Managing Pediatric Pain in Low-Resource Emergency Settings: Barriers,Advances,and Future Directions

Abstract

Pediatric pain remains frequently under-recognized and inadequately managed in emergency departments (EDs), particularly in low- and middle-income countries (LMICs), leading to significant physical and psychological harm. This narrative review synthesizes current evidence on pediatric pain management in LMIC emergency settings, highlighting both established practices and emerging innovations. Established approaches include pharmacologic interventions such as acetaminophen, NSAIDs, and opioids and cost-effective non-pharmacologic methods like distraction, guided imagery, and parental involvement. Despite their demonstrated benefits, implementation in LMICs is hindered by limited provider training, restricted access to essential analgesics, and cultural misconceptions about childhood pain. Emerging innovations involve task-shifting models to expand workforce capacity, digital and AI pain assessment tools, and context-adapted community interventions. Improving pediatric pain care in LMICs demands a multifaceted strategy integrating culturally adapted assessment tools, equitable access to analgesics, scalable non-pharmacologic interventions, and sustainable workforce development supported by technology-driven solutions.

Introduction

Pain is a prevalent and distressing symptom among children presenting to emergency departments worldwide, serving as an indicator of potential physiological and psychological sequelae. ¹ Studies indicate a high prevalence of pain in pediatric ED populations, with estimates ranging from 55% to 75% of patients experiencing moderate to severe pain.^2,3 A persistent concern is the documented discrepancy between child or parent-reported pain intensity and healthcare provider assessments, which often leads to underestimation and undertreatment.^4,5 Effective pediatric pain management is crucial not only for immediate relief but also to mitigate long-term risks, including the development of chronic pain patterns and procedural anxiety. ⁶

Accurate assessment is foundational, utilizing tools ranging from self-report scales like the Visual Analog Scale (VAS) to observer-based instruments like the FLACC (Face, Legs, Activity, Cry, Consolability) scale for non-verbal or younger children. ⁷ Management employs a multimodal approach, integrating pharmacologic and non-pharmacologic strategies. While high-resource settings utilize a broad analgesic arsenal including intranasal fentanyl and opioids, access in LMICs is frequently constrained. ⁸

Despite global advancements, profound disparities persist in low-resource emergency settings. Challenges include critical shortages of essential medicines, a lack of trained healthcare professionals, inadequate pain assessment protocols, and deeply rooted cultural beliefs that minimize childhood pain expression.^9,10 Furthermore, robust evidence on the efficacy, safety, and feasibility of pain management interventions specifically within LMIC contexts remains scarce. ¹¹

This narrative review aims to synthesize the current understanding of pediatric pain management with a dedicated focus on low-resource emergency settings. Its unique contribution lies in its specific synthesis for LMIC EDs, critically examining the intersection of 2 pivotal, yet underexplored, solutions: (1) the potential of AI-driven and digital health innovations for assessment and management, and (2) the scalability of task-shifting and training models to bridge the human resource gap. By integrating evidence on barriers, established practices, and these emerging innovations, this review provides a comprehensive framework for advancing equitable pediatric pain care.

Methods

This state-of-the-art narrative review was conducted to summarize and critically appraise current evidence on pediatric pain management in low- and middle-income country (LMIC) emergency settings. The methodology was designed in accordance with guidance for developing rigorous and practical narrative reviews. ¹²

• Literature Search: A systematic search was executed in January 2025 across 3 electronic databases: PubMed, Scopus, and Google Scholar. The search timeframe encompassed publications from 2000 to 2025, with a deliberate emphasis on identifying literature from 2015 onward to capture recent developments and innovations.

• Search Strategy: The search employed a combination of keywords and Medical Subject Headings (MeSH) terms including: “pediatric pain” OR “child pain,” “pain management” OR “analgesia,” “emergency department” OR “acute care,” “low-resource settings” OR “resource-limited,” “developing countries” OR “LMIC,” and “non-pharmacologic interventions.” Boolean operators (AND, OR) were used to combine these concepts.

• Inclusion Criteria: Articles were included if they: (1) involved pediatric populations (0-18 years), (2) primarily addressed pain assessment or management in emergency or acute care settings, and (3) were conducted in, or were directly relevant to, low- and middle-income or resource-limited contexts as defined by the World Bank.

• Exclusion Criteria: We excluded: (1) non-English language publications, (2) conference abstracts without accessible full text, (3) studies focused exclusively on adult populations or chronic pain in non-acute settings, and (4) articles not providing original data or relevant synthesis (eg, editorials without novel analysis).

• Data Synthesis: The selected literature was narratively synthesized and organized into 7 major thematic areas: epidemiology and burden, barriers to assessment, pharmacologic strategies, non-pharmacologic strategies, task-shifting/training, digital/AI innovations, and policy recommendations. Data extraction focused on study design, population, key findings, and relevance to LMIC emergency contexts. Thematic sufficiency was considered achieved when iterative review of new articles yielded no substantially new concepts within the predefined themes.

• Methodological Considerations: Consistent with the narrative review approach, no formal quality appraisal tool or quantitative meta-analysis was performed. This choice allows for the inclusion of a broad range of study designs necessary to map a complex, multidisciplinary field. To mitigate potential bias from including studies of variable quality, we explicitly discuss the limitations of the evidence base, including study design and generalizability, in a dedicated section of the Discussion.

Epidemiology and Burden of Untreated Pediatric Pain in LMICs

Acute pain is a ubiquitous presentation in pediatric emergency settings globally. Multicenter studies report high prevalence rates; for example, a study in Spain found 53.1% of children in the ED experienced pain, with abdominal and limb pain being most frequent. ¹³ In pre-hospital settings, the vulnerability is pronounced: an Irish study found 41.4% of children transported by ambulance were in pain, yet only 26% received pre-hospital analgesics, highlighting a critical care gap. ¹⁴

A consistent and troubling theme across settings is the discrepancy between clinician and patient/parent pain assessments. Healthcare professionals often underestimate severity, directly contributing to inadequate management and negative treatment experiences. ¹⁵ This assessment failure is the first step in a cascade of negative outcomes.

Inadequate pediatric pain management inflicts significant harm. Beyond immediate suffering, it elevates parental stress and increases the risk of distress and heightened pain perception during future medical procedures, particularly in young children. ¹⁶ Poorly managed acute pain can impair basic functions; a post-tonsillectomy study noted 75% of children exhibited behavioral changes, with majority experiencing sleep and feeding difficulties due to pain. ¹⁷

Persistent systemic and cultural barriers perpetuate this burden. A survey revealed approximately one-third of physicians believed analgesics could mask symptoms in acute abdominal conditions, reflecting enduring misconceptions that impede effective pain relief. ¹⁸ This underscores that the challenge is not solely one of resource availability, but also of knowledge, attitude, and systemic protocol.

Barriers to Accurate Pain Assessment and Intervention in LMIC Settings

Effective pain management is predicated on accurate assessment, which faces multifaceted barriers in LMICs stemming from cultural, professional, and systemic factors.

• Cultural and Professional Biases: Deep-seated cultural norms may view pain expression as a sign of weakness, leading children and families to minimize complaints. Concurrently, healthcare professionals may hold misconceptions about children’s pain tolerance or the necessity of treatment, resulting in inadequate assessment. ¹⁹ Studies consistently identify insufficient provider knowledge as a major impediment to effective pediatric pain relief. ²⁰

• Challenges with Assessment Tools: The implementation of standardized tools is fraught with difficulty. Linguistic and cultural differences can render scales developed in Western contexts invalid or difficult to apply. Translations may not capture nuances, and facial expressions used in tools like the Wong-Baker FACES scale can be interpreted differently across cultures. ²¹ Inadequate training on tool use further compromises accuracy. Furthermore, resource shortages—including time, personnel, and dedicated assessment protocols—in busy EDs directly impede consistent pain evaluation. ²²

• Cognitive and Contextual Limitations: Many tools rely on a child’s cognitive and linguistic abilities, posing challenges in low-literacy settings or with very young children. Adapting tools to local languages and contexts is essential. For instance, the Oucher Scale, which incorporates photographic facial expressions of children from specific ethnic groups, represents a successful model of cultural adaptation for improved self-report. ²³ Addressing these barriers requires a triad of interventions: cultural adaptation of tools, comprehensive provider training, and systemic support to integrate assessment into routine clinical workflow.

Pharmacologic Pain Management in Pediatric LMIC Emergency Settings

Pharmacologic management in LMIC EDs is constrained by a nexus of financial limitations, logistical inefficiencies, and regulatory barriers, creating a landscape of inequitable access and suboptimal use. ²⁴

Accessibility of Pharmacologic Agents

Essential analgesics, particularly opioids, are often unavailable due to strict regulatory controls stemming from concerns about misuse and diversion. Morphine, the gold standard for severe pain, is frequently underutilized due to these restrictions, lack of prescriber training, and bureaucratic procurement hurdles. ²⁵ While acetaminophen and NSAIDs are more widely available, they are insufficient for moderate-to-severe pain. ²⁶

Fragile supply chains and poor infrastructure lead to frequent stock-outs, especially in rural facilities. Disparities are stark between urban and rural access, with even basic analgesics sometimes lacking in remote areas. ²⁷ A critical issue is the paucity of pediatric-appropriate formulations (eg, liquid suspensions), forcing healthcare workers to manipulate adult dosages, which increases the risk of dosing errors. ²⁸

Efficacy, Safety, and Practice Gaps

Acetaminophen and NSAIDs are effective first-line agents for mild-to-moderate pain with a favorable safety profile, though intravenous acetaminophen is rarely available in LMICs.^29,30 Ketamine at sub-dissociative doses is a valuable alternative, demonstrating non-inferiority to opioids for acute pain without causing respiratory depression, making it safer in monitoring-limited settings.^31,32 Opioids (morphine, fentanyl) are highly effective for severe pain but carry risks of respiratory depression and sedation. These risks are amplified in settings lacking continuous monitoring and reversal agents like naloxone. ³³

A pervasive problem is under-dosing, driven by unwarranted fears of addiction and respiratory depression. This, coupled with insufficient training in pediatric pain assessment and pharmacotherapy, leads to widespread inadequate analgesia. ³⁴ The lack of reliable assessment further compromises targeted and effective analgesic use.

Alternative Routes of Administration

When intravenous access is difficult, alternative routes are vital. Intranasal (IN) fentanyl and IN ketamine provide rapid, effective analgesia without need for IV lines. ³⁵ Intramuscular (IM) administration of analgesics like ketamine remains a pragmatic, life-saving option in resource-constrained or pre-hospital scenarios. ³⁶ Table 1 summarizes key pharmacologic options, contrasting their profiles in high- versus low-resource contexts.

Table 1.

Comparison of Pharmacologic Pain Management Options in High- Versus Low-Resource Settings.^{31 -36}

Drug/method	Efficacy & indication	Key safety & constraint concerns	High-resource settings (availability/route)	Low-resource settings (availability/route)
Morphine	Gold standard for severe pain. Strong efficacy.	Regulatory limits, fear of misuse/diversion, risk of respiratory depression. Under-dosing common.	Readily available. IV/Oral formulations.	Restricted access, limited use. Often unavailable.
Fentanyl	Strong efficacy for severe pain. IN provides rapid analgesia.	Highly regulated. Worries about abuse.	IV and intranasal formulations widely available.	IN fentanyl is a key non-invasive alternative when available.
Ketamine	Effective sedative & analgesic. IN/IM forms useful.	Generally well-tolerated. Transient neuropsychiatric effects.	IV/IN for pain/sedation.	IN/IM ketamine is a critical, widely used alternative.
Acetaminophen	Limited efficacy for moderate-severe pain. For mild pain.	Favorable safety. IV form often unavailable.	IV and oral forms accessible.	Oral/parenteral forms common. IV rare.
Ibuprofen	Effective for inflammatory pain. For mild pain.	Renal/GI risks, especially in malnourished children. Insufficient for severe trauma.	Oral and IV formulations.	Primarily oral formulation.
Gabapentinoids	Used for neuropathic/chronic pain.	Neuropsychiatric effects (somnolence, dizziness).	Used for chronic pain.	Very limited availability.
Lidocaine Patches	Localized pain relief.	Risk of systemic toxicity in children.	Common for localized relief.	Rarely available.

Abbreviations: IV, intravenous; IN, intranasal; IM, intramuscular; GI, gastrointestinal.

The evidence base for pharmacologic interventions in LMICs is notably weaker than in high-income countries, relying heavily on observational data and extrapolation. This underscores an urgent need for context-specific clinical trials to establish robust, feasible guidelines for LMIC emergency settings.

Non-Pharmacologic Pain Management Strategies in LMICs

Non-pharmacologic interventions are indispensable in LMIC EDs. They are typically low-cost, scalable, and can be used synergistically with pharmacologic methods to improve overall comfort and outcomes. ³⁷

Cognitive-Behavioral Techniques modify pain perception through psychological engagement.

• Guided Imagery: Involves directing a child’s attention to calming, pleasant mental scenarios, effectively reducing anxiety and perceived pain intensity with minimal resources. ³⁸

• Distraction Techniques: Use engaging stimuli (toys, bubbles, stories, virtual reality) to divert attention from painful procedures. Simple methods are highly effective for young children. ³⁹

• Music Therapy: Listening to or creating music can reduce distress, lower physiological arousal (heart rate, blood pressure), and provide comfort. ⁴⁰

Physical Modalities provide direct sensory input to modulate pain signals.

• Transcutaneous Electrical Nerve Stimulation (TENS): Low-cost TENS units disrupt pain signaling and are becoming a feasible option for musculoskeletal pain in some LMIC settings. ⁴¹

• Acupressure & Massage: These techniques use pressure or touch to promote relaxation and circulation, proving particularly helpful for infants during minor procedures. ⁴²

Family-Centered and Community-Based Approaches

Integrating families is a powerful, no-cost strategy. Parental presence, soothing talk, and holding provide emotional security, reducing a child’s fear. ⁴³ Skin-to-skin contact (kangaroo care) is especially effective for neonates, providing warmth and physiological stabilization during painful procedures. ⁴⁴

Community-based interventions can bridge cultural gaps by thoughtfully integrating evidence-based practices with accepted traditional healing methods. While some traditional practices offer psychological comfort, collaboration is needed to ensure safety and efficacy, promoting adherence through cultural resonance. ⁴⁵ Key strategies are summarized in Table 2.

Table 2.

Non-Pharmacologic Pain Management Strategies and Their Applicability in LMICs.^{41 -45}

Strategy	Mechanism of action	Effectiveness	Resource requirements/cost	Scalability in LMICs
Guided imagery	Alters pain perception via imagination	High	Very low/minimal equipment	High
Distraction	Engages attention away from pain	Moderate-high	Low/simple tools (bubbles, toys)	High
Music therapy	Modulates physiological responses	Moderate	Low	High
TENS therapy	Disrupts pain signaling electrically	Moderate	Moderate (requires affordable device)	Moderate
Acupressure	Stimulates pressure points	Moderate	Very low/no equipment	High
Parental involvement	Provides emotional security	High	No cost	High
Skin-to-skin contact	Promotes physiological stability	High (neonates)	No cost	High

Abbreviation: TENS, transcutaneous electrical nerve stimulation.

Widespread implementation requires focused training for healthcare workers, community awareness campaigns, and the systematic inclusion of these techniques in clinical protocols to reduce over-reliance on scarce pharmaceuticals.

Task-Shifting and Training Initiatives for Pediatric Pain Management in LMICs

Task-shifting delegating specific clinical tasks to less-specialized health workers is a necessary strategy to address the critical shortage of pediatric pain specialists in LMICs, particularly in rural areas. ⁴⁶

• The Need and Evidence: The specialist gap is severe. For example, Mozambique has only a handful of pain-trained physicians and nurses for its entire population, while Kenya’s few pediatric pain clinics are overwhelmed, leaving general practitioners and anesthesiologists to manage complex cases.^47,48 This urban concentration of care exacerbates geographic health inequities.

• Challenges and Enablers: Successful task-shifting requires overcoming challenges including lack of ongoing supervision, interprofessional role conflicts, increased workload, and ambiguous regulatory/liability frameworks.^49,50 Mitigation requires clear scope-of-practice definitions, structured competency-based training, and strong mentorship systems. Interprofessional collaboration is key to building supportive teams. ⁵¹

• Successful Models: Several African nations offer instructive models. Uganda’s policy change allowing trained nurses and clinical officers to prescribe morphine significantly improved access to strong analgesics. ⁵² Multi-country certificate courses in palliative care (eg, in Tanzania, South Africa) have built regional training capacity. ⁵³ Zimbabwe’s National Strategy for Palliative Care (2020) exemplifies a policy-driven approach to improve education, drug availability, and service integration. ⁵⁴ These examples demonstrate that with intentional training, supportive policy, and supervision, non-specialist healthcare workers can safely and effectively manage pediatric pain.

Digital and AI-Based Innovations for Pediatric Pain Assessment and Management

Digital and AI technologies offer promising tools to overcome traditional barriers to pain assessment and management, though their application in LMICs is nascent and faces specific challenges.

• AI for Pain Assessment: Facial expression analysis using convolutional neural networks (CNNs) can detect pain with high accuracy (85%-95%), outperforming some traditional observer scales. ⁵⁵ Multimodal systems integrating facial cues with physiological data (eg, electrodermal activity) show even greater promise. ⁵⁶ However, these systems are often trained on homogeneous datasets and may not generalize across diverse ethnicities and cultures prevalent in LMICs, necessitating local validation.

• Wearable Devices and Mobile Health (mHealth): Wearables that monitor physiological markers (heart rate variability, galvanic skin response) can provide continuous, objective pain data, though they remain underutilized in clinical practice. ⁵⁷ Mobile applications gamify pain assessment, improving engagement and adherence in children and adolescents, and can facilitate remote monitoring and analgesic scheduling.^58,59

• Virtual Reality (VR) for Distraction: VR has strong evidence as a distraction tool during procedures like IV placement, significantly reducing pain and anxiety scores in children.^60,61 While headset costs are falling, the feasibility of VR in busy, under-resourced EDs requires careful consideration.

• Feasibility and Ethical Considerations for LMICs: The translation of these innovations to LMIC settings is not straightforward. Critical barriers include:

• • Cost: Affordability of devices and maintenance.

• • Digital Literacy: Among both providers and patients/caregivers.

• • Data Privacy & Ethics: Robust frameworks for data security, consent, and ethical AI use are often underdeveloped.

• • Context Validation: Tools must be validated in LMIC populations and clinical environments before scale-up.

Therefore, while digital/AI tools hold immense potential, their implementation must be preceded by feasibility studies, cost-benefit analyses, and the development of supportive infrastructural and governance systems (Figure 1).

Figure 1.

Geographical distribution of reviewed studies/interventions by LMIC region.

Future Directions and Policy Recommendations for Scaling Pediatric Pain Management in LMICs

Transforming pediatric pain care in LMICs requires coordinated action across clinical practice, health systems, and policy. The conceptual framework in Figure 2 outlines this multi-level approach.

Figure 2.

Conceptual framework for improving pediatric pain management in LMIC emergency settings.

Health Systems Strengthening

• Supply Chains: Implement robust forecasting, procurement, and distribution systems for essential analgesics, with a focus on reliable pediatric formulations.

• Regulatory Reform: Balance the need for controlled substance security with ensuring equitable medical access to opioids, learning from models like Uganda’s nurse-prescribing policy. ⁵²

• Integrate into UHC: Embed pediatric pain management as a core component of Essential Health Benefit packages and Universal Health Coverage plans to ensure financing and prioritization.

Workforce Development

• Curriculum Integration: Incorporate pediatric pain assessment and management into national medical, nursing, and clinical officer training curricula.

• Scale Task-Shifting: Develop and support accredited, competency-based training programs for nurses and mid-level providers, backed by clear policies, mentorship, and sustainable supervision.

• Leverage Digital Learning: Use distance-learning platforms to reach healthcare workers in remote areas.

Research and Innovation Priorities

• Conduct multicenter pragmatic trials within LMICs to establish context-specific efficacy and safety data for pharmacologic and non-pharmacologic interventions.

• Support the co-design and validation of culturally adapted pain tools and feasible digital/AI solutions with local stakeholders.

• Investigate sustainable financing models and implementation strategies for scaling successful pilot programs.

Global and National Policy Action

• International Agencies (WHO, UNICEF): Should update and actively disseminate pediatric pain management guidelines for resource-limited settings, support essential medicines lists, and fund implementation research.

• National Governments: Must develop and enact national pain management policies and strategies, invest in workforce training, and strengthen pharmaceutical supply systems.

• Call to Action: A global commitment is needed to recognize effective pain relief as a fundamental right of every child. This requires moving from awareness to actionable investment in the systems, tools, and trained personnel necessary to make this right a reality in all emergency settings, regardless of resource level.

Study Limitations

This narrative review has several limitations. Methodologically, the exclusion of non-English literature and reliance on primary databases (PubMed, Scopus, Google Scholar) may have omitted relevant studies published in local journals or gray literature. The narrative synthesis approach, while comprehensive, precludes quantitative meta-analysis and formal assessment of evidence strength.

Substantively, the available evidence base itself has gaps. There is a relative scarcity of high-quality randomized controlled trials conducted within LMIC emergency settings; much of the data is observational or extrapolated from high-income contexts. The reviewed literature on cutting-edge innovations like AI and VR predominantly stems from high-resource settings, limiting direct applicability to LMICs without further validation. Furthermore, significant heterogeneity exists across the vast spectrum of LMICs in terms of culture, health system structure, and resources, challenging the generalizability of any single recommendation. These limitations highlight the critical need for more context-specific, high-quality research in this field.

Conclusion

Pediatric pain in LMIC emergency departments is a pervasive, undertreated problem with profound consequences. Barriers are multifactorial, spanning drug shortages, workforce gaps, cultural misconceptions, and fragile systems. This review synthesizes a dual pathway forward.

Immediate, practical gains are achievable at the bedside: implementing routine pain assessment with adapted tools, empowering families, utilizing non-invasive analgesic routes (IN/IM), and deploying low-cost non-pharmacologic techniques like distraction and comfort positioning.

Sustained improvement, however, demands systemic commitment. This includes strengthening analgesic supply chains, expanding the workforce through supervised task-shifting with rigorous training, and explicitly integrating pediatric pain management into national emergency care policies and financing frameworks. Digital innovations offer promise but require ethical, locally validated, and feasible implementation strategies.

Ultimately, achieving equity in pediatric pain relief is a matter of justice. Providing effective pain management is not merely a clinical best practice but a fundamental human right of every child. Closing the gap between current reality and these imperative demands concerted global action, context-sensitive innovation, and unwavering political will to prioritize the relief of suffering for the most vulnerable.