Pain is an unpleasant emotion and sensory complaint associated with actual or potential tissue damage, as defined by the International Association for the Study of Pain (1–3). Pain is the “fifth vital sign,” and it should be assessed and recorded as usual with other vital signs (4–7). The appropriate intervention for pain is planned based on an accurate valuation of pain. Organized and routine pain assessment using standardized and validated measures is accepted as effective pain management in pediatric patients (8–10). Subjective experience and individual self-reporting are the favourite methods for assessing pain. Hence, when valid self-report is not available, as in children who cannot communicate due to age or developmental status, the observational and behavioural assessment tools are cornerstone substitutions (11).

Pediatric pain treatment protocols have made great progress recently with the advancement and validation of pain valuation tools for pediatric patients (12, 13). With all these advancements, the management of pain in pediatrics is still not well addressed. Unambiguously, neonates and infants are not managed for pain effectively, due to the misperception that they cannot sense pain as adults (14–16). Healthcare professionals’ who care for children are mainly responsible for eliminating or easing pain and suffering when possible (17, 18). The treatment of pain in childhood is like adult management practice, which includes pharmacological and non-pharmacological interventions (19). This management critically depends on an in-depth understanding of the developmental and environmental factors that influence nociceptive processing, pain perception, and the response to treatment during maturation from infancy to adolescence (20).

Data from children's hospitals around the world reveal that pain in pediatric patients from infancy to adolescence is common, under-recognized, and undertreated compared with adult patients (1–7, 21). Pediatric patients with the same diagnoses receive less pain management, and the younger the children are, the less likely it is that they receive adequate analgesia in the medical setting (22–25). Pediatric patients are the most undertreated and present to the hospital for pain compared to adults because of the wrong belief that they neither suffer pain nor remember painful experiences. Uncontrolled pain also has a direct impact on health outcomes and more than a few effects on all areas of life. The behavioral or emotional components of pediatric patients can also be used to assess pain and simplify the management practices (26). A long-term negative effect of untreated pain on pain sensitivity, immune functioning, neurophysiology, attitudes, and healthcare behavior is supported by numerous studies in pediatric patients. The lack of ability to notice pain, immaturity in remembering painful experiences, and other reasons make pain treatment more difficult in children than in adults (27).

A cross-sectional observational study in Toronto hospitals shows that out of the total 265 children, only 58.9% received a minimum of one documented intervention in pain management. Out of the 66 children with recognized pain, 55 received an intervention for their pain (20). The American Academy of Pediatrics (AAP) suggested that the lack of pain assessment and fears of adverse effects of pain medications, including respiratory depression and addiction, are the main barriers to the treatment of pain in children (18). As the underlying disease is expected to advance, a continuous adjustment of pain therapy is required. However, in 2013, in Jima, Ethiopia, a hospital-based study showed that only 44 of 162 children were prescribed pain medications, whereas two received a combination of acetaminophen and tramadol (28). To the extreme, only 11.1% of the patients received an intervention within the first 24 h of the onset of pain. The practice of assessing pain and its management in pediatric patients can show a discrepancy based on the different countries and their respective health institutions. As a result, efforts should be made to explore the inadequacy of pain management and prevention in this age group.

Generally, in consideration of the above challenges, management of pain in pediatric encompasses the use of pharmacological and non-pharmacological interventions to control the patient's identified pain. Studies on the adequacy of pain management and prevention among hospitalized paediatric patients are limited in resource-limited settings, particularly in Ethiopia. Therefore, this study assessed pain management and its adequacy in pediatric patients admitted to UoGCSH, Northwest Ethiopia. The study findings will add to the body of knowledge of both healthcare providers and patients and carers and will serve as the baseline for further study.

Based on the authors’ best searching strategy, no single study that assessed pain management in the paediatric population in the study setting has been published yet. The current finding is fundamental to highlighting the extent of pain management adequacy. This hospital-based cross-sectional study assessed pain management adequacy among admitted paediatric patients. The findings from this study highlighted the management pattern and whether the pain is adequately treated or not based on its WHO class of severity. Additionally, the findings explored potential predictor variables associated with pain management inadequacy. The study revealed that about two-thirds of the patients received inadequate pain medication. Paediatric patients younger than 1 year and patients with severe and moderate levels of pain, respectively, were found to have inadequate pain medication compared with patients older than 5 years and patients with mild pain.

Pain is among a common symptoms in hospitalized children (33). Assessment of pain and optimal treatment in pediatric patients is critical, as inadequate acute pain management can cause chronic pain (34, 35), which lead to morbidities like posttraumatic stress symptoms (36). Additionally, inadequately managed pain can result in adverse physical and psychological patient consequences at the patient level, families and communities at large. Pain should be assessed and managed at the initial stages. Assessing the cause of pain might also be important. In this study, the most frequent cause of pain was related to abdominal problems. Thus, pain management, considering the nature of the cause and individualization, could be important. However, adequate management of pain needs more knowledge of children's self-rating of pain intensity experience (37). To enhance pain management and communication between healthcare providers in health facilities, pain and treatment adequacy should be routinely monitored and documented (38). Evidence also showed that the way to proper pain management is to implement validated pain assessment tools and to invest in education (39, 40). Despite adequate pain management in pediatric patients is of extreme importance, few studies have demonstrated.

In this study, the prevalence of moderate to severe pain was high among hospitalized children, and its management was suboptimal. This is consistent with previous studies (2, 3, 21, 41–43). This finding may indicate that pediatric patients are not received pain medications based on their level of pain severity properly. This might be related to a lower assessment practice of pain in pediatric patients. Therefore, assessing pain using a pain intensity rating tool is an important part of pain management to identify the intensity of pain and to indicate and evaluate pain management (31, 32, 44).

In the management of pain, a multimodal approach with two or more medications has been recommended in pediatric patients with persistent underlined pain (45), as well as for those with acute and post-operative pain (31–33). In contradiction to the evidence, a higher proportion of the patients in this study received a single acetaminophen-based analgesia than the majority of pain medications. However, the evidence indicates that a combination of pain medications that target different mechanisms in different systems, either in the central or peripheral nervous system have a more effective pain relief effect compared with a single analgesic medication (31).

In line with the previous studies (31, 32, 44, 45), the current study showed that pediatric patients received different modalities of non-pharmacological management modalities. Physical therapies (cold or hot therapy), psychological support, distractions, relaxation, and massage were among the common treatments used in admitted pediatric patients. The findings imply that although pharmacological treatment is part of a comprehensive approach towards the treatment of pain, nonpharmacological methods play an undeniable role in relieving pain in pediatric patients. They play a prominent role in the management of chronic pain, in particular. Pictures, music, and computer games are among the non-pharmacological approaches of pain management that can actively distract children's attention away from the pain and procedures (46).

The other interesting aspect that this study demonstrated is the association between pain management adequacy and predictor variables of inadequate pain management. Although the educational background of caregivers, health insurance status, and monthly household income had an association with pain management adequacy in bivariable regression, only the age of the patients and severity of pain were found to have a significant association with pain management adequacy with further analysis using multivariable logistic regression. Consequently, the study found that pediatric patients aged less than 1 year were more likely to have pian management inadequacy compared with those patients with an age greater than 3 years. This might be related to a lower pain assessment in infants because of their difficulty self-reporting their symptoms and pains. Children of a lower age, particularly infants, couldn't report their pains comprehensively. As a result, they sustain the inadequacy of management unless there is a comprehensive pain assessment and management practice. The findings may imply that pediatrics patients, particularly infants, might require special attention towards assessing and managing their pains. Therefore, clinicians could be motivated in the manner of pain management practices. They should adhere to standard tools and guidelines while managing pediatric patients, in particular infant patients.

Consistent with previous studies (21, 41, 47), the current study showed that patients with severe and moderate levels of pain were found to be more likely to receive inadequate pain medications compared with those with a mild level of pain. These studies revealed that severe pain is more prevalent and that patients are more likely to experience inadequate pain management. Unrelieved pain, in particular severe pain, has harmful effects on patients. It could be visualized that patients suffer from pain in many ways. This could be critical for the lives of patients. Patients with pain become depressed, and it is psychologically unsafe to have pain.

Generally, the current study highlighted the adequacy of pain management and the extent of pediatric patient pain treatment in a resource-limited setting. Furthermore, it also demonstrated the need to explore the factors associated with pain medications inadequacy. Therefore, we also hope to give some insight into and add to the body of knowledge for practitioners and patients related to the adequacy of pain treatment and prevention in pediatric patients.

This study concluded that the majority of pediatric patients received inadequate pain management. Patients’ age and level of severity of pain were found to be significantly associated with pain management inadequacy. Pain management in pediatric patients could include compliance with guidelines, focusing on the severity of pain, and age-based assessment and management. Since pain is linked to different systems and has multifactorial causes, a combination of pain medications can provide a better outcome to relieve the pediatric patients from persistent pain. Therefore, patients could be assessed according to their severity, and adequate management should be tailored accordingly. Clinicians could also be highly vigilant and motivated towards adherence to pain assessment and management practices in pediatric patients. Additionally, nurses who care for pediatric patients could become familiar with the assessment tools and management modalities.