From Clinic to Recovery · First Edition
Chapter 25 — Children and Young People
Dr. Tamer Rushdy Elalfy · 11 min read
In this chapter
Operating on a child means caring for a family, not only a patient. Parents carry their own fear, often sharper than the child’s, and children sense it. Consent is legally the parent’s or guardian’s, but a child who is old enough to understand deserves an honest, age-appropriate explanation and a real say in how the day goes. Pain relief, fasting, and anxiety all need an approach specific to children, not a smaller version of the adult plan. This chapter covers consent and assent, preparing a child for the day, and the medicine differences that matter most.
Learning objectives After reading this chapter you should be able to:
|
Table 25.1. Children and young people having surgery, at a glance.
| At a glance | |
|---|---|
| Consent | Given by a parent or legal guardian; the child’s own agreement (assent) is sought at a level suited to their age |
| Fasting | Shorter clear-fluid fasting than adults: most guidelines allow clear fluids until 1 hour before anesthesia in children |
| Pain relief | Weight-based paracetamol and ibuprofen; codeine and tramadol are contraindicated under 12, and tramadol under 18 after tonsil or adenoid surgery |
| Anxiety | A frightened child is common and manageable; preparation and parental presence help the most |
| The key counseling message | “We will explain everything to your child in words they can understand, and we will look after you both.” |
STEP 1 Consent, assent, and explaining the plan
25.1 Consent and assent
Consent for a child’s operation is given by a parent or legal guardian, following local law and hospital policy. Even though a young child cannot give legal consent, the child’s own agreement, or assent, should be sought wherever possible, at a level suited to their age and understanding [1]. A toddler can be told simply what will happen to their body; a seven-year-old can be shown pictures and asked questions; a teenager can take part in the discussion much as an adult would, and many legal systems give older adolescents an increasing role in their own healthcare decisions. When a child clearly objects to a non-urgent procedure, this should be explored and, where possible, addressed rather than overridden.
Script: talking with a child about the operation “We are going to help your [tummy / arm / nose] get better. You will have a special sleep so you will not feel it happening. A grown-up you trust can stay close until you are asleep.” “It is okay to feel scared or want to cry. Lots of children feel that way. Would you like to bring your favorite toy?” |
25.2 Preparing the child and the family
Unmanaged preoperative anxiety is common in children and is linked to more distress during anesthesia induction and to difficult behaviors afterward, such as sleep problems and new fears [2]. Preparation reduces this. Honest, simple explanations; a chance to handle equipment or play with a mask; a comfort object from home; and a parent present during induction where the hospital allows it, all help. A calm parent helps create a calm child, so address parental anxiety directly as well (Figure 25.1).
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 25.1. Five ways to reduce a child’s fear of the operation, for use with families.
25.3 Fasting in children
Fasting rules for children differ from adults and should not simply be copied across. Current European pediatric anesthesia guidance allows clear fluids until 1 hour before anesthesia, breast milk until 3 hours before, and formula or a light meal until 6 hours before, for healthy children [3, 4]. Unnecessarily long fasting in children causes distress, dehydration, and low blood sugar, and is a common avoidable source of a bad day for the whole family. Confirm the exact local protocol, since practice varies.
25.4 Medicines that are different in children
Caution: codeine and tramadol are contraindicated in children
|
Paracetamol (acetaminophen) doses in children are calculated by weight: typically 15 mg/kg every 4 to 6 hours, with a maximum of 4 doses (60 mg/kg) in 24 hours, not exceeding the adult maximum; always check the local formulary and the product information, and use an age- and weight-appropriate preparation. Ibuprofen, when suitable, is typically 5 to 10 mg/kg every 6 to 8 hours. Give exact doses on the discharge instructions, calculated for the individual child’s weight, not as a generic range.
STEP 2 Preparation, the day of surgery, and recovery
25.5 Before the operation
- Weight. Record the child’s current weight for accurate medicine dosing.
-
Vaccinations and illness. A child with a current cough, cold, or fever may need the operation postponed; follow the anesthesia team’s advice.
-
Comfort items. Bring a favorite toy, blanket, or dummy (pacifier).
-
Preparation materials. Many units offer picture books, videos, or a pre-visit to the ward; use them where available.
-
Parents. Explain what to expect in the anesthesia room and recovery area, and prepare them for how a child may look and behave on waking (groggy, tearful, or clingy is normal).
25.6 After the operation
Children often wake from anesthesia confused, tearful, or agitated for a short time (emergence agitation); this usually settles within 20 to 30 minutes with a calm, familiar adult present. Encourage early return to normal activity, play, and school as the specific procedure chapter advises, scaled to the child’s age. Dehydration and reluctance to drink are common concerns; offer small, frequent sips of a preferred drink.
STEP 3 Questions parents ask
“Can I stay with my child until they are asleep?”
In most units, yes, where it is safe to do so. Ask your anesthesia team about their policy.
“Will my child remember the pain?”
Children generally do not remember pain from under general anesthesia. Good pain relief afterward is still important, and we will give you a clear plan.
“Can I give my child the cough medicine with codeine that I have at home?”
No. Codeine is not safe for children under 12, and must not be used after tonsil or adenoid surgery in anyone under 18 [5]. Use only the medicines on the plan we give you.
“Why can’t my child eat until so close to the operation now, when the old advice was midnight?”
Modern guidance allows most children clear fluids until 1 hour before anesthesia, which is kinder and safer than fasting overnight [3].
“My child is very frightened. What can we do?”
This is common and manageable. Bring a comfort toy, use simple honest words, and ask the team about preparation materials. We will support both of you.
“How much pain medicine should I give at home?”
Exactly the dose on your discharge sheet, calculated for your child’s weight. Do not use adult doses or leftover medicines from another illness.
“My teenager wants to make their own decisions. Is that allowed?”
We involve young people in decisions about their own body as much as possible, alongside their parent or guardian, following our local policy.
STEP 4 Risks, warning signs, and consent
25.7 Additional considerations
Table 25.2. Considerations specific to children having surgery.
| Band | Issue | Notes |
|---|---|---|
| Common | Short-lived confusion or agitation on waking | Usually settles within 20 to 30 minutes with a familiar adult present |
| Common | Reluctance to eat or drink for a few hours | Offer small, frequent sips; most children recover their appetite within a day |
| Less common | New sleep disturbance, clinginess, or fear of doctors for some weeks | More likely with high preoperative anxiety; usually settles [2] |
| Rare but serious | Breathing problems from an unsuitable pain medicine | Avoided by never using codeine or tramadol under the ages described above [5] |
25.8 Checklist
Before surgery ☐ Consent obtained from the parent or legal guardian; assent sought from the child where appropriate. ☐ Current weight recorded for medicine dosing. ☐ Age-appropriate preparation offered; comfort item brought. ☐ Fasting instructions given according to pediatric timings, not adult timings. ☐ Pain-relief plan uses weight-based paracetamol and avoids codeine and tramadol at the ages described above. ☐ Parents prepared for the anesthesia room and for normal waking behavior. ☐ Teach-back done with the parent; patient guide given in the family’s language. |
25.9 Warning signs for parents
Table 25.3. Green, amber, and red warning signs for children after surgery.
| Level | Signs | What to do |
|---|---|---|
| Green | Tearfulness, clinginess, or grogginess for a few hours Mild loss of appetite for a day | Expected. Comfort your child and follow the discharge advice. |
| Amber | Not drinking at all for several hours A temperature of 38 °C or more A wound that is red or leaking | Call the clinic or your doctor the same day. |
| Red | Difficulty breathing, blue lips, or excessive sleepiness that is hard to wake from Repeated vomiting, or signs of dehydration (no wet nappies or urine for 8 hours, dry mouth) Severe or worsening pain despite the prescribed medicine | Go to the emergency department now. |
Key points
|
STEP 5 Patient education guide
The following pages may be photocopied and given to families. Complete the weight-based dose with the team, and add your unit’s name, phone numbers, and review date before use.
FAMILY GUIDE Your Child’s Operation For parents and guardians. |
Before the operation
-
Bring a favorite toy, blanket, or comfort item.
-
Use simple, honest words. Do not promise it will not hurt if it might.
-
Follow the fasting times exactly: clear fluids until 1 hour before, as the team told you.
-
Tell the team about any cough, cold, or fever before the day.
My child’s pain medicine (ask your team to complete)
| Medicine | Dose (by weight) | How often | Maximum in 24 hours |
|---|---|---|---|
| Paracetamol | |||
| Ibuprofen (if advised) |
-
Never give codeine or tramadol to a child under 12.
-
Never give tramadol to anyone under 18 after tonsil or adenoid surgery.
-
Use only the medicines and doses written above.
On the day
-
Your child may wake confused, tearful, or clingy. This is normal and usually settles within 20 to 30 minutes.
-
Offer small sips of their favorite drink.
-
A calm parent helps a calm child.
At home
-
Offer food and drink when your child is ready.
-
Let your child rest, but gentle normal activity is fine unless told otherwise.
-
Give pain medicine at the exact dose above.
Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Tearfulness, clinginess, or grogginess for a few hours; mild loss of appetite for a day | This is normal. Comfort your child. |
| AMBER | Not drinking at all for several hours; temperature of 38 °C or more; a red or leaking wound | Call us or your doctor today. |
| RED | Difficulty breathing, blue lips, or very hard to wake; repeated vomiting or signs of dehydration; severe pain despite medicine | Go to the emergency department now. |
My contacts Surgical team: ______________________ Hours: ______________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. American Academy of Pediatrics Committee on Bioethics. Informed consent in decision-making in pediatric practice. Pediatrics. 2016;138(2):e20161484.
2. Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg. 2004;99(6):1648-1654.
3. Thomas M, Morrison C, Newton R, Schindler E. Consensus statement: Pre-operative fasting in children. European Society of Anaesthesiology and Intensive Care. 2023 update.
4. Gustafsson UO, Rockall TA, Wexner S, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery. 2025;184:109397. doi:10.1016/j.surg.2025.109397
5. U.S. Food and Drug Administration. FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. Drug Safety Communication. April 20, 2017.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.