Anaes · Paediatric anaesthesia
Paediatric multimodal analgesia and pain assessment
Also known as FLACC score · Paediatric opioid dosing · Codeine contraindicated tonsillectomy · Multimodal analgesia children
Age-appropriate pain assessment (FLACC, FACES, self-report), multimodal paediatric analgesia with weight-based doses, opioid PCA/NCA principles, and the codeine/tramadol contraindications after tonsillectomy for fellowship exams.
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Red flags
- Codeine is contraindicated in children after tonsillectomy/adenoidectomy because of CYP2D6 variability and fatal respiratory depression risk.
- Do not use adult fixed doses — calculate mg/kg and respect maxima.
- Untreated pain causes ED mislabeling, delayed recovery, and chronic pain risk.
- Sedation is not analgesia — score pain and consciousness separately.
- Discharge opioids without parent education invite dosing errors.
Meet the patient
A three-year-old is admitted overnight after tonsillectomy, in pain, snoring, and drowsy. The ward drug chart still lists codeine — the bottle that has killed children after this exact operation. The registrar asks what to give instead.[1]
The two questions that decide the next analgesic dose are the two that decide every paediatric pain plan: what is the pain score in a tool that fits the age, and is the drowsiness pain, opioid, or emergence delirium? Hold those, and the multimodal ladder, the codeine ban, and the FLACC discipline below all slot into place.[1]
References4ShowHide
- [1]Merkel SI et al. The FLACC: a behavioral scale for scoring postoperative pain in young children Pediatr Nurs, 1997.PMID 9220806
- [2]Lauder G et al. Confronting the challenges of effective pain management in children following tonsillectomy Int J Pediatr Otorhinolaryngol, 2014.PMID 25241379
- [3]Kohler JE et al. Continued Prescribing of Periprocedural Codeine and Tramadol to Children after a Black Box Warning J Surg Res, 2020.PMID 32693330
- [4]Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale Anesthesiology, 2004.PMID 15114210