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November 11, 2020

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

Author Affiliations
  • 1Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
  • 2Department of Preventive Medicine, University of Southern California, Los Angeles
  • 3Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
  • 4Department of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
  • 5Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
  • 6Department of Surgery, University of Michigan Medical School, Ann Arbor
  • 7Department of Pediatric Surgery, University of Michigan, Ann Arbor
  • 8Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, Rhode Island
  • 9Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
  • 10Department of Pediatric Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 11Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus
  • 12Department of Surgery, University of Arizona College of Medicine, Tucson
  • 13Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
  • 14Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
  • 15Department of Surgery, University of Washington School of Medicine, Seattle
  • 16Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
  • 17Division of Pediatric Surgery, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
  • 18Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland
  • 19Division of Library Services, Naval Medical Center, Portsmouth, Virginia
  • 20Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
JAMA Surg. 2021;156(1):76-90. doi:10.1001/jamasurg.2020.5045
Key Points

Question  What are the risks of opioid misuse in children and adolescents, what nonopioid regimens effectively manage pain in children after surgery, and what education on opioid use should be provided to families?

Findings  In this expert panel review and opinion, opioid misuse was found to occur frequently, particularly for adolescents with access to opioids, and nonopioid regimens were found to be effective to minimize or eliminate need for opioids after surgery. Families of children who undergo surgery want instruction on pain management before and after surgery.

Meaning  Health care workers caring for children after surgery should recognize the risks of opioids, maximize nonopioid regimens, and educate families appropriately.


Importance  Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

Objective  To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

Evidence Review  Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

Findings  Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

Conclusions and Relevance  These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

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    1 Comment for this article
    Optimal Pediatric Surgical Care Necessitates Optimal Postoperative Pain Management
    Constance Houck, MD, MPH, FAAP | Boston Children's Hospital/Harvard Medical School
    To the Editor,

    We read with particular enthusiasm the article by Dr. Kelly-Quon and colleagues (1) entitled Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion and agree with the accompanying commentary by Drs. Adler and Chung (2) that these guidelines have the potential to “influence the practice of every surgeon in the US who provides care to children undergoing surgery.” As leaders of the American College of Surgeons Children’s Surgical Verification Quality Improvement Program (ACS CSV), we believe that opioid stewardship and the use of multimodal analgesia techniques are essential to providing optimal
    surgical care of children. We are currently in the final stages of updating the Optimal Resources for Children’s Surgical Care standards, (3) which will be released in 2021. As part of these standards, we have outlined specific requirements for the establishment of an Opioid Stewardship Program at Level I and II ACS CSV-verified surgery centers. In addition, these standards provide an expectation that all Level I and II centers be continually engaged in at least one data-driven quality improvement project to promote multimodal analgesic strategies and opioid stewardship and that Level III centers implement guidelines for opioid prescribing and the use of multimodal analgesic strategies. We commend the authors for their well-researched recommendations and hope that these guidelines can accelerate the development of pediatric opioid stewardship programs and the hospital-wide dissemination of data-informed postoperative opioid prescribing guidelines. Collectively, these efforts will contribute to the delivery of optimal care for all children who undergo a surgical procedure.

    1. Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. JAMA Surg. Published online November 11, 2020. doi:10.1001/jamasurg.2020.5045

    2. Adler AC, Chung D. Children Are Not Little Adults When Prescribing Opioids. JAMA Surg. Published online November 11, 2020. doi:10.1001/jamasurg.2020.5150

    3. American College of Surgeons. Children’s Surgery Verification Quality Improvement Program: Optimal Resources for Children’s Surgical Care. Vol. 1. Chicago, IL: American College of Surgeons;2015.

    Constance S. Houck, MD, MPH, FAAP
    Associate Professor of Anaesthesia
    Department of Anesthesiology, Critical Care and Pain Medicine
    Boston Children’s Hospital & Harvard Medical School
    Boston, Massachusetts

    Mary E. Fallat, MD, FAAP, FACS
    Professor of Surgery
    University of Louisville School of Medicine
    Medical Director, Surgical Quality
    Norton Children's Hospital

    Douglas C. Barnhart, MD, MSPH, FACS, FAAP
    Professor of Surgery
    University of Utah School of Medicine
    Medical Director for Surgical Quality and Patient Safety
    Primary Children’s Hospital
    CONFLICT OF INTEREST: I am on the Verification Committee for the American College of Surgeons