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

We aimed to identify predictors, barriers and facilitators to effective pre-hospital pain management in children. A segregated systematic mixed studies review was performed. We searched from inception to 30-June-2020: MEDLINE, CINAHL Complete, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-method studies of children under 18 years, their relatives or emergency medical service staff were eligible. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. Grading of Recommendations Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research were used to determine the confidence in cumulative evidence. From 4030 articles screened, 78 were selected for full text review, with eight quantitative and five qualitative studies included. Substantial heterogeneity precluded meta-analysis. Predictors of effective pain management included: ‘child sex (male)’, ‘child age (younger)’, ‘type of pain (traumatic)’ and ‘analgesic administration’. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives and 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. Efforts to facilitate analgesic administration should take priority, perhaps utilising the intranasal route. Further research is recommended to explore the experience of the child. Registration: PROSPERO CRD42017058960

TITLE-ABS-KEY ( ( infant* OR child* OR pediatric* OR paediatric* OR adolescen* ) AND ( ambulance* OR "Emergency Medical Service*" OR prehospital OR pre-hospital OR "Out of hospital" OR paramedic* ) AND ( pain OR analgesi* ) ) TS=((Infant* OR Child* OR Pediatric* OR Paediatric* OR Adolescen*) AND (Ambulance* OR "Emergency Medical Service*" OR Prehospital OR Pre-hospital OR "Out of hospital" OR Paramedic*) AND (Pain OR Analgesi*) ) S2 Ambulance* OR "Emergency Medical Service*" OR Prehospital OR Prehospital OR "Out of hospital" OR Paramedic* OR (MH "Emergency Medical Services") OR (MH "Ambulances") Ambulance* OR "Emergency Medical Service*" OR Prehospital OR Prehospital OR "Out of hospital" OR Paramedic* OR (MH "Emergency Medical Services") OR (MH "Ambulances") Ambulance* OR "Emergency Medical Service*" OR Prehospital OR Prehospital OR "Out of hospital" OR Paramedic* OR DE "Emergency Services" Ambulance* OR "Emergency Medical Service*" OR Prehospital OR Prehospital OR "Out of hospital" OR Paramedic* OR ambulance/

Risk of bias assessments
Cross-sectional study quality / risk of bias assessment Question Study Bendall et al (2011) [1] Jennings et al (2015) [2] Karlsen et al (2014) [3] Lord et al (2019) [4] Murphy et al (2017) [5] Whitley et al (2020) [ 11. Were the methods (including statistical methods) sufficiently described to enable them to be repeated? 12. Were the basic data adequately described? 7 Qualitative study quality / risk of bias assessment Question Study Jepsen et al (2019) [11] Holmstrom et al (2019) [12] Gunnvall et al (2018) [13] Murphy et al (2014) [14] Williams et al (2012) [ "When we went through class we were always told to look for reasons to not give medication and there's never a great reason to give morphine . . .. I don't think we covered too much about it in class at all. I just remember the overall generalization of medications: always look for reasons not to give it." [Williams and Rindal et al [15] pg523] 12 "I deferred when close to the hospital because I think there's more of a comfort level in the hospital. They deal with it more. I think they're better. They have the ability to assess pain better than we do. They do drug dosages, which isn't that big of a deal but it's just something that they're more comfortable with . . . ." [Williams and Rindal et al [15]  "If I'm two minutes away from the hospital, it's gonna take me longer to stop, start the IV, put the person on the monitor, put the pulse oximetry on cuz you gotta check for that respiratory effort, and then actually administer the medicine versus driving two and a half or three minutes and havin' the hospital do it." [Williams and Rindal et al [15] pg524]

17
"Morphine is risky if you don't know a child's gonna have an allergic reaction to it." [Williams and Rindal et al [15] pg523] Concern for adverse effect when using strong analgesics 18 " . . .you know if you give an adult too much morphine for example and you make them hypotensive and you depress their respiratory rate and effort, you can fix that pretty quickly in an adult, but the repercussions of doing that in a little kid? The risk is higher." [Williams and Rindal et al [15]  "When we went through class we were always told to look for reasons to not give medication and there's never a great reason to give morphine . . .. I don't think we covered too much about it in class at all. I just remember the overall generalization of medications: always look for reasons not to give it." [Williams and Rindal et al [15] pg523]

22
"A child with a deformed arm is more likely to get significant analgesia than a child in severe abdominal pain, let's say, and appendicitis…" [Murphy and Barrett et al [14] pg496] Decision making; trauma is treated more readily than medical pain Prior clinical experience influences pain management 23 "People won't even consider paracetamol or ibuprofen for tummy pain…" [Murphy and Barrett et al [14] pg496] 24 "…We have a lot of barriers to IV access in younger children. The older ones wouldn't be a major problem but certainly younger children, which again certainly affects your mind set in relation to using the likes of morphine…" [Murphy and Barrett et al [14] pg496] Lack of confidence with IV analgesics 13 25 "I find it really hard to judge when is the right time, when is someone bad enough to warrant inflicting more pain with a cannula, and then the possibility that you might stick it into them two or three times before you would get anywhere, I would say, and with 90% of kids, I would really have no cannula…" [ "When it comes to children, we don't take histories, we don't actually have any hands-on experience and so our experience is very low. I think we are even at the stage whereby I think routinely we don't strip a child, we don't get them down to their nappy, we don't do that…" [Murphy and Barrett et al [14] pg496] 32 "I knew he was in pain because of his presentation. He was screaming with any movement or palpation to the area. He was tachycardic too. His vital signs coincided with his presentation and his discomfort. I looked for elevated heart rate, elevated blood pressures." [Williams and Rindal et al [15] pg523] Prior experience of managing pain is helpful 33 "I can say I have to prepare myself during a trip to a severely ill child... because first of all, I have a noticeably higher rate of stress ... depending on the nature of the alarm, of course ...if it's a prior one and a bad case with a child involved, so to speak, then it is stressful" [Holmström and Junehag et al [12]pg25] Raised clinician anxiety results in increased cautiousness 34 "Makes you a little more anxious when you're dealing with a child. I feel that when our anxiety level is raised we're gonna be a little more hesitant about doing things that we should. A little more cautious I should say. Maybe it hinders our ability to assess the patient appropriately." [Williams and Rindal et al [15] pg524]

35
"I have had a couple of appendicitis', I was at the GP's, and you go in there and the child is obviously in distress, in a lot of abdominal pain, and you're saying (to the GP), "Are you going to give him something for the pain?" And he's like, "No, you can't give him anything for the pain, it will only mask the symptoms when they get up to the hospital." So where do you go with that?" [Murphy and Barrett et al [14] pg496] Discordance between HCPs is challenging Colleagues influence the pain management process External Influences on the Clinician 36 "It's very hard to turn around and say to parents, "I know the GP has said not to give analgesia but the ambulance driver is now saying, Oh I'm going to give them analgesia"… those are becoming issues as well..." [Murphy and Barrett et al [14] pg496] 37 "It's something that could be in the back of your mind as well, the interaction you are having with the emergency department staff when you get there, and you know that if this, if you are going to do something it's actually going to cause a difficulty even though it's within your scope. It may be something that contributes to your decision of whether or not to do it..." [Murphy and Barrett et al [14] pg496]

38
"I think I may be more inclined to call for help from specialised units and the helicopter and such, as compared to when it's an adult." "Seek assistance from the resources at hand. We have good resources, we have specialised units and units with doctors in them and doctors on the phone." [Gunnvall and Augustsson et al [13] pg42] Collaboration between HCPs can be helpful 39 "On the best of days, we are two ambulances when there is a child involved ... then we are four people, which makes an opportunity to designate one person to take care of hysterical parents ... " [Holmström and Junehag et al [12]

58
"And I view this taking care of a child's pain, that it's not only a matter of taking care of the child but the whole situation around it, because it's the child's lifeworld I'm taking care of." [Gunnvall and Augustsson et al [13] pg42]

59
"Its purpose is to lessen pain and to make things better for the patient and that's why we're here-to make the patient better." [Williams and Rindal et al [15] pg523] 60 "Yes, I agree, but spontaneously, I would say that the primary focus is always the child. Parents will be secondary ... So, parents fall a little bit away. You get some kind of tunnel vision if there are few nurses in a place. It's the child and nothing else just then... until the child is stable ... then you can take care of the parents." [Holmström and Junehag et al [12] pg25] Child's experience more important than parent's experience 61 "… I usually prefer to do as much as possible in their home. Like we said before, then you can involve parents, colleagues, other relatives. And you can also involve the room, toys and such …." [Gunnvall and Augustsson et al [13]  "I have to establish contact so I can get close to the child; you have to learn to meet at their level. First of all, I learned to kneel or on the floor so that we reach the same eye level. I've learned to ask questions so that the child understands me. Also, I've learned to meet the child and show that I'm a kind person and not a threat. How I do it depends a bit on what kind of child I have in front of me. If I have a child who does not even want to look at me, I may start with talking to Mom and Dad. " [Holmström and Junehag et al [12] pg25] 66 "… They played at the same time as they were assessing and giving him the treatment…" [Jepsen and Rooth et al [11]  "…We have a lot of barriers to IV access in younger children. The older ones wouldn't be a major problem but certainly younger children, which again certainly affects your mind set in relation to using the likes of morphine…" [Murphy and Barrett et al [14] pg496] 72 "Not only did it relieve some of his pain, but it relieved some of his anxiety. Calmed him down a little bit more. It was easier to deal with him so it does have its benefits." [Williams and Rindal et al [15] pg523] Analgesia improves child anxiety and compliance Analgesics are helpful but administration is challenging 73 "... Nowadays we don't always have to hurt the child by inserting a PVC ... since we have the intranasal technique. And then it could be so anyway, that I have to insert this ... It hurts and can be messy ... They are chubby at a certain age ... it is often difficult to find the vessels..." [Holmström and Junehag et al [12] pg26] IV access is difficult, especially in younger children 74 "If I've got a distressed toddler with a deformed upper limb...pain score of 10/10 (indicating severe pain). This child, like most, won't tolerate oral medication, is even less likely to cooperate with the administration of inhaled nitrous oxide. Securing vascular access is often technically challenging in children, for most APs, even for those experienced in cannulation, so even attempting the procedure will add to the child's anxiety and fear. So there's nothing we currently have that'll work, from a practical perspective. Clearly the intranasal route, if available, would prove ideal in this scenario." [Murphy and Barrett et al [14] pg497] 75 "…We have a lot of barriers to IV access in younger children. The older ones wouldn't be a major problem but certainly younger children, which again certainly affects your mind set in relation to using the likes of morphine…" [Murphy and Barrett et al [14] pg496] 76 "If you have a child that is vomiting and that you can't get a line on, you're kind of snookered as well because it eliminates everything you can do really, which is where your intranasal drug would come in fantastic..." [Murphy Intranasal drugs may be beneficial when IV and Barrett et al [14] pg496] access is difficult 77 "If I've got a distressed toddler with a deformed upper limb...pain score of 10/10 (indicating severe pain). This child, like most, won't tolerate oral medication, is even less likely to cooperate with the administration of inhaled nitrous oxide. Securing vascular access is often technically challenging in children, for most APs, even for those experienced in cannulation, so even attempting the procedure will add to the child's anxiety and fear. So there's nothing we currently have that'll work, from a practical perspective. Clearly the intranasal route, if available, would prove ideal in this scenario." [Murphy and Barrett et al [14]  "We don't actually perform assessments on very young children, so like say at the age of 3 and below, where almost you might as well take them out of the pain relief category because it's nearly impossible to assess it…" [Murphy and Barrett et al [14] pg495] 86 "We're probably less equipped at the younger age and it's really just a general, your general impression…" [Murphy and Barrett et al [14] pg496] 87 "Until they're actually at a stage where they can comprehend what you're saying or they can get to the stage where, they can understand the Wong-Baker chart, it's a bit hit-and-miss…" [Murphy and Barrett et al [14] pg496] 88 "I think you hear how the little child screams and so on. You can recognise the type of scream. Whilst it gets more difficult, I think, when you get to teenagers and some older children. There can be a lot of difficult assessments with teenagers" [Holmström and Junehag et al [12] pg26] Older children are more difficult to assess 89 "Are you screaming because you're in pain? Are you screaming because you're sad? Are you screaming because you're afraid? Are you screaming because … well, I don't know." [Gunnvall and Augustsson et al [13] pg41] Assessment of pain is very difficult in children 90 "When you don't know why they are screaming, I think it's hard…" [Jepsen and Rooth et al [11] pg5] 91 "When it comes to children, we don't take histories, we don't actually have any hands-on experience and so our experience is very low. I think we are even at the stage whereby I think routinely we don't strip a child, we don't get IV -Intravenous, HCP -Health Care Professional them down to their nappy, we don't do that…" [Murphy and Barrett et al [14] pg496] 92 "…I don't think it has taken the importance or it hasn't got to the same level of relevance as say, adult pain relief has, where that's a taken and it's a given that there will be pain relief given as early as possible…" [Murphy and Barrett et al [14] pg494] Difference between treating adults and children is challenging 93 "It's something I would look up just because it's not something that I do as often as other protocols. I would definitely need to look them [pediatric protocols] up more so than for adults . . .." [Williams and Rindal et al [15] pg523] 94 "People aren't used to it and haven't gotten into the mind set that pain relief is an integral part of paediatric treatment…" [Murphy and Barrett et al [14] pg494] 95 "You do not have the same routine to take care of children, you do not meet children seven days a week, like adults ... but children are not like little adults anyway, they are something else that requires extra supervision of the doses .. and other things and that is a stress factor.. " [Holmström and Junehag et al [12]] 96 "Well, their play, in so far as … or, rather, kids' curiosity. All kids are curious. And that's also very important when, like, you see these tired, drooping, pain … if you see the slightest sign of curiosity in their eyes, then you know, well, it's not like … OK, the kid is sick, but not taking it so super seriously … A lot of times you get that feeling." [Gunnvall and Augustsson et al [13] pg42] Physiological signs are helpful in identifying pain 97 "I knew he was in pain because of his presentation. He was screaming with any movement or palpation to the area.
He was tachycardic too. His vital signs coincided with his presentation and his discomfort. I looked for elevated heart rate, elevated blood pressures." [Williams and Rindal et al [15] pg523] 3. The ability of prehospital clinicians to effectively manage pain in children is influenced by child factors such as challenging pain assessment and analgesic administration and the perceived importance of the child's experience. [11][12][13][14][15] Minor concerns regarding methodological limitations that may reduce confidence in the review finding. (Three studies with no concern, one study with minor concern [insufficient rigorous data analysis] and one study with moderate concern [unclear justification for recruitment strategy, no reflexivity and insufficient rigorous data analysis]) [ [11][12][13][14][15] Low Moderate concerns about adequacy of data and minor concerns about methodological limitations and relevance 3. The ability of prehospital clinicians to effectively manage pain in children is influenced by child factors such as challenging pain assessment and analgesic administration and the perceived importance of the child's experience.