Paeds · clinical-pharmacology-and-therapeutics
Opioids and acute pain medicines
Also known as Opioid analgesia in children · Acute pain management in children · Morphine oxycodone fentanyl dosing · Codeine contraindication in children · Tramadol contraindication in children · WHO analgesic ladder for children
A fellowship approach to opioids and acute pain medicines in children covering the WHO two-step analgesic ladder, mu-opioid receptor pharmacology and its dose-limiting adverse effects, developmental morphine pharmacokinetics, weight-based dosing for morphine, oxycodone, fentanyl and hydromorphone, the CYP2D6 prodrug mechanism that makes codeine and tramadol contraindicated in children, multimodal opioid-sparing analgesia, patient- and nurse-controlled analgesia safety, age-appropriate pain assessment, and naloxone reversal of opioid-induced respiratory depression.
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Target exams
Red flags
- Any prescription of codeine or tramadol to a child under 12 years, or to any child or adolescent for postoperative pain after tonsillectomy or adenoidectomy
- Reduced or slow respiratory rate, small pupils, and unrousable sedation after an opioid dose — opioid-induced respiratory depression until proved otherwise
- A basal (background) opioid infusion running in an opioid-naive child, especially with a concurrent benzodiazepine
- A regular opioid prescribed without a prophylactic stimulant laxative
- An infant or a child with obstructive sleep apnoea or obesity started on an opioid without continuous oximetry and sedation scoring
- Naloxone given as a single large bolus to an opioid-tolerant child, risking acute withdrawal and severe pain
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people requiring safe prescribing of analgesic medicines
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person including safe acute-pain relief
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safety and acute-pain service governance
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 8. Quality improvement and patient safety
- General Paediatrics: Prescribes analgesia safely, avoids codeine and tramadol in children, and recognises opioid-induced respiratory depression
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication Management
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Systems-Based Practice 1: Coordination of Care and Safe Prescribing
- Patient Safety/Quality Improvement 1: Medication Safety and Acute-Pain Governance
- Medical Expert
- Collaborator
- Pediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions
Overview & Definition
A four-year-old waking from appendicectomy, a teenager with sickle-cell crisis, a neonate before a chest drain — these are the children whose acute pain you will be asked to relieve safely. Acute pain is pain of recent onset and expected short duration, arising from a defined injury, procedure, or illness, and it is a clinical sign that demands treatment in its own right rather than a symptom to be endured. Untreated acute pain is not benign: it drives tachycardia and hypertension, splinting and atelectasis, sleeplessness, and a behavioural sensitisation that can seed chronic pain, so the goal of therapy is prompt, sustained relief with the least harm. [8] [9]
Opioids are the most powerful acute-pain medicines we have, and they earn their power from a single pharmacological fact: they agonise the mu-opioid receptor. That same receptor produces analgesia in the brain, spinal cord, and peripheral nerves, and it also produces the dose-limiting harms — respiratory depression, sedation, constipation, nausea, and pruritus — that govern every prescribing decision. A fellowship candidate must therefore hold two truths at once: opioids are effective and necessary for moderate-to-severe acute pain, and every opioid prescription is a controlled negotiation between analgesia and respiratory depression. [9]
The single most important regulatory change in modern paediatric analgesia is the removal of codeine and tramadol. Both are prodrugs: they are inactive or weak until the cytochrome P450 2D6 (CYP2D6) enzyme converts them into active opioid — codeine to morphine, tramadol to O-desmethyltramadol. Because CYP2D6 activity is inherited, an ultrarapid metaboliser turns a normal dose into a lethal one, and a series of post-tonsillectomy deaths in young children forced regulators to act. The United States Food and Drug Administration issued a boxed warning, and the United Kingdom and European regulators issued contraindications: codeine and tramadol are now contraindicated in children under 12 years, and for postoperative pain management after tonsillectomy or adenoidectomy in children under 18 years. [1] [2] [3]
From first complaint of pain to a safe monitored regimen
- 1
1 · Assess
Use an age-appropriate tool — FLACC for two months to seven years, the Faces Pain Scale for four to twelve years, the numeric rating scale for eight years and over — and record a score before you treat.
- 2
2 · Non-opioid first
Start with non-pharmacological measures (comfort, positioning, distraction) plus scheduled paracetamol and, where appropriate, an NSAID. This is the foundation of opioid-sparing multimodal analgesia.
- 3
3 · Add a strong opioid
For moderate-to-severe pain add morphine (oral 0.2 to 0.5 milligram per kilogram every four hours, or intravenous 0.1 to 0.2 milligram per kilogram titrated). Oxycodone, fentanyl, and hydromorphone are alternatives with defined weight-based doses.
- 4
4 · Monitor
Record paired pain and sedation scores, watch the respiratory rate (the earliest sign of opioid harm), and keep naloxone at the bedside. Never run a basal opioid infusion in the opioid-naive child.
- 5
5 · Review and step down
Reassess before and after every dose, titrate to effect, prophylax constipation, and step down from intravenous to oral as pain settles before discharge.
References12ShowHide
- [1]Racoosin JA, Roberson DW, Pacanowski MA, et al. New evidence about an old drug — risk with codeine after adenotonsillectomy New England Journal of Medicine, 2013.PMID 23614474
- [2]Tobias JD, Green TP, Coté CJ Codeine: Time to Say No Pediatrics, 2016.PMID 27647717
- [3]Dean L, Kane M Tramadol Therapy and CYP2D6 Genotype Clinical Pharmacology and Therapeutics, 2012.PMID 28520365
- [4]Dean L, Kane M Codeine Therapy and CYP2D6 Genotype Medical Genetics Summaries, 2012.PMID 28520350
- [5]Kohler JE, Cartmill RS, Kalbfell E, et al. Continued Prescribing of Periprocedural Codeine and Tramadol to Children after a Black Box Warning Journal of Surgical Research, 2020.PMID 32693330
- [6]Lynn A, Nespeca MK, Bratton SL, et al. Clearance of morphine in postoperative infants during intravenous infusion: the influence of age and surgery Anesthesia and Analgesia, 1998.PMID 9585276
- [7]Morse JD, Sundermann M, Hannam JA, et al. Population pharmacokinetics of oxycodone: Premature neonates to adults Paediatric Anaesthesia, 2021.PMID 34469607
- [8]Olejnik L, Lima JP, Sadeghirad B, et al. Pharmacologic Management of Acute Pain in Children: A Systematic Review and Network Meta-Analysis JAMA Pediatrics, 2025.PMID 39899301
- [9]Niesters M, Overdyk F, Smith T, et al. Opioid-induced respiratory depression in paediatrics: a review of case reports British Journal of Anaesthesia, 2013.PMID 23248093
- [10]Sharp D, Jaffrani A A PRISMA Systematic Review on the Safety and Efficacy of Patient-Controlled Analgesia (PCA) in Pediatrics Journal of Pediatric Nursing, 2021.PMID 34139608
- [11]Malmros Olsson E, Lönnqvist PA, Stiller CO, et al. Rapid systemic uptake of naloxone after intranasal administration in children Paediatric Anaesthesia, 2021.PMID 33687794
- [12]Shao B, Tariq AA, Goldstein HE, et al. Opioid-Sparing Multimodal Analgesia After Selective Dorsal Rhizotomy Hospital Pediatrics, 2020.PMID 31862854