By Pat Anson

Fears about children becoming addicted and overdosing on opioid medication have led to the undertreatment of acute pain in pediatric patients, according to a new clinical guideline by the American Academy of Pediatrics (AAP).

The AAP guideline – the organization’s first to address opioid prescribing to children and adolescents -- urges pediatricians to start with non-opioid medication when treating mild to moderate acute pain. Opioids can be prescribed if a child is in severe pain or doesn’t respond to non-opioid treatment.

“There’s been a big pendulum swing in the practice of medicine over the last two decades—first with opioid-overprescribing, then with a huge cutback in opioid prescribing, likely leaving some children’s pain undertreated,” said lead author Scott Hadland, MD, Chief of Adolescent Medicine at Massachusetts General Hospital and an Associate Professor of Pediatrics at Harvard Medical School

“We want pediatricians to prescribe opioids when they’re needed because untreated pain can lead to distress and psychological harm. At the same time, physicians need to take steps that reduce the long-term risk for addiction.”

The guideline recommends that immediate release opioids be used, starting with a low dose and an initial supply of five days or less. Opioids can be prescribed for longer periods if a child is recovering from trauma or surgery and the pain is expected to last longer than 5 days. Every prescription for opioids should also include a prescription for naloxone, an overdose reversal drug.

The AAP warns that codeine or tramadol should not be prescribed to patients younger than 12 years; adolescents 12 to 18 years of age who have obesity, sleep apnea, or severe lung disease; or when treating surgical pain after a tonsillectomy or adenoidectomy.

“For a patient with mild to moderate pain, doctors should always start nonopioid medications and treatment,” said guideline co-author Rita Agarwal, MD, a Pediatric Anesthesiologist and Professor at Stanford Medicine. “Opioids do remain an important tool for acute pain relief.  But there are times when acetaminophen and ibuprofen may be equally effective with fewer side effects, such as in procedures such as tonsillectomy, wisdom teeth removal, and fractures.”

The AAP’s guideline is based on a review of 11 clinical studies involving pediatric outpatients being treated for acute pain. Hundreds of other studies were excluded from the analysis because they involved adults or hospitalized patients.

The use of opioids by children and adolescents has been a contentious issue for many years. Opioids were once commonly prescribed after wisdom teeth removal, a practice that is now discouraged.

The AAP’s guideline review committee found that most children prescribed opioids do not become addicted or have an overdose. The risk of a child developing opioid use disorder or experiencing an overdose one year after a prescription ranged from 0.3% to 5.8%.

The World Health Organization (WHO) released a guideline in 2021 recommending that opioids only be given to children who are dying or seriously ill and not expected to recover. The WHO guideline found that “evidence of the effectiveness and safety of opioids is completely lacking in children.”