound or wound area 1
Lying rigid and/or pull up with legs and arms to the body 2


Measured Factor
Pain levels
Measured Factor Disease
  • Pain
Measured Factor Detail
Although pain is something that everyone is able to feel and innately understand, not everyone is able to communicate the level of pain they feel. This can cause specific populations, such as children, to go untreated for their pain. Pain is felt after surgegy. Due to a patient's instinctive ability to respond to pain, health care providers may be able to assess pain levels through observation. The Behavioral Observational Pain Scale follows this method of assessing pediatric patients aged 1 to 7 years for nonverbal cues of pain and rating specific factors on a scale of 0-2 for a total score up to 6.
Body System
Multiple body systems
Measured Factor High Impact
  • High pain levels

Result Interpretation

Ranges Ranges
  • Critical High: Scores ≥ 3
  • Normal Pediatric: Scores 0-2
Result High Conditions
  • Significant pain
Test Limitations
Since the pain scale is based on observations, the score is highly subjective to the rating by nurses or caregivers. The observational pain scale can also be enhanced by hunger, fear, anxiety, and parental separation. Nurses who rate the pain are instructed to correct any contributing factors to attempt to correct the pain scale.
References: 3


Study Validation 1
This study assessed the usefulness of the Behavioral Observational Pain Scale (BOPS) among children who had undergone a surgery. The researchers outlined the BOPS and explained the use of the scale and its point system. The study analyzed the use of the pain scale among 76 children aged 1 to 7 years at a day surgery care unit for children and a neurosurgical postoperative care unit.. Chidlren who were assessed to have pain greater than 2 were given analgesic therapy. The patients who were given analgesic therapy were assessed for pain before analgesic administration and at 15 minutes after administration, 30 minutes after administration, and 60 minutes after administration. The researchers found that there was a significantly lower pain level after analgesic therapy at each time interval (p<0.01). The BOPS scores between 15 and 60 minutes after administration of analgesia were significantly different (p < .01) . Based on the response of the children in the study, the researchers determined that the BOPS is an easy and simple tool that caregivers can use to evaluate children and improve their pain management.
References: 3
Study Additional 1
Sevoflurane is an surgical anesthetic that may cause emergence delirium (ED). This prospective randomized double-blind study examined whether an ultrasound-guided ilioinguinal/iliohypogastric nerve block could reduce the incidence of Sevoflurane-induced ED. The study included 40 boys aged 1-6 who were undergoing an inguinal hernia repair in the outpatient setting. The primary outcome was ED, which was measured using the Pediatric Anesthesia Emergence Delirium (PAED) scale at 30 minutes after emergence from general anesthesia. The secondary outcomes were postoperative pain,  which was measured using the Behavioral Observational Pain Scale (BOPS), and the amount of intra-operative Sevoflurane given. The nerve block did not significantly reduce the incidence of sevoflurane-induced ED at 30 minutes  (p=0.41) or BOPS scores. The researchers found that the ultrasound-guided ilioinguinal/iliohypogastric nerve block group required a significantly less amount of intra-operative Sevoflurane (p<0.01).
References: 4
Study Additional 2
This study used the Behavioral Observational Pain Score (BOPS) to assess pain management among pediatric patients receiving morphine after a selective dorsal rhizotomy. Due to the high levels of pain that children experience after this surgery, the researchers were looking for a method of reducing pain as needed without  giving unnecessary opioids to children. The chidlren were given continuous intrathecal (IT) morphine and bupivacaine to adequately manage pain and minimize adverse effects to the morphine. The study included 26 children. The researchers examined whether a higher dose of medication caused a difference in pain between the groups. Postoperatively 11 children received a continuous infusion of morphine 0.4 micrograms x kg(-1) x hour(-1) and bupivacaine 40 micrograms x kg(-1) x hour(-1) (low-dose group), and 15 children received a continuous infusion of morphine 0.6 micrograms x kg(-1) x hour(-1) and bupivacaine 40 micrograms x kg(-1) x hour(-1) (high-dose group). The data were analyzed with the Wilcoxon-Mann-Whitney rank sum test and Fisher's permutation test. The higher dose group had a significantly lower pain score based on the BOPS compared with the low-dose group (P=0.03). The low dose group had a 64% incidence of a BOPS pain score >2 compared to the high dose group which had 40% incidence (P=0.027). There was no statistical difference in pruritus and postoperative nausea and vomiting between the groups. The study concluded that the higher dose of continuous IT morphine 0.6 micrograms x kg(-1) x hour(-1) combined with bupivacaine 40 micrograms x kg(-1) x hour(-1) provided safe and superior analgesia after major spinal operations.
References: 5
Study Additional 3
This study analyzed the use of behavioral observation of pain to assess a child's pain when receiving a botulinin toxin. The reseachers compared the use of ultrasound to electrical stimulation to accurately target the muscle receiving the injection. The goal of this study was to assess which method of localization (ultrasound or electrical stimulation) would cause the least amount of perceived pain to the patient. The prospective study included 107 sessions of lower limb injections to decrease spasticity. The researchers assessed pain through personal report using the Visual Analog Scale (VAS) or observation by a health care team using the Face, Legs, Activity, Cry, Consolability (FLACC). Two groups of children were compared: localization by ultrasound only (60 children), detection by stimulation only or by stimulation combined with ultrasound (47 children). The Mann-Whitney and Wilcoxon tests were used to analyze the data. VAS average and FLACC average were significantly higher with detection by stimulation than with ultrasound alone: 4.5cm±2.54 versus 2.7cm±2.27; P<0.001 for VAS scale and 3.7±2.1 versus 2.7±2.3; P<0.05 for FLACC scale. The researchers concluded that ultrasound was a less painful method of localization than electrical stimulation.
References: 6


Kanwaljeet Anand
MD, PhD, Standford University, Professor of Pediatrics (Pediatric Critical Care) and of Anesthesiology, Perioperative and Pain Medicine at the Stanford University Medical Center
Kenneth Craig
The University of British Columbia, Professor Emeritus Department of Psychology, His research focused on the clinical management of pain


  1. Anand KJ, Craig KD. New perspectives on the definition of pain. Pain. 1996 Sep;67(1):3-6
  2. Hesselgard K, Larsson S, Romner B, Strömblad LG, Reinstrup P. Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain measurement in children 1-7 years of age. Pediatr Crit Care Med. 2007 Mar;8(2):102-8.
  3. Hesselgard K, Larsson S, Romner B, Strömblad LG, Reinstrup P. Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain measurement in children 1-7 years of age. Pediatr Crit Care Med. 2007 Mar;8(2):102-8.
  4. Ohashi N, Denda S, Furutani K, Yoshida T, Kamiya Y, Komura R, et al. Ultrasound-guided ilioinguinal/iliohypogastric block did not reduce emergence delirium after ambulatory pediatric inguinal hernia repair: a prospective randomized double-blind study. Surg Today. 2016 Aug;46(8):963-9.
  5. Hesselgard K, Strömblad LG, Romner B, Reinstrup P. Postoperative continuous intrathecal pain treatment in children after selective dorsal rhizotomy with bupivacaine and two different morphine doses. Paediatr Anaesth. 2006 Apr;16(4):436-43.
  6. Bayon-Mottu M, Gambart G, Deries X, Tessiot C, Richard I, Dinomais M. Pain during injections of botulinum toxin in children: Influence of the localization technique. Ann Phys Rehabil Med. 2014 Dec;57(9-10):578-86.

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