Pain is a highly complex sensory and emotional experience; the biological, psychological and social aspects must each be considered. The intersection between the phenomenon of pain, the unpredictable pre-hospital environment and children is highly convoluted. Studies have shown that pre-hospital pain management in children is poor, despite access to pain management being considered a fundamental human right. Without effective pain treatment, children may suffer long-term psychological changes (e.g. altered pain perception) and are at risk of developing post-traumatic stress disorder. The aim of this thesis was to identify predictors, barriers and facilitators associated with effective pre-hospital pain management in children suffering acute pain and to identify ways to improve the quality of care.

A postpositivist paradigm was adopted for the study, with a critical realist ontology and a modified objectivist epistemology. A mixed methods sequential explanatory design was adopted, informed by a systematic mixed studies review. The initial quantitative study employed a multivariable logistic regression analysis using routinely collected clinical data to identify predictors of effective pain management. The final qualitative study used face-to-face semi-structured interviews with ambulance clinicians to help explain the identified predictors, identify barriers and facilitators and explore ways to improve the quality of care. Interviews were audio recorded and transcribed verbatim with thematic analysis used to analyse the data.

The systematic mixed studies review included 13 studies (8 quantitative and 5 qualitative) and highlighted the importance of analgesic administration. The initial quantitative study included 2312 clinical records; only 39% of children suffering acute pain achieved effective pain management. Predictors of effective pain management included children who were younger, administered analgesics, attended by a paramedic or living in an area of low or medium deprivation. The final qualitative study included 12 ambulance clinicians (9 paramedics and 3 emergency medical technicians) who provided possible explanations for these disparities. Novel barriers and facilitators were also identified along with ways to improve pain management. Meta-inferences were developed which provided a more comprehensive understanding of this complex phenomenon. To improve pre-hospital pain management in children, the following recommendations were made; 1) explore methods to increase rates of analgesic administration, perhaps by utilising the intranasal and inhaled route; 2) reduce fear and anxiety in children, perhaps by using child friendly uniform, non-pharmacological techniques and more public interaction and 3) reduce fear and anxiety in clinicians, by enhancing training, optimising crew mix and developing a more pragmatic pain assessment tool. A theoretical model of pre-hospital pain management in children was developed as part of this thesis.

Pre-hospital pain management in children may be improved by increasing rates of analgesic administration and reducing the fear and anxiety experienced by children and clinicians. Future research should explore the experience of the child and determine the most important outcome measures. Robust clinical trials are needed to determine the efficacy and safety of intranasal (fentanyl/ketamine) and inhaled (methoxyflurane) analgesics in the pre-hospital setting. Investment in future research and intervention development is imperative; we need to make children’s pain in the pre-hospital setting matter.