In humanitarian settings, the priorities of assistance provision are often focused on urgent medical support. Within this realm, data collection and usage of validated measurements of medical conditions are generally low. Several organizational and personal reasons are associated with the failure to collect data in these settings. First, in many cases there is no data collection procedure as part of the organizational protocol. Yet, if such a procedure does exist, the mere sense of emergency does not always enable the medical staff to record its actions. Moreover, humanitarian agencies are often avoiding sharing or publishing data due to considerations of confidentiality, organizational concerns, awareness, or low quality of the data collected. Even if published, it is difficult to draw a policy from such publications due to the lack of standardization amongthe measures described in the publications. The above challenges were addressed by the World Health Organization (WHO) standards, enabling databases to be analyzed, compared, and validated. Yet few agencies will follow the standard reporting system developed by the WHO.¹

The phenomena of under-reporting and the lack of data may have more severe implications when it comes to the condition of pain.Reference Rosa, Grant and Knaul² Pain in these humanitarian contexts could be chronic or acute, due to disaster-related injuries or its consequences (migration, malnutrition, infections, etc). Generally, pain is defined by the International Association of the Study of Pain (IASP) as: "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”³ In the general population, based on reviews, the prevalence of different types of pain is 10.6% for chronic widespread painReference Mansfield, Sim and Jordan⁴, 52.2% for headaches, 14% for migrainesReference Stovner, Hagen and Linde⁵, and 3.9%–19.6% for chronic low back pain subject to age.Reference Meucci, Fassa and Faria⁶

Data on various types of pain and palliative care are even more difficult to obtain from published field reports compiled during or after humanitarian assistance. Several publications have shown under-reporting and under-treatment of pain in such contexts.Reference Doherty and Petrova^7–Reference Schnall, Hanchey and Nakata¹² This under-reporting is in line with the general perception around addressing pain as presented in a systematic review of a handful of programs thataddressed palliative care or pain in humanitarian contexts.Reference Schneider, Pautex and Chappuis¹³

Within the described programs in that review, we failed to find a report addressing the subject of pain related to age, and specifically to pediatric pain. This leads to the conclusion that pain in children is a topic that has been overlooked and neglected as an important issue in humanitarian actions.

Neglecting pain assessment and treatment in children is a known phenomenon in general hospitals out of the humanitarian context as well.Reference Birnie, Chambers and Fernandez^14–Reference Markenson²³ This phenomenon may be a result of children’s ways of expressing pain, which are different from those of adults,Reference Hewes, Dai and Mann^17–Reference Zieliński, Morawska-Kochman and Zatoński²⁴ or due to barriers held by the medical staff, such as unfamiliarity and discomfort with pediatrics, unfamiliarity with the protocols, insufficient clinical education, or concerns from adverse effects of analgesics.Reference Williams, Rindal and Cushman²⁵ As it comes to humanitarian settings, research shows that children are more vulnerable to consequences of disasters and conflicts because they often lack the experience, independence, and cognitive and verbal skills to deal with the ordeals they are facing. Therefore, these all impair children’s pre-existing ability to cope with such stressful events.Reference Awuah, Ng and Mehta^26–Reference Raskoff, Thurm and Miguel³¹ Such limited skills and the inability to verbalize their pain, especially among infants, might also affect the level and nature of reported pain. In such cases, children learn fast that expressing pain is futile and it does not lead to pain relief. This might lead to developing helplessness, particularly in prolonged and uncontrollable disasters. Such a sense of helplessness is part of the broader concept of catastrophizing, a set of negative pain-related cognitions, which is correlated with pain in general and more specifically with pediatric pain.Reference Friedrichsdorf, Giordano and Desai Dakoji³²

Another reason for under-reporting pain could be related to culture. In some cultures, or situations, children may have been told not to complain or cry because they should be brave or silent in cases of a consistent violent threat to their life and the lives of their close ones. Finally, observed and reported pain are not always a result of a measurable physical malfunction or injury, but rather a stress related symptom requiring psychosocial care rather than typical medical care.Reference Ayede^33–Reference Nelson, Miller and Timmers³⁵ This requires adequate communication with children who speak other languages, which is not always possible in urgent humanitarian contexts.