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Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for Post-Op Pediatric Pain

Calculators  Multiple body systems
The CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) is a behavioral scale for evaluating postoperative pain in young children. It can be used to monitor the effectiveness of interventions for reducing the pain and discomfort.
No crying 1
Moaning 2
Crying 2
Screaming 3
Facial appearance
Smiling 0
Composed, neutral 1
Grimace 2
Verbal reaction
Positive statements 0
Not talking 1
No complains about pain 1
Complains about pain 2
Complains about pain and other subjects 2
Neutral/resting 1
Shifting 2
Tense 2
Shivering 2
Upright 2
Restrained 2
Wound evaluation
Child not touching their wound 1
Reaching for their wound 2
Touching their wound 2
Grabbing vigorously at wound 2
Arms are restrained 2
Neutral position 1
Squirming/kicking 2
Drawn up, tensed legs 2
Standing/kneeling 2
Legs are restrained 2


Measured Factor
CHEOPS score
Measured Factor Disease
  • Post Operative Pain
Measured Factor Detail
The CHEOPS is an observational scale for measuring postoperative pain in children aged 1-7 yrs. It can be used to monitor the effectiveness of interventions for reducing the pain and discomfort. It includes six categories of pain behavior, each with 3-4 levels and scores range from 4 points (no pain) to 13 points (the worst pain). CHEOPS score is obtained by addition of selected points after observing the behavioural features of the child such as
Crying:  No cry -1, Moaning -2 , Crying- 2, Scream- 3
Facial:  Smiling -0, Composed-1, Grimace-2
Child Verbal: Positive -0, None-1, Other complaints-1, Pain complaints-2, Both complaints -2
Torso: Neutral-1,Shifting- 2,Tense- 2, Shivering -2, Upright- 2, Restrained-2
Legs: Neutral-1, Squirm/kicking-2, Drawn Up/tensed-2, Standing-2, Restrained -2
Body System
Multiple body systems
Measured Factor Low Impact
  • No Pain present
Measured Factor High Impact
  • Pain

Result Interpretation

Ranges Ranges
  • Critical High: 4
  • Normal: 4
  • Normal Pediatric: 4
Result High Conditions
  • Post operative pain


Study Validation 1
This study examined concurrent self-reports of pain intensity and behavioral responses in 25 children aged 3-7 yr obtained following a major surgery. The two self-report measures were strongly and significantly correlated, and the pattern of scores over the 36-hour observation period was as expected. There was little relationship between the scores for the self-report and the behavioral measures. Many children who reported severe pain manifested few of the behavioral indicators of distress used in the CHEOPS. This behavioral response pattern may occur commonly in children experiencing pain after surgery and may limit the applicability of current behavioral scales as sole measures of pain intensity in younger children
References: 2
Study Validation 2
This study was conducted to explore the validity of pain measurement tools for use in children in the postoperative period. The general approach was to determine the extent to which a measurement tool conformed with the clinical expectations about pain in the postoperative period; namely, that pain is low prior to surgery, increases following surgery, decreases with pain medication and decreases over time following surgery. In children aged 6 months to 3 years  the CHEOPS and Observer pain scales were evaluated. In children 3-6 years of age, CHEOPS, Observer and Faces scale was used. In children 6-12 years of age the CHEOPS, Faces and visual analogue scales were studied. In all instances, each of the scales conformed with the clinical expectations about pain following surgery. In addition, these scales were correlated with each other.
References: 3
Study Validation 3
This study validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. Six behavioral pain and distress scales: Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD) were analysed in details. The results of the study indicated that despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited.
References: 4
Study Additional 1
The aims of this study were to quantify the pain and distress associated with the administration of intranasal (IN) midazolam in young children using 4 observational measures and to evaluate the degree of validity of these measures. A prospective observational pilot study was conducted in children aged 1 to 7 years requiring IN midazolam. Children were videotaped, and scores were assigned to baseline and administration phases using the Observational Scale of Behavioral Distress-Revised (OSBD-R), Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), and the Faces-Legs-Activity-Cry-Consolability (FLACC) scale. The cry duration following administration was assessed. Interrater reliability and convergent validity were determined for all 4 measures. Internal consistency and responsivity for the OSBD-R, CHEOPS, and FLACC scales were determined. The study reported that estimates of pain and distress associated with administration of IN midazolam in young children that can be used to determine desired effect sizes for trials that study interventions to treat this pain and distress. The OSBD-R, CHEOPS, and FLACC scales are suitable choices for outcome measures.
References: 5
Study Additional 2
The study compared the Non-Communicating Children's Pain Checklist Postoperative Version (NCCPC-PV), the Echelle Douleur Enfant San Salvador (DESS) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Two external observers and the child's caregiver assessed 40 children with cognitive impairment for pain levels. We assessed inter-rater agreement, correlation, dependence on knowledge of the child's behaviour, simplicity and adequacy in pain rating according to the caregiver for all three scales. The correlation between the NCCPC-PV and the DESS was strong (Spearman correlation coefficient = 0.76) and better than between each scale and the CHEOPS. Although the DESS showed better inter-rater agreement, it was more dependent on familiarity with the child and was judged more difficult to use by all observers. The NCCPC-PV was the easiest use and the most appropriate for rating the child's pain.
References: 6
Study Additional 3
The purpose of this study is to evaluate pain using 2 pediatric pain scales when removing K-wires from the distal humerus in children in the office setting. A total of 98 percutaneous smooth K-wires were removed from 47 patients who had sustained displaced supracondylar fractures of the elbow. Pain was measured using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The maximum score is 13 and the minimum score is 4 points. In addition, after K-wire removal, each child indicated on a numbered pain-face diagram (Wong-Baker FACES: a scale consisting of faces with varying emotional expressions and corresponding numbers on a scale from 0 to 5) the amount of pain that they felt. In the present manuscript, 64% of patients had little or no pain measured by the CHEOPS scale--score of ≤6 and 36% had little or no pain self-reported by the FACES scale--score of ≤1. No patient reported severe pain by the CHEOPS scores (CHEOPS 11 to 13) and only 1 patient reported having severe pain with a FACES of 5. No complications occurred. The results of this study suggest that the removal of K-wires in the office setting is safe and acceptable.
References: 7


Patrick J. McGrath
Professor, Columbia University
Research Interests: Pharmacogenetics and radiological imaging of brains to determine potential genetic response to antidepressant medications


  1. McGrath PJ Johnson G et al. CHEOPS: A behavioral scale for rating postoperative pain in children. Adv Pain Research Therapy. 1985; 9: 395-402.
  2. Beyer JE McGrath PJ Berde CB. Discordance between self-report and behavioral pain measures in children aged 3-7 years after surgery. J Pain Symptom Manage. 1990; 5: 350-356.
  3. Tyler DC, Tu A, Douthit J, Chapman CR.Toward validation of pain measurement tools for children: a pilot study. Pain. 1993 Mar;52(3):301-9.
  4. Crellin D, Sullivan TP, Babl FE, O'Sullivan R, Hutchinson A. Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting.Paediatr Anaesth. 2007 Aug;17(8):720-33.
  5. Tsze DS, Ieni M, Flores-Sanchez PL, Shen ST, Bregstein JS, OʼConnell NC, Dayan PS.Quantification of Pain and Distress Associated With Intranasal Midazolam Administration in Children and Evaluation of Validity of Four Observational Measures. Pediatr Emerg Care. 2018 May 23. doi: 10.1097/PEC.0000000000001526. [Epub ahead of print]
  6. Massaro M, Ronfani L, Ferrara G, Badina L, Giorgi R, D'Osualdo F, Taddio A, Barbi E. A comparison of three scales for measuring pain in children with cognitive impairment. Acta Paediatr. 2014 Nov;103(11):e495-500.
  7. Sorenson SM, Hennrikus W. Pain during office removal of K-wires from the elbow in children. J Pediatr Orthop. 2015 Jun;35(4):341-4.

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