Version July 2025
INTRODUCTION —
Perioperative pain control is an essential component of the anesthetic plan for infants and children. Inadequately treated pain, even in infants, may have both short-term and long-term deleterious effects [1]. Parents rightfully expect care providers to mitigate their child's experience of pain to the extent that is possible. Establishing an appropriate level of patient and parent expectation that is safely achievable prior to the procedure may help allay anxiety and improve their understanding of contemporary pain management.
This topic will discuss evaluation of perioperative pain and a general approach to management in infants older than one month of age and in children. Pharmacologic options for perioperative pain management in these children are discussed separately. (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children".)
Evaluation and management of pain in neonates, and the effects of untreated pain in neonates, are discussed separately. (See "Management and prevention of pain in neonates" and "Assessment of pain in neonates".)
ASSESSMENT OF PAIN THROUGHOUT THE DEVELOPMENTAL CONTINUUM —
Assessment and management of pain in children is complicated by the developmental changes that occur from the neonatal period through puberty. It may be challenging to distinguish pain from other sources of discomfort, and to measure its intensity, quality, or location. Self-report of pain remains the gold standard, but in children we must often interpret non-verbal signals of discomfort.
●Assessment of pain severity is necessary to determine the intervention that is required and to evaluate its efficacy.
●Pain localization may be aided by having the child point to the site of pain by using a cartoon image or doll, especially if they are not willing or able to communicate verbally. Often the major site of discomfort is a sore throat following intubation, the IV or other catheter, tape or a bandage, and not the surgical site itself.
●Differentiating pain from other causes of distress may be challenging in patients who are not verbally communicative. Other causes of discomfort that should be ruled out include wetness, cold, hunger, poor positioning, or need for caregiver contact. The parent or other caregiver of a non-verbal child may provide valuable insight on the child's usual pain behaviors.
●Importantly, emergence delirium may be difficult to distinguish from pain in a child who is inconsolable in the immediate postoperative period, particularly for preschool-age children who have received a potent inhaled anesthetic (eg, sevoflurane). Emergence delirium is discussed separately. (See "Emergence delirium and agitation in children".)
Examples of tools that may be used to assess pain in children are provided (table 1 and form 1 and figure 1). Assessment of pain in neonates and children is discussed in detail separately. (See "Pain in children: Approach to pain assessment and overview of management principles" and "Management and prevention of pain in neonates".)
GENERAL APPROACH TO ACUTE PEDIATRIC PAIN MANAGEMENT —
The approach to acute pain management in children is similar to the approach in adults, and consists of a multimodal opioid-sparing strategy appropriate for the expected degree and duration of pain [2].
Goals for pain management — Establishing a tolerable degree of pain is mandatory, but the true goal is functional recovery, not a specific pain score. For children, functional recovery may include the ability to mobilize; eat and drink as appropriate; achieve normal bowel and bladder function; participate in physical, occupational and respiratory rehabilitation; engage in play or concentrate on schoolwork; and return to a restorative sleep wake cycle.
Both pain assessment and treatment must be age- and development-specific, and must include the educated involvement of the child's caregivers, with expectations established.
Multimodal pain control — Nonpharmacologic therapies discussed below should be used for all patients when appropriate, and may reduce the need for medications. (See 'Start with nonpharmacologic therapy' below.)
Other therapeutic options, which are often used in combination, may include topical or local anesthetic patches and neuraxial or regional anesthesia techniques in addition to non-opioid and/or opioid systemic medications. (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children".)
Avoiding excessive opioid use — An overarching principle of pain management in both children and adults is to avoid the excessive use of perioperative opioids, including avoiding excessive prescription of opioids at discharge. Opioids are associated with short-term side effects (ie, respiratory depression, excessive sedation, nausea and vomiting, pruritus, urinary retention, constipation) and long-term adverse effects (ie, tolerance, dependence, opioid induced hyperalgesia or withdrawal upon conclusion of therapy) and in older children and adolescents, possible opioid misuse [3].
We are implementing the CRAFFT screening questionnaire (car, relax, alone, forget, friends, trouble) for risk of substance misuse in adolescents as part of our preoperative evaluation. We also provide information on the appropriate disposal of any remaining opioid. The CRAFFT screening tool and other aspects of screening for alcohol and substance use in adolescents are discussed separately. (See "Screening tests in children and adolescents", section on 'Nicotine, alcohol, and substance use'.)
ENHANCED RECOVERY AFTER SURGERY (ERAS) —
Procedure specific protocols focused on enhanced recovery are increasingly used in adult surgical patients. ERAS protocols typically include standardized preoperative, intraoperative, and postoperative care, including perioperative analgesia. The effect of enhanced recovery protocols on postoperative surgical recovery and analgesia in children is yet to be elucidated. Numerous pediatric protocols, largely based on retrospective studies, have been published in a variety of subspecialties. In general, these studies have found greater use of regional anesthesia techniques, a decrease in overall opioid use, and decreased length of stay [4,5].
Principles of ERAS are discussed separately. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)".)
CREATING A PLAN FOR PERIOPERATIVE ANALGESIA —
The plan for perioperative analgesia must necessarily be based on the procedure and expected degree of postoperative pain. However, individual patient characteristics and surgical procedures vary widely, and the degree of pain after surgery may be difficult to predict. Thus, the plan for analgesia must be flexible, tailored to the patient, and guided by ongoing assessment of treatment effect. Any multimodal analgesic protocol should serve as a checklist only, and should be modified to meet the needs of the individual patient, considering patient comorbidities, staffing and institutional resources, the available medication formulary, and the clinical environment [6-9]. A primary goal of perioperative pain management is to have the child comfortable upon awakening from anesthesia, with a smooth transition from post-anesthesia care to the surgical unit or home [10].
Start with nonpharmacologic therapy — Nonpharmacologic methods of pain control are low risk and may reduce the need for analgesic medication.
Preemptive behavioral therapy — Children with preoperative anxiety may be predisposed to increased postoperative pain and postoperative behavioral problems [11-13]. Preoperative patient and family education as well as psychological preparation may decrease preoperative anxiety and increase patient and caregiver satisfaction, but it is unclear whether such preparation reduces postoperative pain. Prevention of preoperative anxiety, including premedication and parental presence, is discussed separately. (See "General anesthesia in neonates and children: Agents and techniques", section on 'Prevention and treatment of preoperative anxiety'.)
Many centers have preoperative protocols designed to familiarize patients and their families with the perioperative environment and provide realistic information about expected pain and treatment options. In our experience, such accurate expectation management is a key determinant of patient and parent satisfaction as well as compliance with postoperative rehabilitation and pain management programs.
Other nonpharmacologic options for pain control — Other nonpharmacologic options include swaddling, skin-to-skin contact, aroma therapy, application of warm or cold compresses, massage, elevation, rest or immobilization of an extremity, and careful positioning. Behavioral options for older children include cognitive techniques, distraction, visualization, and focused breathing. Child life involvement and use of expressive therapies during recovery such as art and music may also decrease anxiety and hence may influence pain perception. Newer modalities such as virtual reality and augmented reality programs are also being investigated.
Pharmacologic therapy based on expected degree of pain — In addition to nonpharmacologic therapy, most children who have surgery will require analgesic medications as well. An approach to the use of medications for perioperative pain management based on the expected degree of pain is described here, with representative examples of our usual strategies. These should not be regarded as the only acceptable approaches, and should be modified based on patient factors. Doses and further information about these therapeutic options are discussed separately. (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children", section on 'Systemic analgesics'.)
Mild pain — Mild postoperative pain can usually be managed with multimodal analgesia without the use of postoperative opioids. Mild pain is expected after many ambulatory procedures, including dental extractions, diagnostic procedures (eg, percutaneous biopsy), and myringotomy.
Example: myringotomy — As an example, our usual strategy for analgesia after myringotomy is as follows:
●Preoperative – Oral acetaminophen, distraction to allay anxiety (table 2)
●Intraoperative – Acetaminophen (if not given preoperatively), IV nonsteroidal anti-inflammatory drugs (NSAIDs) with or without low dose fentanyl, discretionary use of dexmedetomidine to prevent emergence delirium and possible analgesic effects.
●Postoperative – Regularly scheduled acetaminophen, ibuprofen as needed
The uses of these medications for perioperative pain are discussed separately:
Moderate pain — Most laparoscopic and soft tissue surgeries are expected to result in at least moderate postoperative pain. In addition to nonpharmacologic analgesic measures and nonopioid analgesic adjuvants, local or regional analgesia may provide adequate analgesia. A short course of postoperative opioids may be required, particularly if regional analgesia is not possible.
Tonsillectomy causes moderate to severe pain for many children. Analgesia for tonsillectomy is discussed separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Plan for analgesia' and "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Pain'.)
Example: hernia repair — As an additional example, our strategy for pain control for inguinal hernia repair is as follows:
●Preoperative – Acetaminophen
●Intraoperative
•Local anesthetic wound infiltration and/or ilioinguinal/iliohypogastric nerve blocks
•IV acetaminophen if not given preoperatively, ketorolac, dexmedetomidine
●Postoperative – Regularly scheduled alternating ibuprofen and acetaminophen, each dosed every six hours, so that one or the other drug is administered every three hours for the first 24 hours. After 24 hours, ibuprofen or acetaminophen as needed.
The uses of these medications and nerve blocks for perioperative pain are discussed separately.
Severe pain — Severe pain can be expected after open abdominal surgery, thoracotomy, and most orthopedic procedures. Regional analgesia techniques should be used whenever possible (either single shot techniques or continuous infusions) supplemented by nonopioid analgesics and nonpharmacologic measures. If continuous regional analgesia is not possible or is ineffective, intravenous opioids are usually required postoperatively. Patients may require oral opioids on discharge from the hospital. As examples, our strategy for scoliosis surgery is as follows:
Example: scoliosis surgery (adolescent idiopathic)
●Preoperative – Acetaminophen, gabapentin
●Intraoperative
•Opioid (eg, morphine, fentanyl, hydromorphone, or remifentanil, depending on anesthetic preference and technique) (table 3)
•Acetaminophen IV six hours after preoperative dose; if no preoperative dose was administered, IV dose one hour before the end of surgery
●Postoperative
•Acetaminophen, regularly scheduled for 48 to 72 hours, then as needed.
•NSAIDs – Regularly scheduled ketorolac every six hours starting approximately 12 hours after completion of surgery and after ensuring adequate volume status and control of bleeding, 12 scheduled doses, then as needed ketorolac or ibuprofen, beginning six hours after the last scheduled dose of ketorolac.
•Patient-controlled opioid analgesia (PCA), started in the recovery area, discontinued once the patient tolerates oral liquid and has been mobilized (table 4). (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children", section on 'Patient-controlled analgesia in children'.)
•Oxycodone orally – Once PCA has been discontinued (usually by the afternoon of postoperative day 1), oxycodone on either a scheduled or as needed basis, for breakthrough pain or one half hour prior to physical therapy (table 5). (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children", section on 'Oral opioids'.)
•Diazepam at reduced dose while on opioid, if needed for spasm. (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children", section on 'Dosing precautions'.)
•Senna and docusate prophylaxis for opioid-induced constipation as soon as oral medication is tolerated (table 6). (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children", section on 'Prevention and treatment of opioid-related side effects'.)
●After discharge
•Acetaminophen and ibuprofen regularly scheduled.
•Oxycodone, usually a three to five day prescription for breakthrough pain. (See "Pharmacologic management and regional anesthesia for acute perioperative pain in infants and children", section on 'Postdischarge analgesia with opioids'.)
CHRONIC POSTSURGICAL PAIN IN CHILDREN —
Chronic postsurgical pain (CPSP) is also referred to as chronic postoperative pain, persistent postoperative pain, or persistent postsurgical pain. The definition of CPSP varies in the literature, and may refer to pain that lasts at least 3, 6, or 12 months after surgery. (See "Chronic postsurgical pain in adults: Incidence, risk factors, and potential risk reduction", section on 'Definitions'.)
CPSP is increasingly recognized as a potential problem in children, though literature on CPSP in children is limited and of low quality.
●Incidence and risk factors – The incidence of CPSP has not been determined, at least partly due to variability in the definitions of CPSP, as well as low quality studies and wide variation in the populations studied.
A 2017 systematic review of the literature evaluated 12 observational studies of children 6 to 18 years of age who had various types of surgery [14]. The prevalence of CPSP at 3 to 12 months ranged from 11 to 54 percent. The estimated median prevalence of CPSP at 12 months was 20 percent. Presurgical pain intensity and psychosocial factors in the child and parent were predictors of CPSP. Conclusions were limited by the overall low quality of the included studies.
A 2024 systematic review of the literature evaluated 17 studies of CPSP in children who underwent various orthopedic, general surgical, cardiothoracic, or mixed procedures, in studies published between 2014 and 2021 [15]. The reported incidence of CPSP varied from 2 to 100 percent, with the highest incidence after spine surgery. The existing literature was judged to be of low quality, consisting of mostly small studies too heterogeneous to determine incidence, risk factors, or impact of CPSP in children.
Studies of the effects of child and parent preoperative anxiety or pain catastrophizing on postoperative pain trajectories and the development of CPSP have found mixed results [16].
●Risk reduction – Strategies for reducing the risk or preventing chronic postsurgical pain (CPSP) may include preoperative, intraoperative, and postoperative interventions.
In adults, other than avoiding surgery, the efficacy of most such interventions is unclear, and they have not been studied in children. In adults, although acute postoperative pain is a risk factor for CPSP, effective postoperative pain control does not appear to prevent CPSP. No specific anesthetic or perioperative analgesic technique has been shown to prevent CPSP. These issues are discussed in detail separately. (See "Chronic postsurgical pain in adults: Incidence, risk factors, and potential risk reduction", section on 'Risk reduction'.)
Surgical causes, including nerve entrapment syndromes, should always be considered in patients with persistent pain [17].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute pain management".)
SUMMARY AND RECOMMENDATIONS
●Pain assessment and goals
•Assessment of postoperative pain in young children may be challenging. Pain must be distinguished from other causes of discomfort (eg, hunger, wetness, cold, poor positioning, need for caregiver contact) and from emergence delirium. (See 'Assessment of pain throughout the developmental continuum' above.)
•The goal for pain control is functional recovery, rather than a specific pain score, while achieving a tolerable degree of pain. (See 'Goals for pain management' above.)
●Multimodal opioid sparing approach
•The approach to acute pain management in children consists of a multimodal opioid sparing strategy appropriate for the expected degree and duration of pain. An overarching principle of pain management is to avoid the excessive use of opioids. (See 'Avoiding excessive opioid use' above and 'Multimodal pain control' above.)
•Age appropriate nonpharmacologic pain control therapy should be used for all patients. (See 'Creating a plan for perioperative analgesia' above.)
●Strategy based on expected degree of pain
•Mild postoperative pain (eg, after dental extraction, percutaneous biopsy, myringotomy) can usually be managed with multimodal analgesia without the use of postoperative opioids. (See 'Mild pain' above.)
•For moderate postoperative pain, in addition to nonpharmacologic analgesic measures and nonopioid analgesic adjuvants, local or regional analgesia may provide adequate analgesia. A short course of postoperative opioids may be required, particularly if regional analgesia is not possible. Moderate pain should be expected after most laparoscopic and soft tissue surgeries (eg, tonsillectomy, hernia repair). (See 'Moderate pain' above.)
•For severe postoperative pain (eg, after open abdominal or orthopedic surgery), regional analgesia techniques should be used whenever possible, supplemented by nonopioid analgesics and nonpharmacologic measures. If continuous regional analgesia is not possible or is ineffective, intravenous opioids are usually required postoperatively, and patients may require oral opioids on discharge from the hospital. (See 'Severe pain' above.)
●Chronic postsurgical pain in children – Chronic postsurgical pain is an increasingly recognized problem in children. The incidence, risk factors, preventive measures, and impact on children have not been elucidated. (See 'Chronic postsurgical pain in children' above.)
