AAP updates guidance on iatrogenic opioid dependence and withdrawal in children

AAP updates guidance on iatrogenic opioid dependence and withdrawal in children | Image Credit: © BillionPhotos.com - stock.adobe.com.

The American Academy of Pediatrics (AAP) has issued updated clinical guidance for pediatricians on recognizing and managing opioid dependence and withdrawal in children resulting from medically prescribed opioids. The clinical report, Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children, was published in the September 2025 issue of Pediatrics and serves as an update to a prior 2014 statement.^1,2

The report emphasizes that opioid use is common in children for acute injuries, chronic conditions, postoperative pain, and intensive care management. While opioids are often necessary in these settings, the AAP notes that “around-the-clock dosing of opioids taken for as few as 5 days can produce physiologic opioid dependence and may lead children to exhibit withdrawal symptoms on abrupt discontinuation or tapering of these medications.” The authors distinguish between physiologic dependence and opioid use disorder, stating that “it is important not to conflate addiction, also known as an opioid use disorder, with physiological dependence or tolerance, because patients appropriately treated with prolonged opioid therapy may develop physiological dependence and sometimes tolerance”.

Scope of the report

The new guidance addresses children prescribed opioids in inpatient and outpatient contexts, but does not include infants treated for neonatal abstinence syndrome due to prenatal exposure. The report summarizes available literature on opioid withdrawal in children and highlights assessment tools validated for pediatric populations, such as the Sophia Observation Scale (SOS) and the Withdrawal Assessment Tool-1 (WAT-1). These scales help clinicians detect withdrawal symptoms, which may present as anxiety, agitation, insomnia, tremors, tachycardia, tachypnea, fever, gastrointestinal upset, or hypertension.

Children in intensive care units are particularly vulnerable because they often receive opioids at higher doses and for longer durations to manage pain, sedation, or mechanical ventilation. The report notes that while most patients who receive opioids for fewer than 5 days do not develop withdrawal symptoms, those requiring longer therapy should be considered at risk.

Management strategies

The AAP advises that children who require opioids for more than 5 days should be tapered rather than abruptly discontinued. Tapering typically involves gradually reducing the dose in 10% to 20% increments every 24 to 48 hours, with adjustments based on patient response. The report stresses the need for individualized tapering schedules because pharmacogenomic variability and clinical status can influence withdrawal risk and severity.

Monitoring is critical throughout the tapering process, and validated tools such as WAT-1 can be applied even in nonverbal patients. Rescue opioid doses may be required for children experiencing moderate to severe withdrawal.

Adjunctive medications, including dexmedetomidine, have been used in practice but lack robust evidence in pediatric withdrawal management. Nonopioid analgesics such as acetaminophen, NSAIDs, ketamine, gabapentin, and local anesthetics are recommended to reduce overall opioid requirements. Regional anesthesia and multidisciplinary support, including physical therapy, behavioral interventions, and involvement of child life specialists,are encouraged to mitigate withdrawal symptoms and improve functional outcomes.

Importance for clinical practice

The updated report underscores the prevalence of prescription opioid use in pediatrics and the importance of structured tapering strategies. It emphasizes coordination among primary care providers, families, and multidisciplinary teams to ensure safe withdrawal management. “For those patients requiring opioids for longer than five days, providers should consider tapering the dose of opioid as well as assessing regularly for withdrawal symptoms,” the AAP stated in its release.¹

The authors conclude that safe prescribing requires careful balance: adequate analgesia for acute or chronic conditions, vigilance for iatrogenic dependence, and proactive withdrawal management. They caution that nonrecognition or misattribution of withdrawal symptoms can complicate patient care.

This clinical report provides physicians with updated tools and strategies to identify and manage iatrogenic opioid dependence in children, while distinguishing it from opioid use disorder. The guidance will remain active for 5 years unless reaffirmed or revised.

References:

1. American Academy of Pediatrics. American Academy of Pediatrics Updates Guidance on Opioid Dependence, Withdrawal Associated With a Medical Prescription. AAP. August 18, 2025. Accessed August 20, 2025. https://www.aap.org/en/news-room/news-releases/aap/2025/american-academy-of-pediatrics-updates-guidance-on-opioid-dependence-withdrawal-associated-with-a-medical-prescription/
2. Adler AC, Siegel LB, Wilder RT, et al. Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children: Clinical Report. Pediatrics. Published online August 18, 2025. doi:https://doi.org/10.1542/peds.2025-073169