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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-025-02941-2.

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 [7–9]. 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, 18–28], and 34.8% were quantitative studies [1, 29–35]. 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, 25–27, 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, 25–27, 31–34, 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 [22–24, 28, 29, 36]. Asian studies represented 21.7%, with research conducted in Thailand, China, Indonesia, and Iran [18, 21, 25–27]. American contributions made up 34.8%, including studies from Canada and the USA [19, 30, 31, 33–35, 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

	Title	Author/Country	Design	Aim	Participants	Methods	Findings	Barriers	Facilitators
1	Pharmacological management of invasive procedural pain in children: Facilitators and barriers	Anim-Boamah et al(2024)/ Ghana	Quali ative exploratory, descriptive study	Explore the factors that enhance or mitigate pharmacological management of invasive procedural pain in pediatric	16 nurses from the pediatric units	Semi-structured interviews by using conventional content analysis	Perceived facilitators: 1. Nurses’ initiative 2. Advocacy by nurses, 3. Desire to use pain medication expectations from team members Perceived barriers: 1. lack of knowledge, 2. shortage of staff, 3. time constraints, 4. doctor’s prescription patterns 5. lack of policies and facilities 6. cost implications of medications	A.Nurses’ limited knowledge, B.staffing C.Time limitations, D.Doctors’ prescription habits E. Lack of supportive policies and facilities F.Medication costs	A.Nurses’ initiative, B.Advocacy, C.Desire for effective pain medication use, D.expectations from other team members to manage pain.
2	Thai Nurses’ and Midwives’ Perceptions Regarding Barriers, Facilitators, and Competence in Neonatal Pain Management	Mala et al(2024)/Thailand	Qualitative	Investigate nurses’ and midwives’ perceptions of barriers, facilitators, and competence regarding effective neonatal pain management in Thai NICUs	Neonatal nurses and midwives in three units of two tertiary hospitals	Virtual one-to-one, semi-structured interviews	Pain management relies on the expert care of nurses and midwives and understanding the contextual nuances of pain management.	Various organizational, structural, and cultural factors could impede effective pain management.	Not specified
3	Improving ambulance care for children suffering acute pain: a qualitative interview study	Whit (22)ley et al(2022)/UK	Qualitative	Identify clinicians’ perceptions of barriers, facilitators, and potential improvements for the management of pre-hospital acute pain in children	12 ambulance clinicians participated, including nine registered paramedics and three emergency medical technicians	Face-to-face semi-structured recorded interviews & Thematic analysis was used to generate themes	Several themes relating to barriers and facilitators were identified, including physical, emotional, social, organizational, environmental, management, knowledge, and experience. Improvement themes relating to management, organization, and education were identified.	Physical, emotional, social, organizational, environmental, management, knowledge, and experience aspects of pre-hospital care.	A.Exploring methods to increase rates of analgesic administration, including utilizing intranasal or inhaled routes B.Reducing fear and anxiety in children by using child-friendly uniform C. Additional non-pharmacological techniques D.More public interaction E. Reducing fear and anxiety in clinicians by enhancing training and optimizing crew mix
4	An exploration of the facilitators and barriers to paramedics’ assessment and treatment of pain in pediatric patients following Trauma (EX-PAT)	Handyside et al(2021)/UK	Qualitative	Understanding the facilitators and barriers experienced by paramedics in their assessment and management of pain in children who have sustained traumatic injuries	Paramedics employed by the South Central Ambulance Service NHS Foundation Trust	Face-to-face, audio-recorded semi-structured interviews using a piloted topic guide& analysed by using thematic analysis.	Facilitators: 1. Facilitators to pain assessment: previous positive experiences with pain scoring tools and patients’ understanding of and compliance with these tools. 2. Management facilitators: colleagues’ support, exposure, being a parent, technology, severity of the injury, and subjective pain scoring. 3. Organizational facilitators: medicines, routes, and alternative methods. 4. Situational facilitators: patient-specific solutions and parents. Barriers: 1. Barriers to pain assessment: lack of confidence in pain scoring tools. 2. Barriers to management: issues with medicines, skills, consequences to self or patient, negative interactions, limited exposure, equipment issues, and training and culture.	A.Lack of confidence in using pain scoring tools, B.Medication issues C. lack of skills D.Consequences E.Negative interactions F. Limited exposure, G.Equipment issues H. training I. culture.	A.Support from colleagues, B.Exposure to different situations, C.Parenting experience, D.Tchnology, E.Injury severity, F.Subjective pain assessment, G.Medication, H. alternative treatment methods, I.Patient-specific solutions J. Parental participation
5	784 Healthcare professionals’ experiences of the barriers and facilitators to community paediatric pain management at end-of-life	Greenfield et al(2021)/UK	Qualitative	Explore the barriers and facilitators to community-based pediatric pain management for infants, children, and young people at end-of-life	Nine healthcare professionals: 12 nurses, five GPs, five consultants and registrar doctors, two pharmacists, and five support therapists working in primary, secondary, or tertiary care	Semi-structured interviews by inductive thematic analysis	Seven themes: 1. Parents’ abilities, beliefs, and well-being 2. Working relationships between families and healthcare professionals, 3. Working relationships between healthcare teams 4. Healthcare professionals’ knowledge, education, and experience 5. Health services delivery 6. Nature of pain treatment 7. Paediatric-specific factors.	A.Challenges in parents’ abilities, beliefs, and well-being, B.Need for improved working relationships, C.Knowledge sharing among healthcare professionals	A.Partnership working between families and healthcare professionals B.Partnership working within healthcare teams, sharing expertise for effective pain management
6	Barriers and Facilitators to Effective Pain Management by Parents After Pediatric Outpatient Surgery	Tam et al. (2020)/Canada	Qualitative	Describe the experience of postoperative pain management from parents’ perspectives and areas for improvement.	40 parents or legal guardians of children aged 5–18 years who underwent outpatient surgery	Semi-structured interviews	Facilitators included a combination of verbal and written instructions. Barriers to effective pain management included discrepancies in the information provided by different healthcare professionals and the experience of stress during pain management communication.	A.Discrepancies in the information provided by different healthcare professionals B. Experience of stress at the time of pain management communication	Combination of verbal and written instructions
7	Nursing-Related Barriers to Children’s Pain Management at Selected Hospitals in Ghana: A Descriptive Qualitative Study	Kusi Amponsah et al(2020)/Ghana	Descriptive qualitative study	Identify and understand the nursing-related barriers to children’s pain management in the Ghanaian context.	28 nurses working in the pediatric units of five hospitals	Over three months of interviewing by participants	1. Communication difficulties in assessing and evaluating pain management interventions with children who have nonfunctional speech 2. Insufficient training, misconceptions about the experience of pain in children 3. Lack of assessment tools 4. Insufficient number of nurses to manage the workload 5. Nurses’ inability to prescribe analgesics	Organisational, structural, and cultural factors	Education, empowerment, and support with the requisite material resources for nurses could serve as facilitators for effectively managing children’s pain.
8	Barriers and facilitators to effective procedural pain treatments for pediatric patients in the Chinese context: A qualitative descriptive study	Hu et al(2020)/China	Qualitative descriptive study	Explore nurse and physician leaders’ perceptions of barriers and facilitators to using evidence-based procedural pain treatments for hospitalised infants and children.	By purposive sampling, nurse/physician leaders engaged in the clinical management of three pediatric inpatient surgical units in one hospital.	Focus groups, individual interviews& consolidated Framework for Implementation Research guided the data analysis.	Barriers: 1. healthcare professionals’ limited knowledge and misconceptions about pediatric pain management, 2. lack of specific policies, low priority, heavy workload, staff shortage, and limited time. 3. Unique determinants in the Chinese context included parents’ concerns about new interventions, parent wrath, a hierarchical managerial system, and nurses’ lower authority.	A.Health care professionals’ limited knowledge and misconceptions about pediatric pain management B. No specific policies C. Low priority D. Heavy workload E. Staff shortage F.Limited time G. Unique determinants in the context	Not specified
9	Availability of researcher-led eHealth tools for pain assessment and management: barriers, facilitators, costs, and design	Higgins et al. (2018)/Canada	An online survey by authors according to systematic review results	Exploring the availability and implementation of eHealth tools for pain assessment and management	Researchers of eHealth tools	After systematic reviews about eHealth tools for pediatric pain assessment, a survey was conducted with authors about identified tools to gather information on barriers and facilitators of eHealth tools in pain management	Few pediatric pain-related eHealth tools were reported in the literature, and authors’ beliefs in tool selection were dominant	A. Outdated technology B.System-level barriers like lack of funding and institutional infrastructure.	Consideration of personal beliefs in making tools for users
10	An exploration of Indonesian nurses’ perceptions of barriers to pediatric pain management	Mediani et al(2017)/Indonesia	Exploratory descriptive qualitative study	Explore Indonesian nurses’ perceptions of barriers to effective pain management in pediatric patients	37 nurses from two hospitals in Indonesia, selected through purposive sampling	Semi-structured, in-depth interviews	Organizational, structural, and cultural factors that impeded nurses’ ability to deliver effective pain care to pediatric patients	Nurses’ inappropriate clinical practice due to organizational structure and culture.	Strategies to improve clinical nurses’ performance and competency in providing effective pain care
11	Experience of nurses about barriers to pain management in pediatric units: A qualitative study	Aziznejadroshan et al. (2017)/ Iran	Qualitative	Assess the perception of Iranian nurses on the barriers to pain management in pediatric units and centers	19 nurses from Amirkola Children’s Hospital in Babol and Children’s Medical Center in Tehran	Unstructured and deep interviews & analyzed by conventional content analysis method.	Five themes of barriers to pain management: 1. Inappropriate organizational structure 2. Interruption in pain relief activities 3. Inadequate competency of the nurses 4. Individual characteristics of the child and parents 5. Inefficacy of caregivers	A.Inappropriate organizational structure B.Interruption in pain relief activities C.Inadequate competency of the nurses D.Individual characteristics of the child and parents E.Inefficacy of companions	Improving organizational structure and enhancing nursing competencies
12	Experiences of Iranian Nurses on the Facilitators of Pain Management in Children: A Qualitative Study	Aziznejadroshan et al. (2016)/ Iran	Qualitative	Assess the perception of Iranian nurses on the facilitators of pain management in pediatric units and centres	19 nurses from Amirkola Children’s Hospital in Babol and Children’s Medical Center in Tehran	Unstructured interviews with the participants by purposeful sampling and conventional qualitative content analysis	Four themes: 1. Mother and child participation in diagnosis and pain relief; 2.Timely presence of medical staff and parents, 3.Proper communication, 4. Training and supportive role of nurses	Not specified	A, Mother and child participation B.Presence of medical staff C.Proper communication D. Nurse training
13	A qualitative study of the barriers to prehospital management of acute pain in children	Murphy et al(2014)/Ireland	Qualitative	Identify the barriers to achieving optimal prehospital management of acute pain in children.	Sixteen advanced paramedics	Two focus group interviews & were analyzed by Attride–Stirling’s framework for thematic network analysis	Barriers: 1.Analgesic Practioner education and training; 2. Current clinical practice guidelines for pediatric pain management 3. Realities of prehospital practice. Challenges: 1. Limited exposure to children in the prehospital setting, 2. Difficulty assessing pain intensity in small children, 3. Challenges in administering oral or inhaled analgesic agents to distressed and uncooperative children. 4. Short transfer times to the emergency department 5. Medical because of pain	A. Limited exposure to pediatric cases B.Difficulties in pain assessment and medication administration in children C.Situational factors like short transfer times and the nature of the pain’s cause	A.Practitioner education and training, offering alternatives to assessing pain in preverbal children B.Exploring the intranasal route of drug delivery in managing acute severe pain C.Robustly developed evidence-based guidelines that are practitioner-friendly and patient-focused
14	Assessment of pain management adequacy among hospitalized pediatric patients: institutional-based cross-sectional study	Kasahun et al(2023)/Ethiopia	Institutional-based cross-sectional study	To assess the adequacy of pain management among hospitalized pediatric patients at the University of Gondar Comprehensive Specialized Hospital	422 pediatric patients	Structured interview-based questionnaires and reviews of the patient’s medical records. The pain management index (PMI) score was used to determine pain management adequacy.	62.8% of the participants were prescribed pain medication, but about 63.3% received inadequate analgesics. The type of painkillers administered did not match the severity of the pain experienced by the patients. Pediatric patients less than one month old and those between one month and one year were found to have inadequate pain medication compared with their counterparts.	A. Inadequacy of pain medication prescribed B. Mismatch between the type of painkillers administered and the severity of the pain.	Using the PMI score for assessment and structured interviews could facilitate an understanding of pain management adequacy.
15	Reducing pain in children with cancer at home: a feasibility study of the KLIK pain monitor app	Simon et al(2021)/Netherland	Feasibility study	Assess adherence to, the feasibility of, and barriers and facilitators to the implementation of the KLIK Pain Monitor app, which is designed to reduce pain in children with cancer at home	Children aged 8–18 years undergoing cancer treatment and their parents (for children aged 0–7 years) participated in the study	The KLIK Pain Monitor app was used for 3 weeks, with pain assessed twice daily using an 11-point numeric rating scale (NRS-11). Healthcare professionals from the hospital’s Pediatric Pain Service were instructed to follow up with clinically significant pain scores within set timeframes	63% of families used the app daily during the three weeks, and 18.5% reported pain scores twice daily. Clinically substantial pain scores were reported by 44.4% of children at least once, with healthcare professionals following up within the set timeframe in 70% of cases	Not specified	Most app functions were evaluated positively by ≥ 70% of families and healthcare professionals, indicating feasibility.
16	Understanding the toolbox: A mixed methods study of attitudes, barriers, and facilitators in the parental intervention of children’s cancer pain at home	Parker et al(2021)/UK	Mixed methods study	Understand How parents of children with cancer manage their child’s pain at home.	Parents of children with cancer on active treatment	Convergent, parallel mixed methods design including pain diaries, surveys, and interviews. Each data collection method was analyzed separately and then integrated	Parents frequently under-medicate their child’s pain at home. Practical barriers such as the analgesic context and children finding medications unpalatable led parents to prefer non-pharmacological interventions. Attitudinal and practical barriers resulted in parents having an “empty toolbox” of pharmacological interventions, making non-pharmacological interventions essential to managing their child’s cancer pain at home.	A.Analgesic context B. unpalatability of medications C. Attitudinal barriers that led to an underuse of pharmacological interventions.	The study did not explicitly mention facilitators but implied that understanding parents’ attitudes and the context in which they manage pain could lead to better support systems.
17	COVID-19 pandemic impact and response in Canadian pediatric chronic Pain care: A National Survey of Medical Directors and pain professionals	Killackey et al(2021)/Canada	National survey-based study	Evaluate the impact of the COVID-19 pandemic on Canadian pediatric chronic pain care.	Pediatric pain clinic directors and other multidisciplinary pediatric pain healthcare professionals from Canadian pediatric pain clinics and rehabilitation programs.	Two online cross-sectional surveys	All clinics provided virtual care during the pandemic. Most clinics reported no perceived change in patient pain levels (69%) or occurrence of pain flares (77%). The study also highlighted the rapid mobilization of virtual care as a response to the pandemic.	A. Challenges of providing comprehensive care virtually B. Potential disparities in access to technology among patients Need for additional resources to support virtual care	A.Transition to virtual care was facilitated by the existing infrastructure B.Willingness of healthcare professionals to adapt to new modes of care delivery
18	Barriers and facilitators to using pain treatment during newborn screening blood tests at a mother-baby unit	Venegas (2019)/Canada	Online survey	Explore the nurse’s preferences for pain treatment during newborn screening (NBS)	Nurses in a mother-baby unit	Registered nurses and registered practical nurses mainly work in the mother-baby unit.	Nursing staff preferred sucrose over family-led interventions like breastfeeding and skin-to-skin care during newborn screening procedures.	Predominance of nurses’ preferences in pain management than family-centered care	The potential of family-centered care as facilitators in the context of mother-baby units
19	Nurses’ knowledge and attitudes regarding pediatric pain management in western Australia	Peirce et al. (2018)/ Australia	Cross-sectional, descriptive study	Investigate nurses’ knowledge and attitudes regarding pain management	590 nurses in an Australian pediatric hospital	Pediatric Pain Knowledge and Attitudes Questionnaire	The mean knowledge score was 77.56 out of 100; the mean attitude score was 72.46 out of 100 Senior registered nurses and. Nurses with specialist pediatric qualifications had significantly more positive attitude scores than others. 51% of respondents believed that children tolerate pain better than adults do.	Inadequate knowledge	It does not explicitly focus on facilitators but suggests that targeted education using in-service education and workshops could serve as facilitators.
20	An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management	Whitley et al. (2017)/USA	Quantitative assessment	Assess the prevalence of newly identified barriers and enablers to prehospital narcotic analgesic administration in a sample of paramedics. Determine whether these barriers and enablers differ between new and experienced paramedics	A convenience sample of paramedics from urban, suburban, and rural practice settings in an emergency medical services system.	Descriptive statistics were calculated to describe responses, and differences between new (≤ 5 years) and experienced (> 5 years) providers were assessed.	Notable barriers to analgesic administration: 1. Causing more pain from intravenous catheter insertion 2. Parental influences 3. Difficulty assessing pain 4. Worry about allergic reactions. Enablers: 1. Belief that analgesic administration is important 2. Education to administer analgesics 3. Support from agency leadership. Differences between new and experienced providers: 1. Overall comfort with pediatric patients 2. Receiving negative responses from superiors about giving pediatric patients analgesics 3.Usefulness of the Broselow tape for dosing fentanyl for children	Skills and knowledge deficits	A.Support from agency leadership B.Personal views on analgesics
21	Prehospital Pediatric Pain Management: Continued Barriers to Care	Mellion et al(2017)/USA	Not explicitly mentioned	Assess the current state of prehospital pediatric pain management in children with fractures and burns and identify ongoing barriers to care.	Examining prehospital pain management for children with fractures and burns is not detailed in the sources	Not provided specific information about the participants	Disparities exist in rates of prehospital pain management for children with fractures and burns	Lack of validated pain scales for prehospital use	A.Leadership support in EMS B.Single guidelines for pain management
22	Pediatric pain management in the emergency department: the triage nurses’ perspective	Thomas(2015)/Canada	cross-sectional survey-based study	Understand triage nurses’ perspectives on pain management for children	Triage nurses at three Canadian pediatric emergency departments	A paper-based survey	Nurses reported a longer acceptable delay between triage time and administration of analgesia. Most nurses felt more comfortable with protocols involving the administration of acetaminophen or ibuprofen than for oral morphine or oxycodone. Three reported barriers were monitoring capability, time, and access to medications	A.Monitoring capability B.Time constraints C. Access to medications	Nurses were open to improving pain management protocols for children in the ED.
23	Reported practice variation in pediatric Pain Management: A Survey of Canadian Pediatric Emergency physicians	Ali et al(2014)/Canada	Prospective survey-based study	Describe pediatric emergency medicine (PEM) physicians’ reported pain management practices and explore factors that facilitate or hinder pain management.	Canadian pediatric emergency physicians	Through the Pediatric Emergency Research Canada physician database	Almost all pain screening in emergency departments (EDs) occurred at triage (97%). 24% of physicians noted institutionally mandated pain score documentation. Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain. The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively. The training background and gender of physicians affected the likelihood of using nonpharmacologic interventions. Physicians noted time restraints to be the most significant barrier to optimal pain management. Request for improved access to pain medication, better policies and procedures, and further education	A.Time constraints B.Lack of institutionally mandated pain score documentation C.Variability in the use of nonpharmacologic interventions	A.Improved access to pain medications Better policies and procedures C.Further education

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.

Fig. 1.

Model for Understanding Barriers and facilitators of pediatric pain management

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.

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

Barriers
Knowledge& Training Deficits	Organizational & Structural Issues	Medication & Prescription Challenges	Environmental & Situational Constraints	Communication & Information Discrepancies	Technological Barriers	Parental Influences & Beliefs	Policy & System-Level Barriers	Practical & Logistical Issues	Specific Contextual Barriers
-Insufficient training in pediatric pain assessment and management techniques -Misconceptions about pain perception and management in children -Lack of confidence in pain-scoring tools -Limited exposure to pediatric patients -The need for improved knowledge-sharing	-Time limitations -Heavy workloads -Staff shortages -Lack of supportive policies -Lack of supportive institutional structures -Inappropriate organizational culture	-Pharmacological Barriers -Doctors’ Prescription habits -Costs	-Physical, emotional, social, organizational, and environmental aspects of pre-hospital care -Short transfer times and situational realities	-Communication Difficulties -Discrepancies in Information	-Outdated Technology -Virtual Care Challenges	-Parental Barriers -Parental Preferences	-System-Level Barriers -Institutional Policies	-Practical Barriers in Administering analgesics -Logistical Constraints	-Contextual Nuances -Pediatric-Specific Factors
Facilitators
Nurse & Healthcare Professional Initiatives	Organizational & Structural Improvements	Family & Parental Involvement	Educational & Training Strategies	Technological Tools & Innovations	Procedural & Practical Enhancements	Virtual & Remote Care Adaptations	Policy & Protocol Improvements	Supportive Relationships
- Nurses’ initiative in pain management - Necessary support and resources for nurses - Strategies for improving pain care proficiency	- Organizational structure and nursing competencies improvement - Leadership support and guidelines for pain management - Agency leadership support and personal views on analgesics - Enhanced access to pain medications, improved policies and procedures, and additional education	-Partnership working for effective pain management -Mother and child participation -Proper communication -Nurse training -Combination of verbal and written instructions -Understanding parents’ attitudes for better support -Family-centered care	- Practitioner education and training for assessing pain in preverbal children - Exploration of intranasal drug delivery for managing acute severe pain -Development of practitioner -friendly and patient-focused evidence-based guidelines - Targeted education through in-service sessions and workshops	- Pain monitor app’s functions - Consideration of personal beliefs in making eHealth tools for users	- Explore methods to increase rates of analgesic administration, such as using - Reduce fear and anxiety in pediatric patients - Increase public interaction - Reduce fear and anxiety in clinicians - Use the score and structured interviews to assess pain	-Transition to virtual care by new models of care delivery	-Improving pain management protocols	-Partnership working between families and healthcare professionals -Partnership working within healthcare teams -Sharing expertise for effective 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 [46–48].

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.

Electronic supplementary material

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Author contributions

The author made a significant contribution to all the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

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Consent for publication

The author has given her consent for the publication of this study and its findings.

Competing interests

The authors declare no competing interests.