The predictors, barriers and facilitators to effective management of acute pain in children by ambulance services: A systematic mixed studies review

Background:Pre-hospital analgesic treatment of injured children is suboptimal with very few children in pain receiving analgesia. Without effective pain treatment, children are at risk of adverse consequences including posttraumatic stress disorder and altered pain perception. The aim of this review was to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services.Methods:A segregated systematic mixed studies review was performed. We searched from inception to 01-Aug-2019: MEDLINE, CINAHL, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-methods studies of children under 18 years, their relatives or EMS staff were eligible. The outcome measure for quantitative studies was effective pain management, defined as a pain score reduction ?2 out of 11. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. GRADE and CERQual were used to determine the confidence in cumulative evidence.Results:From 3526 articles screened, 70 were selected for full text review, with 7 quantitative and 5 qualitative studies included. Considerable heterogeneity precluded meta-analysis. Predictors of effective pain management included: “child sex (male)”, “child age (younger)”, “type of pain (traumatic)” and “analgesia (administered)”. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives, colleagues) influences on the clinician along with child factors (child’s experience of event, pain assessment and management). Confidence in the cumulative evidence was deemed low.Conclusions:To improve prehospital pain management in children, efforts to facilitate analgesia administration should take priority, perhaps utilising the intranasal route. The culture of treating traumatic pain more readily than medical pain should also be addressed. Further research is recommended to explore the child’s perspective, investigate the conflicting data around “child age” and unexplained data around “child sex” and to improve the confidence in cumulative evidence.