Is your paediatric intensive care (PICU) patient free of pain, comfortable and calm? The answer to this seemingly innocuous question may not be straightforward. Recognition and management of pain in intensive care units (ICUs) is challenging because of the many exacerbating and confounding factors that exist in this setting. Adding to this complexity may be misconceptions which relate to patient perception and capacity, the healthcare system and the clinicians themselves [1]. Clinician-associated barriers to adequate pain relief in ICU patients include knowledge deficits, low prioritization, failure to assess, acknowledge or evaluate treatment effects, plus attitudes and biases related to pain relief and communication difficulties.Nearly 50 % of adult patients report experiencing moderate to severe pain during their ICU stay [1]. In adults, inadequate pain relief with persistent pain has profound short-and long-term consequences, including negative physiological and psychological impacts, which in turn affect socio-economic health. Alarmingly, children are even less likely to receive appropriate analgesia than adults [2]. This is further complicated by recent concerns regarding the adverse effects of sedation (particularly deep sedation [3]) and analgesia in both adult [4] and paediatric patients. Thus this is a very difficult area of medicine to get right-steering between the Scylla of deep sedation and opiate comas on the one hand, and the Charybdis of pain, agitation and the chronic sequelae of these on the other.In a recent article in Intensive Care Medicine, a multidisciplinary group of experts from the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) have reviewed the literature relating to the assessment and management of pain, anxiety, withdrawal and delirium in critically ill children and neonates [5]. The authors have provided a comprehensive summary of the relevant literature and recommended scoring tools based on 32 manuscripts (after screening 1151) pertaining to 15 recommended assessment tools. The recommended scoring systems come with the advantages of some standardization and formalization of review processes-these may be particularly helpful for less experienced staff.The need for standardization has been highlighted in studies in other areas, such as in accident and emergency departments where knowledge, biases (e.g. sex, racial [6], age, opiophobia, etc.) and emergency department culture itself were identified as variables that influenced provision of adequate analgesia [7].However, the use of assessment scores has not been entirely validated as a means of improving the quality of care of pain, anxiety and distress. Added to this we know that parental attitudes towards pain differ [8] and there is discordance between self reports and behavioural pain measures following surgery in 3-to 7-year-olds [9], raising questions about the applicability of behavioural scales as sole measures of pain intensity in younger children. A recent review on pain management in children in the em...