Acute Pain Management in Children: A Systematic Review and GRADE-Based Recommendations

Background: Acute pain in children is frequently under-recognized and undertreated despite validated assessment tools and effective therapies. This systematic review aimed to synthesize recent evidence on assessment and management of acute pediatric pain. Methods: The review followed PRISMA 2020 guidelines. Clinical questions were developed using the PICO framework, and evidence certainty was assessed with GRADE. PubMed and Embase were searched for studies published from 2016 to 2025. Italian pediatric scientific societies and specialists involved in acute pediatric care contributed to the process. Results: A total of 13 studies were included. Validated pain scales showed high reliability and were associated with reduced pain scores after analgesic administration. Paracetamol and ibuprofen showed comparable efficacy for mild-to-moderate pain; evidence suggesting a modest late advantage of ibuprofen was inconsistent. Combination therapy reduced rescue analgesia in individual studies. Non-pharmacological interventions, including virtual reality, distraction, and hospital play, reduced anxiety and procedural distress, although certainty of evidence was low. Evidence on opioids was limited and did not show clear superiority over non-opioid strategies. Intranasal fentanyl appeared comparable to intravenous morphine and more feasible in emergency settings. Overall, evidence for several clinical questions remains limited, and GRADE recommendations were only possible for selected PICOs. Conclusions: Acute pediatric pain management should rely on structured assessment and multimodal strategies. Validated pain scales should be used routinely. Paracetamol and ibuprofen remain first-line treatments for mild-to-moderate pain, with possible context-specific benefits of ibuprofen or combination therapy. Non-pharmacological interventions may be useful adjuncts, especially for anxiety and procedural distress. Further high-quality studies are needed on opioids, intranasal administration, alternating regimens, and inhaled versus topical analgesia.