Pediatric pain: SMARTER , SAFER, KINDER: a narrative review

Background: Although pain is one of the most frequent reasons for pediatric emergency department (ED) visits, it continues to be underappreciated, underassessed, and undertreated. Despite the availability of validated pain scales and evidence-based pharmacological and non-pharmacological strategies, many children leave the ED without adequate relief. The consequences of poorly managed pain extend beyond immediate encounters with psychological and physiological sequelae that may persist into adulthood.Methods: A structured narrative review was conducted using PubMed, MEDLINE, and the Cochrane Library from January 2013 to July 2025. The search terms included pediatric pain, analgesia, ED, multimodal analgesia, non-pharmacologic, opioid safety, and family-centered care. The inclusion criteria included randomized controlled trials, systematic reviews, meta-analyses, and high-quality observational studies focusing on acute pediatric pain in the ED. Studies confined to chronic or perioperative pain without ED relevance were excluded.Results: This review presents recent advances in pediatric pain management and introduces the practical mnemonic Systematic, Multimodal, Awareness, Reassessment, Targeted treatment, Empowering, Resource utilization (SMARTER), Safety, Avoid dangerous analgesics, Fail-safe pain management, EHR integration, Risk mitigation (SAFER), Kid-centered, Integrated non-pharmacologic support, Nurturing environment, Dignity preservation, Engagement, Reduction of procedural distress (KINDER) as a structured framework for clinicians. This mnemonic highlights systematic assessment, multimodal approaches, patient safety safeguards, and child- and family-centered care as essential principles for improving pediatric pain management practices. By integrating these domains, clinicians can address not only the technical aspects of analgesia but also the dignity and developmental needs of children with pain.Conclusions: The mnemonic SMARTER, SAFER, KINDER integrates systematic assessment, multimodal and safe pharmacology, and compassionate family-centered care. The adoption of this framework can bridge the gap between evidence and practice, ensuring systematic, vigilant, and humane pediatric pain management.