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Observational Study
. 2025 Apr 18;20(4):e0320373.
doi: 10.1371/journal.pone.0320373. eCollection 2025.

Validity and reliability of the Critical-Care Pain Observation Tool (CPOT) for critically ill pediatric patients

Haruhiko Hoshino  1 , Mitsuki Ikeda  2 , Yujiro Matsuishi  3 , Yuki Enomoto  2 , Nobutake Shimojo  2 , Misaki Kotani  2 , Shunsuke Kobayashi  2 , Takahiro Kido  4 , Satomi Hayashi  1 , Yoko Furuya  1 , Yoshiaki Inoue  2
Affiliations
Observational Study

Validity and reliability of the Critical-Care Pain Observation Tool (CPOT) for critically ill pediatric patients

Haruhiko Hoshino et al. PLoS One. .

Abstract

Introduction: In some regions, critically ill pediatric and adult patients are cared for in the same intensive care unit, complicating pain assessment due to mixed age groups. To address this, it is essential to use pain scales that are applicable to a wide age range. The Critical-Care Pain Observation Tool (CPOT) was developed to assess pain in both intubated and non-intubated adult patients. However, its applicability in pediatric patients has not been confirmed. The purpose of this study was to evaluate CPOT for critically ill pediatric patients.

Methods: We conducted a prospective observational study in an eight-bed open PICU from January 2022 to March 2023. Three research nurses independently assessed pain using CPOT, the Face, Legs, Activity, Cry, Consolability (FLACC) scale, and an Observational Visual Analog Scale (VAS obs). Criterion-related and construct validity were examined using Spearman's rank correlation coefficients between CPOT, VAS obs, and FLACC. Diagnostic performance was evaluated via ROC analysis using a FLACC score ≥ 4 as the reference. CPOT scores with and without medical interventions were compared using the Mann-Whitney U test, and inter-rater reliability was assessed with Cohen's weighted κ.

Results: Ninety-one patients were observed 165 times. CPOT strongly correlated with VAS obs (Spearman's ρ = 0.87, p < 0.01) and FLACC (Spearman's ρ = 0.84, p < 0.01). At a CPOT cut-off score of 3, sensitivity was 100% and specificity was 96.7%. CPOT effectively reflected pain levels during medical interventions (p < 0.01), and inter-rater reliability was high (weighted κ = 0.89, 95% CI: 0.799-0.941).

Conclusions: This study suggests that CPOT may be a useful tool for pain assessment in pediatric patients.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Receiver Operating Characteristic (ROC) curves for the Critical-Care Pain Observation Tool (CPOT) in critically ill pediatric patients, with different CPOT cut-off scores compared against the FLACC scale score of 4 or higher as the pain criterion.
The blue line represents CPOT ≥  2 (AUC =  0.95), the yellow line represents CPOT ≥  3 (AUC =  0.98), and the green line represents CPOT ≥  4 (AUC =  0.89). The optimal CPOT cut-off score was identified as 3, with a sensitivity of 100% and a specificity of 96.7%.
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