This study evaluated 20,405 pediatric emergencies with 12,000 children being affected by trauma and 8,108 children with acute pain due to non-trauma. 4,608 (38.4%) children with trauma had a NRS > 4 at first survey (mean 6.9 (SD 1.5)). Children with acute pain due to non-trauma were less likely to have moderate to high pain scores (3.5%) but if relevant pain was present (NRS > 4), it tended to be severe (mean NRS 6.7 (SD 1.5)) (Table 1). Surprisingly, analgetic treatment differed significantly despite similar NRS regarding trauma and acute pain due to non-trauma. Thus, children in the trauma group received opioids in 62.0% and ketamine in 34.5%. In the non-trauma group opioids (35.8%) and ketamine (2.8%) were administered significantly less frequent and paracetamol and metamizole were given instead.

Over the past decade, numerous recommendations have been published on pre-hospital pain management in children [10], which have not yet found widespread implementation. Different drugs for analgesia have been suggested and recommended depending on the severity of the pain. But this also raises the question which analgesics are available in the different ambulance systems and how experienced the users are with possible application routes (e.g. intravascular, nasal or intramuscular). For management of moderate to severe pain, fentanyl appears to be the first line treatment for children [10, 28]. In our study, fentanyl was primarily used for analgesia, with piritramide being the second most commonly opioid used. The results of our study show a trend towards restrained use of opioids in young children and an increase in opioid administration in children older than 6 years, these results are consistent with a recent study by Rugg et al. [29]. In children with an initial NRS > 4, an opioid was administered in 62% of all cases. In toddlers and infants with severe pain, ketamine is the most commonly used analgesic. We assume that there is a greater uncertainty in the treatment of younger children, especially regarding the side effects of opioids. Thus, it indeed seems convincing to rather use ketamine due to its lower side effect profile and/or to apply opioids intranasally with the aim of achieving a greater therapeutic breadth [28, 30, 31]. From the age of 6 years, opioids are more often administered for analgesia and the use of ketamine becomes less frequent.

The comparison of the trauma and the non-trauma group showed a lower NRS in trauma children at the time of hospital admission (mean NRS 1.9) than in children with non-trauma (mean NRS 2.7). When NSAID mono therapy or even no analgesics were administered, the results were poor: 10.4% NSAID resp. 15.7% (no analgesics) of the patients reported NRS > 4 at hospital admission (Table 2). Around 9,4% of all children with trauma and a total of 28,4% in the non-trauma group with NRS > 4 received no pain medication at all.

We consider these numbers to be worrying because they clearly reflect uncertainty in the treatment of children. We can only speculate about the causes of the inadequate pain therapy in our setting, as all emergency physicians on our helicopters are required to have expertise in pediatric analgetic treatment. However, our findings are consistent with those of many other studies that have drawn attention to inadequate pain management for children in emergency medicine worldwide. Another study of pre-hospital analgesia found that although pain was noted in 446 cases, analgesia was administered in only 3.3% [2]. In one Canadian study, children with fractures of the extremities received analgesia in 37%, but only 3.2% received opioids [3]. Lord et. al also reported that in the case of the most severe pain (NRS 8–10), only 45% of children received analgesia [6]. According to these findings, children are at comparatively high risk for inadequate pre-hospital analgesia. A comparison of the studies is difficult as the ambulance systems in the different countries are not necessarily identical and a distinction must be made between physician and non-physician care. We believe that the more appropriate pain management in our study compared to most other studies is related to the fact that an emergency physician (trained in pediatric emergencies) was always involved.

Murphy et al. describe possible reasons such as communication problems in infants and young children, inadequate training of emergency personnel, and uncertainty and lack of experience in the assessment and care of children [21]. Paramedics and physicians are trained in providing and treating children, but pediatric emergencies occur less frequently, and invasive procedures and therapies are rarely needed. Reluctance associated with placing intravenous access in children appears to be a significant concern for paramedics and physicians, leading to hesitation and ultimately contributing to lower administration of analgesics [17].

The difficulty of correctly assessing pain in children has been cited as another potential cause of inadequate pain management in children. The major problem in pain assessment appears to be subjectivity and finding an adequate scale for the age. In our study, NRS was reported for almost all children, which is possibly due to the electronic patient report form used, in which two documented NRS scores are mandatory, one at first contact on scene and one at hospital admission. A large proportion of our patients were younger than 8 years, limiting the applicability of the NRS. Certainly, some children were unable to assign a number to their pain, e.g. depending on their common status. Presumably, the reported value in these patients corresponded to the personal impression of the emergency physician. It remains unclear whether in some cases other scores were additionally collected but not documented. In several studies the NRS was validated in children aged 8 + years [22]. The minimal clinically relevant difference in the numerical rating scale is 2 points on a 10- point scale [23, 24]. Other authors define effective analgesia as a reduction in pain score by at least 30% [25]. In our study population, an effective reduction in pain (> = 2 scale points) was achieved in 95.9% for pediatric trauma and resp. 86.3% for children in the non-trauma group (Table 3).

For children, there are further scales according to their age, including the Wong-Baker faces scale, on which children are asked to select the face that best represents their pain; this scale has been validated from the age of 3 years [26]. The Children´s Discomfort and Pain Scale according to Büttner is used for pain assessment in children from neonatal age to the age of four and has been validated for postoperative pain [27]. To our knowledge, there are no validated pain scoring systems for children in the pre-hospital setting and there is no requirement at DRF to use one specific scoring method. Nevertheless, we are convinced that the common scales are also suitable for the assessment of pain in the pre-hospital setting. Furthermore, the available data show that the pain scale used reliably reflects the treatment success.

Our study has several limitations starting with the retrospective character. As mentioned above, accuracy and objectiveness of the pain assessment might be a query. We were also not able to assess the influence of non-pharmacological pain management techniques such as slings and bandages. That is interesting because some patients with severe pain also showed improvement in NRS even though they did not receive analgesic medication. In these cases, conservative measures may have alleviated the pain. We were also not able to assess the influence of transport time on pain relief. Bendall et al. reported that children with a shorter care time are less likely to achieve effective pain management (18). Whitley et al. found no coherence concerning the length of transport to the hospital and effective pain management. Due to the digital data collection, it was not possible to record which dosages of each medication administered and the application route chosen.