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This comment aims to illustrate and discuss the complexity of the pain management process for children in the pre-hospital setting. We have developed a process map illustrating the four facets of pre-hospital pain management in children; the illness / injury causing the pain, the child’s perception of the pain, the ambulance clinician’s assessment of the pain and the ambulance clinician’s management of the pain. These four facets are influenced by a number of factors and informed by an overarching theory of pain: gate control theory. Pre-hospital pain management in children is extremely complex. Further research is required to explore the associations and influencing factors within this process map.

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 med

Aim :To undertake a qualitative systematic review that explores psychological and social impact, reported directly from children and adolescents at least 6 months after their critical illness. Background :Significant advances in critical care have reduced mortality from childhood critical illness, with the majority of patients being discharged alive. However, it is widely reported that surviving critical illness can be traumatic for both children and their family. Despite a growing body of literature in this field, the psychological and social impact of life threatening critical illness on child and adolescent survivors, more than 6 months post event, remains under-reported. Data sources: Searches of six online databases were conducted up to February 2012. Review methods : Predetermined criteria were used to select studies. Methodological quality was assessed using a standardized checklist. An adapted version of the thematic synthesis approach was applied to extract, code and synthesize data. Findings : Three studies met the inclusion criteria, which were all of moderate methodological quality. Initial coding and synthesis of data resulted in five descriptive themes: confusion and uncertainty, other people's narratives, focus on former self and normality, social isolation and loss of identity, and transition and transformation. Further synthesis culminated in three analytical themes that conceptualize the childhood survivors' psychological and social journey following critical illness. Conclusions : Critical illness in childhood can expose survivors to a complex trajectory of recovery, with enduring psychosocial adversity manifesting in the long term. Nurses and other health professionals must be aware and support the potential multifaceted psychosocial needs that may arise. Parents and families are identified as fundamental in shaping psychological and social well-being of survivors. Therefore intensive care nurses must take opportunities to raise parents' awarenes

The involvement of patients and the public in the development, implementation and evaluation of health care services and research is recognized to have tangible benefits in relation to effectiveness and credibility. However, despite >96% of children and young people surviving critical illness or injury, there is a paucity of published reports demonstrating their contribution to informing the priorities for aftercare services and outcomes research. We aimed to identify the service and research priorities for Paediatric Intensive Care Unit survivors with children and young people, their families and other stakeholders. We conducted a face‐to‐face, multiple‐stakeholder consultation event, held in the Midlands (UK), to provide opportunities for experiences, views and priorities to be elicited. Data were gathered using write/draw and tell and focus group approaches. An inductive content analytical approach was used to categorize and conceptualize feedback. A total of 26 individuals attended the consultation exercise, including children and young people who were critical care survivors; their siblings; parents and carers; health professionals; academics; commissioners; and service managers. Consultation findings indicated that future services, interventions and research must be holistic and family‐centred. Children and young people advisors reported priorities that focused on longer‐term outcomes, whereas adult advisors identified priorities that mapped against the pathways of care. Specific priorities included developing and testing interventions that address unmet communication and information needs. Furthermore, initiatives to optimize the lives and longer‐term functional and psycho‐social outcomes of Paediatric Intensive Care Unit survivors were identified. This consultation exercise provides further evidence of the value of meaningful patient and public involvement in identifying the priorities for research and services for Paediatric Intensive Care Unit survivors an

Introduction: Over 5 million children attend the Emergency Department (ED) annually in England with an ever-increasing paediatric emergency caseload echoed globally. Approximately 60% of children present with illness and the majority have non-urgent illness creating burgeoning pressures on children’s ED and this crisis resonates globally. To date no qualitative systematic review exists that focuses on the parental reasons for childhood attendance at the ED in this subgroup. Aim: To identify parental reasons for attending ED for their children presenting with minor illness. Method: A qualitative systematic review was conducted against inclusion/exclusion 10 criteria. Five electronic databases and key journals were searched in June 2015. Findings: 471 studies were identified and following study selection, 4 qualitative studies 12 were included. Nine themes were identified e.g. dissatisfaction with family medical services, perceived advantages of ED and ‘child suffering’ with novel and insightful sub-themes of ‘hereditary anxiety’, ‘taking it off our hands’, ED as a ‘magical place’. Conclusion: This novel qualitative systematic review examined parental attendance presenting with childhood minor illness of interest to emergency care reformers and clinicians. ED attendance is complex and multifactorial but parents provide vital insight to ED reformers on parental reasons for ED attendance in this sub group.

The purpose of this study was to explore the experience of decision making in the care of children with palliative care needs in Jordan, from the perspective of their mothers. This study employed a collective qualitative case study approach. Data were collected in 3 pediatric wards in a Jordanian hospital. The study used 2 data collection methods: participant observation (197 observational hours) and 56 semi-structured interviews with 24 mothers, 12 physicians and 20 nurses. The findings show how Jordanian mothers seek to transfer the role of decision making to physicians, as they perceive themselves to be unable to make decisions about critical issues related to the treatment of their children. Mothers had a widespread apprehension of “future guilt,” especially when they feared that any decisions they might make could have an adverse impact on their children. Contrary to the predominant pattern, some mothers took a proactive approach towards decision making about their children’s treatment. These mothers requested detailed information from primary physicians and sought different sources of knowledge such as second opinions, reading online resources, or talking to other parents who had a child with similar circumstances. The study concludes that mothers prefer to involve physicians in decisions about their children’s healthcare and treatment to eliminate their fear of probable future guilt; this modifies any tendency to autonomously decide for their children. These findings are underpinned by the Jordanian culture in which doctors’ opinions are highly regarded.

Health care is becoming increasingly complex. The pre-hospital setting is no exception especially when considering the unpredictable environment. To address complex clinical problems and improve quality of care for patients, researchers need to use innovative methods to create the necessary depth and breadth of knowledge. Quantitative approaches such as randomised controlled trials and observational (e.g. cross-sectional, case control, cohort) methods, along with qualitative approaches including interviews, focus groups, and ethnography have traditionally been used independently to gain understanding of clinical problems and how to address these. Both approaches however have drawbacks: quantitative methods focus on objective, numerical data and provide limited understanding of context, whereas qualitative methods explore more subjective aspects and provide perspective, but can be harder to demonstrate rigour. We argue that mixed methods research, where quantitative and qualitative methods are integrated, is an ideal solution to comprehensively understand complex clinical problems in the pre-hospital setting. The aim of this article is to discuss mixed methods in the field of pre-hospital research, highlight its strengths and limitations and provide examples. This article is tailored to clinicians and early career researchers and covers the basic aspects of mixed methods research. We conclude that mixed methods is a useful research design to help develop our understanding of complex clinical problems in the pre-hospital setting.

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 med

Objective: We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting. Methods: A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong & Baker faces scale or FLACC [face, legs, activity, crying and consolability] scale). Results: 2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 65% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18-1.97), administered analgesia (AOR 2.26; CI 1.87-2.73), attended by a paramedic (AOR 1.40; CI 1.15-1.71) or living in an area of low deprivation (index of multiple deprivation [IMD] 8-10) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.24; CI 1.01-1.53). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant. Conclusion: These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.

Background: Pre-hospital pain management in children is poor, with very few children in pain receiving analgesia. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting. Methods: A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong & Baker faces scale or FLACC [face, legs, activity, crying and consolability] scale). Results/Findings: 2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.57; 95% confidence interval [CI] 1.21-2.03), administered analgesia (AOR 2.35; CI 1.94-2.84), attended by a paramedic (AOR 1.39; CI 1.13-1.70) or living in an area of medium deprivation (index of multiple deprivation [IMD] 4-7) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.41; CI 1.10-1.79). Child sex, type of pain, transport time and clinician experience were not significant. Conclusion: These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.

Introduction: The management of pain is complex, especially in children, as age, developmental level, cognitive and communication skills and associated beliefs must be considered. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. The aim of this review is to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services. Methods: A mixed-methods approach has been adopted due to the research question lending itself to qualitative and quantitative inquiry. The segregated methodology will be used where quantitative and qualitative papers are synthesised separately, followed by mixed-methods synthesis (meta-integration). We will search from inception: MEDLINE, CINAHL and PsycINFO via EBSCOHost, EMBASE via Ovid SP, Web of Science and Scopus. The Cochrane Library, the Joanna Briggs Institute, PROSPERO, ISRCTN and ClinicalTrials.gov will be searched. We will include empirical qualitative and quantitative studies. We will exclude animal studies, reviews, audits, service evaluations, simulated studies, letters, Best Evidence Topics, case studies, self-efficacy studies, comments and abstracts. Two authors will perform full screening and selection, data extraction and quality assessment. GRADE and CERQual will determine the confidence in cumulative evidence. Discussion: If confidence in the cumulative evidence is deemed Moderate, Low or Very Low, then this review will inform the development of a novel mixed-methods sequential explanatory study which aims to comprehensively identify predictors, barriers and facilitators to effective pain management of acute pain in children within ambulance services. Future research will be discussed among authors if confidence is deemed High.

Background: When children suffer acute pain, the ambulance service is often involved to provide initial assessment, treatment and transport. Several predictors of effective pain management have been identified, including children who are younger (0-5 years), administered analgesics and living in homes from more affluent areas. Objective: To explain previously identified predictors of effective pre-hospital pain management in children. Design: Mixed methods sequential explanatory study. Setting and participants: East Midlands Ambulance Service National Health Service Trust paramedics and emergency medical technicians (EMTs) participated in face-to-face semi-structured interviews. These were audio recorded, transcribed verbatim and coded using thematic analysis. Meta-inferences were generated and illustrated within a joint display. Results: 12 clinicians (9 paramedics and 3 EMTs) were interviewed. Median (interquartile range) age was 43.5 years (41.5, 45.75), 58% were male (n=7) and 58% were parents (n=7). Possible explanations were provided for all predictors. Younger children were perceived to express more emotion, were easier to distract and lived more in the moment than their older counterparts, which explained why younger children were more likely to achieve effective pain management. Analgesics were perceived to have a psychosocial benefit in addition to the pharmacological action. Ambulance clinicians felt that children living in more affluent areas were more likely to achieve effective pain management because the kempt environment facilitated assessment and management and clinicians spent more time on scene; this allowed more time for analgesics to take effect. Participants perceived paramedics to be more confident, and it was found that paramedics were older, more experienced, had a greater scope of practice and spent more time on scene than EMTs. Conclusion: Pre-hospital pain management in children could be improved by facilitating and prioritising analgesic