Is prehospital opioid administration safe in children? A register-based study

Pain in prehospital paediatric patients is often poorly managed. Prehospital opioid doses generally stay below the upper limits recommended by guidelines. Concerns about the risk of overdosing may affect analgesic administration in children. This study investigated whether prehospital administration of opioids in children resulted in clinical signs of adverse effects at hospital admission. This retrospective, register-based study included children aged 0–14 years who received prehospital opioids in the Region of Southern Denmark between 2017 and 2022. Medical records were reviewed for clinical signs of opioid-related adverse effects. The effects were categorised as nonspecific signs, including nausea/vomiting, drowsiness and sedation and more serious clinical signs, comprising bradycardia and respiratory depression. We assessed diagnoses, antidote use, and vasopressor administration. In-hospital analgesia was recorded. 1,531 children were included. Fentanyl was administered alone or in combination with other analgesics to 99.7% of the children. Although 97.0% received opioids within the recommended dosage range,15.1% (231 children) exhibited at least one clinical sign compatible with opioid-related adverse effects. In 9.2% (141 children), no other explanation for the observed signs was identified. Nausea was present in 5.6% (86 children) and drowsiness in 2.5% (39 children). More serious clinical signs were less frequent, with bradycardia observed in 0.7% (12 children) and respiratory depression in 0.7% (10 children). No opioid antidotes were administered at the hospital. At hospital arrival, 63.6% (974 children) were in pain. 51% (781 children) received additional in-hospital analgesia. Serious signs potentially compatible with opioid-related adverse effects were uncommon. A substantial proportion of children had pain documented at hospital arrival and received additional analgesia soon after admission. The analgesic effect may have diminished before handover; however, persistent pain at the transition to hospital care may indicate insufficient pain management. Because the retrospective design does not capture transient prehospital events or standardised pain trajectories, these findings should not be interpreted as proof of prehospital opioid safety or as direct evidence of prehospital undertreatment. Prospective studies are needed to characterise the timing, severity, and causality of adverse effects and pain trajectories after prehospital opioid administration in children.