Barriers and facilitators of pain management in children: a scoping review

Abstract

Effective pain management in pediatric care is essential to safeguarding the well-being and recovery of children; however, numerous barriers impede optimal pain relief. Identifying and understanding these barriers, along with facilitators that enhance care, is crucial for advancing clinical practices and patient outcomes. This study presented a comprehensive scoping review of the barriers and facilitators to pediatric pain management, synthesizing findings from research published between 2014 and 2024 to inform evidence-based clinical strategies. A systematic search was conducted using key terms such as “pain management,” “children,” “barriers,” and “facilitators” across PubMed, ProQuest, Web of Science, and Scopus databases, focusing on English-language articles.

The review identified several key barriers to effective pediatric pain management, including deficits in provider knowledge and training, organizational and structural limitations, medication and prescription challenges, environmental and situational constraints, communication gaps, technological barriers, parental factors, policy and systemic issues, logistical difficulties, and context-specific limitations. Conversely, facilitators emerged as essential components for improvement, including professional initiatives by healthcare providers, structural and organizational enhancements, family engagement, targeted educational and training interventions, technological innovations, procedural improvements, remote and virtual care adaptations, policy enhancements, and supportive interprofessional relationships.

Addressing these multifaceted barriers requires a holistic approach that integrates enhanced education, organizational support, technological development, and active family involvement. Implementing these facilitators has the potential to significantly improve pain management practices, promoting a higher standard of care and quality of life for pediatric patients.

Introduction

Pain management remains a significant challenge in pediatric healthcare. Many children still experience inadequate pain relief during medical procedures and hospitalizations. Pain management in children is often described as an unpleasant experience due to the difficulty in pain assessment and communication by children, leading to inappropriate treatment [1]. Up to 80% of hospitalized children report experiencing pain during their stay, with nearly two-thirds reporting moderate to severe levels of pain, yet management remains frequently suboptimal [2]. A recent study by Andersson and colleagues found that 72% of children and adolescents experienced moderate to severe pain within the past 24 h, with 43% reporting additional procedural pain alongside their primary condition [3]. In recognition of this ongoing issue, the WHO has emphasized the need for standardized guidelines in pediatric pain management to ensure high-quality care [3]. However, despite such guidelines, unrelieved pain persists across various clinical settings.

Children differ significantly from adults in their experience and expression of pain due to distinct physiological and psychological factors. Unlike adults, children often struggle to convey their pain due to developmental stages, communication challenges, and heightened anxiety during medical procedures [4, 5]. As a result, managing pediatric pain demands a nuanced approach that considers these unique developmental and cultural factors. Pediatric patients, particularly infants and young children, frequently receive inadequate pain management compared to older children and adults, underscoring the ongoing risk of undertreated pain within this vulnerable population [1, 6].

Effective pain management is crucial for children, as it directly influences their immediate comfort, long-term health, psychological well-being, and overall quality of life. Research has shown that inadequately managed pain in childhood can lead to long-term consequences, including hyperalgesia and chronic pain in later years, as well as an increased risk for anxiety and depressive disorders [7,8,9]. For families, the experience of unrelieved pain can lead to frustration, helplessness, and unpreparedness in managing pain post-discharge [10]. Furthermore, healthcare providers also face adverse effects, as ineffective pain management in pediatric care can contribute to moral distress, career dissatisfaction, and burnout [11]. Additionally, suboptimal pain management often results in prolonged hospitalizations, increased interventions, and long-term complications that collectively raise healthcare costs [3, 12]. Addressing these issues requires a comprehensive understanding of the barriers and facilitators that influence pain management practices in pediatric care.

Despite the development of evidence-based guidelines, there is a substantial gap between research and clinical application in pediatric pain management [7]. Several factors contribute to this disparity, including difficulties in accurately assessing pediatric pain, limited familiarity with appropriate pain assessment tools, and concerns regarding the side effects of analgesics. Inadequate provider knowledge and attitudes about pediatric pain management further complicate care delivery, highlighting the need for targeted interventions [1, 13, 14]. A comprehensive literature review is therefore essential to identify both barriers and facilitators in pediatric pain management, providing a basis for strategies that can bridge this gap and improve clinical practices [15].

To address the complex and often contentious issues surrounding pediatric pain management, this study presents a model specifically designed from the findings of this comprehensive review. This model integrates key facilitators and barriers identified in the literature to support informed clinical and therapeutic decisions in pediatric pain management. Current research highlights various factors influencing pain management efficacy, such as patient demographics, type of pain, and clinician expertise [16]. Furthermore, existing studies identify significant barriers, including limited knowledge among healthcare providers and the absence of standardized guidelines, which can hinder effective management. Conversely, factors such as continuous education and robust interprofessional collaboration are recognized as facilitators that contribute to improved outcomes [17]. However, much of this research is centered on adult populations, underscoring a critical gap in pediatric-specific insights.

The model developed in this study seeks to bridge this gap by incorporating pediatric-specific facilitators and barriers to offer a structured framework for healthcare providers. This model is intended to optimize pediatric pain management strategies, promote patient-centered care, and reduce the long-term adverse effects associated with inadequately managed pain. Moreover, this model provides a foundation for allocating clinical resources effectively, structuring training programs, and informing policy development in pediatric pain management [18, 19]. Therefore, the objective of this study was to identify and categorize key barriers and facilitators in pediatric pain management and to construct a practical model that will guide healthcare providers in delivering efficient, empathetic, and evidence-based care.

Materials and methods

Study design

This scoping review systematically maps and synthesizes existing literature on barriers and facilitators in pediatric pain management from 2014 to April 2024. The methodology follows the framework proposed by Arksey and O’Malley, incorporating qualitative and quantitative studies to ensure a comprehensive examination of the topic. This approach allows for the identification of research gaps and themes, contributing to a deeper understanding of the subject.

This review specifically focuses on clinical studies involving pediatric patients aged 18 years or younger who are experiencing pain and undergoing pain management interventions. Studies focusing on pathophysiological mechanisms of pain, editorials, letters, commentaries, non-English articles, studies conducted outside clinical settings, and studies involving adult populations were excluded.

Search strategy

The original search was conducted using robust terms across multiple databases (PubMed, ProQuest, Web of Science, and Scopus) with predefined inclusion/exclusion criteria. These criteria were developed to focus on high-quality, clinically relevant studies published between 2014 and 2024. A rigorous search strategy was developed to identify relevant studies. The search terms “Pain management” AND “Children” OR “Pediatrics” AND “Barriers” OR “Challenges” AND “Facilitators” OR “Enablers” were applied across PubMed, Web of Science, and Scopus databases. Studies were included based on the following criteria: Clinical studies involving pediatric participants (≤ 18 years), Full-text articles available in English, Studies based on qualitative or quantitative research designs focusing on pediatric pain management, barriers, and facilitators. Articles that did not meet the criteria, including those focused on pathophysiological mechanisms, editorials, and non-English studies, were excluded to ensure thematic relevance and methodological rigor.While the original search yielded over 6,000 records, the stringent inclusion criteria were applied to focus on studies directly aligned with the review’s objective. This process inevitably excluded studies not meeting quality or thematic relevance thresholds.

Study selection and data extraction

Two independent reviewers with expertise in scoping reviews conducted study selection and data extraction following the Arksey and O’Malley framework. Titles and abstracts were screened for relevance, and eligible studies underwent a full-text review. Data extraction focused on study characteristics, participant demographics, and key barriers and facilitators, ensuring a systematic and transparent synthesis process. Duplicate records were removed, and discrepancies were resolved through consensus between reviewers.

Following the revised search, additional studies were identified and assessed for eligibility. Of these, the studies were found to meet the inclusion criteria and have been incorporated into the review, resulting in an expanded dataset. A standardized data extraction form was employed to collect data from each study, including study characteristics (e.g., author, year, country, study design), participant demographics (e.g., age, sample size), intervention types, measured outcomes, and specific barriers and facilitators related to pediatric pain management.

Quality appraisal

The methodological quality of the included studies was assessed using the Critical Appraisal Skills Programme (CASP) tool for qualitative studies or a mixed-methods quality assessment tool. These tools evaluate aspects such as study design, recruitment procedures, data collection methods, and result consistency. Studies identified with a high risk of bias were noted; however, their findings were retained to maintain a comprehensive view of the field.

Data synthesis

Data synthesis involved thematic analysis for qualitative data and narrative synthesis for quantitative data. In the thematic analysis, qualitative data were coded and grouped into overarching themes associated with barriers and facilitators in pediatric pain management. This iterative coding process included regular discussions between reviewers to refine themes and ensure analytical consistency. Quantitative data were summarized narratively, focusing on outcome measures and statistical findings to identify trends in barriers and facilitators.

To enhance rigor, the themes identified in qualitative studies were triangulated with findings from quantitative studies, offering a robust synthesis of current knowledge on pediatric pain management. This approach provided comprehensive insights into obstacles and enablers relevant to clinical practice.

After applying the inclusion and exclusion criteria, twenty-three studies met the eligibility requirements and were included in the final analysis. By following this structured methodology, the review aims to present a comprehensive synthesis of current knowledge on pediatric pain management, revealing practical insights into challenges and facilitating factors for healthcare practitioners.

Results

Description of the selected studies

This scoping review included 23 selected articles that employed various research methodologies. Of these, 26.1% were qualitative studies [8, 11, 18,19,20,21,22,23,24,25,26,27,28], and 34.8% were quantitative studies [1, 29,30,31,32,33,34,35]. Qualitative studies comprised exploratory, descriptive, and qualitative descriptive designs. Quantitative studies utilized a variety of methodologies, including feasibility studies [29] and cross-sectional surveys [1, 32, 34]. Additionally, one study adopted a mixed-methods approach [36], while one lacked a specified research design [37]. Notably, 4.3% of the studies were conducted online [31, 38], with one online study based on the results of a systematic review [38].

The selected studies involved various healthcare participants in pediatric pain management. The majority focused on clinical settings, including pediatric units [11, 18, 20, 21, 25,26,27, 31, 32], emergency departments [34, 35], and prehospital care [22, 23, 28, 33, 37]. Nurses were the most frequently studied healthcare participants, accounting for approximately 87% of the studies [4, 18, 20, 21, 25,26,27, 31,32,33,34, 38], followed by physicians [18, 24, 35, 38] and paramedics [22, 23, 28, 33]. Several studies also examined the experiences of parents [19, 36] and children [1, 20, 29], highlighting the importance of understanding their perspectives as the primary target population.

The most frequently studied category was procedural pain, including research on pharmacological management [20], neonatal pain [21], procedural pain in general [18], and pain associated with pediatric cancer [29, 36]. Acute pain management in children was another prominent theme covered in studies related to ambulance care [22], pain following trauma [23], and prehospital management of acute pain [28]. Specific pain conditions were also addressed, such as post-surgical pain [19] and chronic pain [30].

Geographically, the studies were distributed internationally, with European research accounting for 26.1%, including studies from the UK, Ireland, and the Netherlands [22,23,24, 28, 29, 36]. Asian studies represented 21.7%, with research conducted in Thailand, China, Indonesia, and Iran [18, 21, 25,26,27]. American contributions made up 34.8%, including studies from Canada and the USA [19, 30, 31, 33,34,35, 37, 38]. African studies represented 13%, with research from Ghana and Ethiopia [1, 4, 20]. One study (4.3%) was conducted in Australia [32].

Two studies employed focus group techniques to assess expert opinions on pain management [18, 28], while three studies focused on telehealth applications in health and virtual care [29, 30, 38]. Table 1 summarizes these 23 reviewed studies.

Table 1 Summary of studies findings

Barriers to pediatric pain management

Knowledge and training deficits

A recurrent barrier identified across the studies was the gap in knowledge and training for healthcare professionals, particularly nurses, in pediatric pain management [11, 18, 20, 23, 28, 34]. Insufficient training in pediatric pain assessment and management techniques, misconceptions about pain perception in children, and a lack of confidence in pain scoring tools hindered effective pain management. Limited exposure to pediatric cases, especially in prehospital settings, further exacerbated this issue [28]. Additionally, the need for enhanced knowledge sharing and continued education was underscored as crucial for improving pediatric pain management [24, 34].

Organizational and structural issues

The review highlighted several organizational and structural barriers to effective pediatric pain management. Staffing issues, such as time constraints, heavy workloads, and staff shortages, were cited as major obstacles [18, 20]. The lack of supportive institutional policies and structures also emerged as a key issue, with studies emphasizing the importance of comprehensive pain management policies to ensure consistent care [18, 20]. Moreover, a misaligned organizational culture, characterized by inadequate prioritization of pain management, lack of open communication among healthcare teams, and insufficient emphasis on evidence-based pain management practices, was identified as a barrier in some healthcare settings [25, 26]. Specific examples include the absence of structured protocols for pediatric pain management, limited opportunities for interdisciplinary collaboration, and a reluctance to integrate non-pharmacological approaches. Such cultural aspects can hinder the delivery of consistent and effective care.

Medication and prescription challenges

Pharmacological barriers, such as the unpalatability of medications and their underuse, were highlighted as significant issues [36].Parents often preferred non-pharmacological approaches due to their reluctance to administer medications, a phenomenon supported by studies highlighting parental attitudes and practices in pediatric pain management. For example, Parker et al. (2021) found that parents often under-medicate their children’s pain due to attitudinal barriers and practical concerns, making non-pharmacological methods a critical component of pain relief strategies at home. Contrarily, the study by Huguet and Miró (2008) reported that over 70% of children used analgesics as the first option for pain relief, indicating variations in parental preferences and regional practices [1, 20, 23, 36, 39].

Environmental and situational constraints

Pre-hospital care providers faced a range of environmental and situational constraints that hindered effective pain management in pediatric patients. Challenges such as limited time for assessment and intervention, urgent care requirements, and complex pre-hospital settings limited providers’ ability to deliver appropriate pain relief [22, 28]. Short transfer times and situational realities in these settings further complicated efforts to manage pain effectively.

Communication and information discrepancies

Inconsistencies in communication and information sharing significantly impacted pediatric pain management [11, 13]. In particular, assessing pain in non-verbal children posed challenges for healthcare providers. Discrepancies in information provided by different healthcare providers further contributed to confusion and stress among parents, undermining their confidence in the pain management process [19].

Technological barriers

The studies’ synthesis revealed significant technological obstacles to effective pediatric pain management. Outdated technology, including a lack of modern eHealth tools, was identified as a major barrier [38]. Additionally, the shift to virtual care, particularly during the COVID-19 pandemic, presented challenges in delivering comprehensive care remotely. Disparities in access to technology, especially among patients from lower socioeconomic backgrounds, exacerbated these issues, leading to unequal pain management outcomes [30].

Parental influences and beliefs

Parental influences, including their beliefs and attitudes toward pain management, were identified as significant barriers. Parents’ underestimation of their children’s pain and reluctance to use medications often hindered effective pain relief [24, 36]. Parental stress and anxiety also played a role in how effectively they managed their child’s pain. Conflicts between parents’ preferences and healthcare providers’ practices, especially regarding family-centered care, further complicate the pain management process [31].

Policy and system-level barriers

System-level barriers, such as lack of funding, inadequate infrastructure, and the absence of comprehensive pediatric pain management policies, were significant impediments to effective care [38]. The variability in institutional pain management practices and inconsistent use of non-pharmacological interventions were also cited as critical challenges [35]. Standardized pain assessment protocols and greater emphasis on non-pharmacologic interventions were recommended to address these barriers.

Practical and logistical issues

Practical and logistical barriers were particularly prominent in pre-hospital and emergency care settings. Challenges arise in delivering timely and effective pain relief for distressed and uncooperative children was important [28, 33, 37]. Logistical issues, such as time constraints during triage and the overall emergency department workflow, also contributed to suboptimal pain management [23, 34, 35]. Variability in the use of pain assessment tools and non-pharmacologic interventions further complicated the situation.

Specific contextual barriers

The studies also highlighted specific contextual barriers that impacted pediatric pain management. Effective pain management requires specialized expertise and a deep understanding of the unique contexts in which pediatric pain occurs [21]. Pediatric-specific factors, such as developmental considerations and the emotional dimensions of pain, require tailored approaches to pain management, particularly in end-of-life care settings.Preschool-aged children often experience heightened reliance on parental involvement due to their limited capacity for verbal communication and self-reporting of pain. Communication challenges in this age group necessitate tailored approaches, such as behavioral observation tools, to assess pain accurately. School-aged children, on the other hand, demonstrate an improved ability to articulate their pain but remain influenced by parental and environmental factors. For this group, enhancing school-based health education programs and involving teachers in pain management protocols emerged as effective facilitators. Adolescents exhibited more autonomy in managing their pain, with their unique barriers including a higher likelihood of underreporting pain due to social stigma and resistance to parental intervention. Facilitators for adolescents focused on leveraging peer support groups and incorporating technology-driven tools such as apps for self-monitoring pain. Recognizing these developmental differences provides critical insight into tailoring interventions to enhance pain management efficacy across age groups. Future studies should explore these distinctions further to develop age-specific pain management protocols [24].

Facilitators of pediatric pain management

Nurse and healthcare professional initiatives

The analysis of the selected studies identified key factors enhancing pediatric pain management, particularly through the roles of nurses and other healthcare professionals. One critical factor is the proactive involvement of nurses in advocating for effective pain medication use. The importance of nurses’ advocacy emphasizes their responsibility to ensure pain management is prioritized across healthcare teams [20]. Additionally, the provision of education, resources, and empowerment for nurses is essential, and it was found that supporting nurses with adequate training improves pain management efficacy [4]. Furthermore, targeted strategies aimed at enhancing the performance and competence of clinical nurses are crucial for optimal pain care, as highlighted in Study [25].

Organizational and structural improvements

Several organizational and structural improvements were identified as facilitators of pediatric pain management. Enhancing organizational structure and nursing competencies was a significant factor, as noted in Study [26], which emphasized the need for appropriate organizational frameworks and improved nursing training to optimize pain management. Leadership support also played a pivotal role, stressing the need for unified pain management guidelines [37]. further emphasized the importance of leadership views on analgesic use in influencing effective pain management [33]. Additionally, improved access to pain medications, better policies and procedures, and continuous education were key facilitators [35].The integration of multimodal treatment models, such as the one proposed by Harrison et al. (2019), offers a comprehensive framework for improving pediatric pain management. This model emphasizes the coordinated use of pharmacological, psychological, and physical therapies to manage chronic pain effectively, particularly in pediatric populations. By adopting such evidence-based frameworks, healthcare organizations can enhance their structural and organizational capacities, ensuring that pain management strategies are both holistic and practical. Incorporating these approaches into the discussion underscores the importance of structured, multimodal interventions in optimizing pain outcomes for children while providing a robust guideline for implementation across diverse healthcare settings [40].

Family and parental involvement

Family and parental involvement is fundamental in ensuring effective pediatric pain management. Studies consistently highlighted the importance of collaboration between families and healthcare professionals. Effective pain management is achieved when families actively engage in care, ensuring both child and family needs are addressed [24]. Active participation by both parents and children, in conjunction with medical staff, enhances pain management outcomes [26]. Providing families with verbal and written instructions has been shown to improve adherence to pain management protocols [19]. Understanding parental attitudes and the context of pain management is critical, which stresses the need for tailored support to address specific concerns and enhance pain management outcomes [36]. Additionally, family-centered care, as emphasized, supports the integration of family involvement into clinical practice [31].

Educational and training strategies

Educational and training programs have proven effective in improving pain management practices. Comprehensive education ensures healthcare providers are equipped with the skills to manage pediatric pain effectively. Importance of evidence-based guidelines that focus on patient-centered care, particularly in assessing pain in nonverbal children and exploring alternative drug delivery methods [13]. the success of targeted in-service training and workshops in addressing knowledge gaps among healthcare providers.

Technological tools and innovations

Technological innovations, particularly eHealth tools, and pain monitoring apps, have proven to be valuable in pediatric pain management. It is important to tailor eHealth tools to align with the preferences of patients and healthcare providers, thus improving acceptance and effectiveness [38]. The KLIK pain monitor app, demonstrated the feasibility and positive reception of technological innovations, with over 70% of families and healthcare professionals rating its functions favorably [29].

Procedural and practical enhancements

Enhancements in procedural and practical approaches to pain management have contributed to more effective pain relief. There is a need to increase analgesic administration rates through pharmacological and non-pharmacological techniques, such as alternative drug delivery routes and child-friendly uniforms to reduce anxiety [22]. Non-pharmacological methods, including distraction and relaxation techniques, play a significant role in alleviating pain and anxiety. Structured assessment tools, such as the Pain Management Index (PMI) score, provide a systematic approach to evaluating pain management effectiveness [1].

Model development for barriers and facilitators of pediatric pain management

The conceptual model depicted in Fig. 1 was developed by synthesizing barriers and facilitators identified in various studies on pediatric pain management. This model offers a valuable framework for understanding the complexities inherent in managing pain in children. It highlights key factors that influence effective pain assessment and treatment, integrating well-established barriers and facilitators.

The model identifies barriers to effective pediatric pain management, including deficits in knowledge, communication challenges, systemic and resource limitations, parental concerns and beliefs, issues with pain assessment and treatment, medication and prescription challenges, environmental and situational constraints, technological limitations, policy and system-level barriers, and practical and logistical issues. Furthermore, specific contextual barriers were also considered in the development of the model.

Conversely, facilitators that enhance effective pain management are identified as improved knowledge and education, enhanced communication strategies, adequate resource allocation, initiatives by healthcare professionals, technological innovations, family and parental involvement, procedural and practical enhancements, and adaptations for virtual and remote care. These facilitators play a crucial role in optimizing pain management practices for pediatric patients.

The model’s strength lies in illustrating the bidirectional relationship between certain concepts, which are recognized both as barriers and facilitators. For example, ineffective pain management processes can hinder pain assessment and treatment, resulting in suboptimal outcomes. In contrast, an ideal pain management process, supported by facilitators, can improve assessment and treatment practices, leading to more favorable outcomes.

Furthermore, the model emphasizes the importance of recognizing concepts that share the same identity and categorizing them under a unified framework. Such categorization can enhance the accuracy of pain evaluations and the selection of optimal treatment strategies. Additionally, concepts highlighted in different colors represent areas with potential for further exploration, presenting opportunities for novel approaches. Factors such as environmental constraints and medication challenges, though not directly involved in the interplay between barriers and facilitators, can significantly influence a child’s pain experience.

Moreover, the model identifies facilitators that may offer greater potential than their current categorization suggests. For instance, virtual care adaptations and the empowerment of nurses could substantially improve pain assessment and treatment practices, particularly in geographically isolated or resource-limited settings.

By examining the interplay between barriers and facilitators within this model, healthcare professionals can identify specific areas for improvement in their practices. Addressing barriers, such as communication challenges, through the implementation of facilitators, like communication skills training, could optimize pain management in pediatric care. A deeper exploration of these factors and their interactions with the core concepts could pave the way for the development of novel, comprehensive approaches to pediatric pain management, ultimately enhancing patient outcomes.

Fig. 1

Model for Understanding Barriers and facilitators of pediatric pain management

Discussion

This review incorporated 23 studies focused on identifying the barriers and facilitators of pediatric pain management. The concepts that emerged were discussed within the framework of a model, which categorized factors that acted as both barriers and facilitators within the same domain, illustrating their parallel nature. Additionally, concepts that were identified as independent were categorized separately, reflecting their unique characteristics in influencing pediatric pain management. This section aims to summarize key findings and provide a comparative analysis of barriers and facilitators in pediatric pain management, with a focus on both the challenges they present and the opportunities they offer for improvement (Table 2).

Table 2 Barriers and facilitators of pediatric pain management

Concepts with parallel nature

Knowledge & training deficits - educational & training strategies

A key challenge in pediatric pain management is the significant knowledge and training deficit among healthcare professionals. The review consistently found that inadequate training in pediatric pain assessment and management, especially among nurses, contributes to ineffective pain management [11, 18, 20]. This lack of training results in misunderstanding pain perceptions in children, leading to insufficient assessment and treatment [18, 20, 23]. Moreover, healthcare providers often lack confidence in pain-scoring tools, which complicates accurate pain evaluation and decision-making [23, 28]. These training deficiencies, particularly in pre-hospital settings where exposure to pediatric patients is limited, exacerbate difficulties in managing pediatric pain effectively [28]. However, addressing these gaps through focused educational and training strategies presents a significant opportunity to enhance pediatric pain management practices [24, 34].

Educational interventions have proven effective in mitigating knowledge deficits and improving pain management outcomes. Comprehensive education and evidence-based training programs have been shown to enhance pain management in pediatric settings. The importance of education, training, and professional development in enhancing pediatric pain management is unequivocal. However, aligning these efforts with updated, evidence-based models that integrate a multidisciplinary and biopsychosocial approach is paramount. Recent literature underscores that interventions involving physiotherapy and psychological strategies demonstrate significant efficacy, particularly in managing chronic pediatric pain. Emphasizing these domains could guide the prioritization of educational programs, ensuring alignment with the most impactful methods. Moreover, recognizing and addressing the scarcity of training in identifying and managing adverse events associated with pain interventions is crucial. This addition would advocate for a more comprehensive educational framework that prioritizes both the efficacy and safety of pediatric pain management practices.It is crucial to develop practical, evidence-based guidelines that healthcare providers can easily implement, especially for managing pain in young children who cannot verbally express their discomfort [13]. Additionally, targeted workshops and in-service training sessions have been identified as key methods for addressing specific knowledge gaps and improving practitioners’ confidence in using pain assessment tools [19]. The importance of these educational strategies is corroborated by recent studies, such as Petovello’s (2013) review of pediatric procedural pain management, which underscored the need for evidence-based approaches to improve nursing competencies [40]. Similarly, the American Academy of Pediatrics (AAP) has emphasized the challenges in pediatric pain management, particularly in assessing pain accurately and using appropriate pain-assessment tools [41]. These findings align with our study’s results, reinforcing the importance of addressing knowledge gaps through structured educational initiatives.

Organizational & structural issues - organizational & structural improvements

Organizational and structural issues significantly impede effective pediatric pain management. Time constraints, heavy workloads, and staff shortages are frequent barriers, limiting healthcare providers’ ability to deliver personalized care [18, 20]. Furthermore, the absence of supportive institutional policies exacerbates these challenges, making it difficult to establish consistent pain management practices across healthcare settings [25, 26]. Healthcare systems that are not yet adapted to prioritize pain management or that lack the necessary structural and systemic support not prioritizing pain management can also create a disconnect between institutional practices and the needs of pediatric patients [25, 26]. These organizational obstacles highlight the need for improvements in institutional structures and policies to better support pediatric pain management.

Recent literature reinforces the importance of addressing organizational barriers in pain management. A study by Twycross and Finley (2013) emphasized the critical role of organizational factors in effective postoperative pain management for children, highlighting the need for institutional support and standardized policies [43]. Similarly, Petovello’s (2013) review of pediatric procedural pain management reiterated the importance of enhancing nursing competencies and implementing pain management protocols [41]. These findings align with our study, suggesting that addressing organizational barriers, such as staff shortages and time constraints, can facilitate better pain management practices. Leadership support for pain management protocols, coupled with increased access to pain medications and ongoing education for healthcare professionals, is essential for overcoming these barriers [33, 37].

Parental influences & beliefs - family & parental involvement

The influence of parents in pediatric pain management is multifaceted and plays a critical role in shaping pain management strategies. Our findings, in line with previous research by Hain et al. (2020), show that parental influences and beliefs can act as both barriers and facilitators [42]. Parental attitudes, such as underestimating the severity of pain or reluctance to use medications, can hinder effective pain management [24, 36]. Additionally, emotional distress and differing views between parents and healthcare providers can complicate pain management strategies [31]. However, parental involvement, when encouraged, can also significantly enhance pain management outcomes. Studies emphasize the importance of building strong partnerships between healthcare professionals and families, fostering shared decision-making, and providing parents with clear, comprehensive information to empower them in managing their child’s pain [19, 24, 26]. These collaborative approaches improve treatment adherence and overall outcomes, underscoring the dual role of parental beliefs and involvement as both challenges and opportunities for enhancing pediatric pain care.

Communication & information discrepancies - supportive relationships

Communication and information inconsistencies represent significant barriers to effective pediatric pain management. Studies highlight the importance of clear communication between healthcare providers and parents to improve pain management outcomes [44, 45]. Misinterpretation of pain indicators in nonverbal children and discrepancies in information provided by healthcare professionals can cause confusion and erode parents’ confidence in the care process [19]. These communication barriers need to be addressed to improve pain management in pediatric settings.

Building supportive relationships between healthcare providers, parents, and multidisciplinary teams is essential for improving pediatric pain management. Effective partnerships ensure active parental involvement in decision-making and facilitate the development of comprehensive pain management plans. Multidisciplinary teams, when properly coordinated, can enhance pain management outcomes by improving communication and providing a more holistic approach to care. Addressing communication barriers through better collaboration and information-sharing can significantly improve pediatric pain management [46,47,48].

Technological barriers - technological tools & innovations

Technological barriers, such as outdated eHealth tools and limited access to current technological solutions, hinder effective pediatric pain management. The lack of investment in advanced eHealth tools restricts healthcare providers’ ability to implement innovative pain management strategies [30]. The shift to virtual care during the COVID-19 pandemic revealed significant disparities in access to technology, which further exacerbated challenges in pain management, particularly among patients from lower socioeconomic backgrounds [38]. Despite these barriers, technological innovations, such as eHealth solutions and pain-monitoring apps, have shown potential to enhance pain management. The use of personalized, user-friendly tools, like the KLIK pain monitor app, has been positively received by both families and healthcare professionals, demonstrating their effectiveness in improving pain management outcomes [29]. Moreover, wearable devices and virtual reality have emerged as promising technologies in pediatric pain management, as highlighted by Afolalu et al. (2023), suggesting that overcoming technological barriers and integrating advanced tools into practice could improve care delivery [50].

Policy & system-level barriers - policy & protocol improvements

Systemic and policy-related barriers significantly impact the quality of pediatric pain management. The lack of adequate funding, institutional infrastructure, and standardized policies undermines the development and integration of effective pain management practices [48, 49]. Variability in pain assessment protocols and inconsistent use of nonpharmacologic interventions further contribute to suboptimal care. However, improving institutional policies and protocols is crucial for overcoming these challenges. The integration of multimodal pain management strategies and the development of comprehensive institutional policies have been shown to enhance pediatric pain management outcomes [49, 51]. By standardizing pain assessment protocols and ensuring consistent application of pain management strategies, healthcare systems can improve the quality of care and reduce disparities in pain management.

Practical & logistical issues - procedural & practical enhancements

Practical and logistical challenges, such as difficulties in administering pain relief to uncooperative children and constraints in prehospital and emergency settings, impede effective pediatric pain management. Time constraints and variability in pain assessment tools further complicate the process [28, 33]. Addressing these barriers involves improving procedural approaches, such as increasing analgesic administration rates, exploring alternative delivery methods, and implementing standardized pain assessment tools [1, 20]. Quinn et al. (2015), highlighted the importance of structured assessment tools to evaluate the adequacy of pain management, ensuring that interventions meet necessary standards [52, 53]. By enhancing procedural and logistical aspects of pain management, healthcare providers can significantly improve the efficiency and effectiveness of pain relief interventions.

Barriers and facilitators with independent nature

Several studies identified barriers related to medication and prescription practices in pediatric pain management, including the underuse of medications due to attitudinal barriers and the unpalatability of certain analgesics [36]. Doctors’ prescription habits, such as hesitancy to prescribe adequate analgesics due to concerns about misuse or side effects, further complicate pain management [20, 23]. Additionally, the review revealed challenges in pre-hospital care settings, where short transfer times and other situational factors hinder the ability to perform thorough pain assessments [28]. Addressing these contextual barriers through education, improved prescription practices, and better training for healthcare providers can enhance pediatric pain management in diverse settings.

In conclusion, while the review highlights numerous barriers to pediatric pain management, it also underscores significant opportunities for improvement. Addressing these barriers through targeted education, organizational support, technological innovation, and policy improvements can transform the challenges into facilitators of better care. The findings by Eccleston et al. (2021) serve as a cornerstone for understanding systemic barriers and enablers in pediatric pain management. Their meta-analysis echoes our study’s emphasis on interdisciplinary education, policy integration, and family-centered care as critical avenues for improving pain relief outcomes in pediatric settings. The insights provided by this review can guide future interventions and strategies to enhance pediatric pain management and ensure optimal outcomes for children.

Strengths and limitations of the study

The study has identified barriers and facilitators of pediatric pain management based on a literature review and developed a relevant model. However, there could be some limitations, including restrictions on the databases and languages searched. On the other hand, our approach to identifying relevant studies was rigorous, but we may have missed some relevant work without a fully systematic approach. The model can be addressed cohesively by healthcare practitioners, policymakers, and health promoters. It is recommended to develop research into pain management technology-based resources. Policymakers and healthcare professionals can promote pain management throughout the pediatric population and create lasting change in their health and well-being according to research findings.

Conclusion

The review identified several key barriers to effective pediatric pain management, including knowledge and training deficits, organizational and structural challenges, medication and prescription issues, environmental and situational constraints, communication discrepancies, technological gaps, parental influences, policy and system-level barriers, practical and logistical challenges, and specific contextual barriers. Several key facilitators also significantly enhance pediatric pain management, including nurse and healthcare professional initiatives, organizational and structural improvements, family and parental involvement, educational and training strategies, technological tools and innovations, procedural and practical enhancements, virtual and remote care adaptations, and policy and protocol improvements. These findings highlight the need for comprehensive strategies to address these barriers and improve pediatric pain management.