Multimodal strategies for alleviating postoperative pain in children: a narrative review on research progress and evidence-based practice

Introduction

Background

Postoperative pain is one of the most frequent and consequential challenges in pediatric perioperative care. Children often experience clinically meaningful pain after surgery, yet pain remains undertreated because of developmental variation in pain expression, difficulty with age-appropriate assessment, inconsistent home management, and concerns about analgesic adverse effects (1,2). Poorly controlled pain can interfere with mobilization, sleep, hydration, feeding, mood, and participation in recovery, while repeated exposure to inadequately treated pain may also contribute to longer-term sensitization and negative behavioral outcomes (1-3).

The need for improved management is especially clear in children because pain assessment and treatment cannot rely on adult assumptions. Infants, toddlers, school-age children, and adolescents differ in their ability to communicate pain, tolerate procedures, metabolize medications, and respond to environmental or caregiver influences (2). In addition, pediatric postoperative pain is embedded in a broader family context. Parental knowledge, beliefs, self-efficacy, and anxiety can shape analgesic adherence, interpretation of pain behaviors, and the use of supportive strategies after discharge (1,4-7). These features make pediatric postoperative pain management both a clinical and a relational task.

Traditional opioid-centered approaches are increasingly viewed as insufficient for this setting. Although opioids remain necessary in selected situations, their use is limited by risks such as respiratory depression, nausea, vomiting, constipation, oversedation, delirium or emergence-related neurobehavioral disturbance, and concerns about dependence or inappropriate exposure (3,8,9). These limitations have accelerated interest in multimodal postoperative pain management, which combines medications and techniques with different mechanisms of action in order to improve analgesia, reduce single-agent toxicity, and support faster recovery (10-13). In pediatric practice, this multimodal logic must also incorporate developmental appropriateness, family participation, and procedure-specific adaptation (2,14,15).

Recent literature suggests that pediatric postoperative pain management is moving toward an integrated model that combines non-opioid pharmacologic foundations, selective regional anesthesia, supportive non-pharmacologic interventions, theory-guided nursing care, standardized pathways, and digital follow-up tools (16-20). However, evidence remains uneven across procedures and intervention types, and implementation barriers continue to limit translation into routine care (17,21). A narrative synthesis is therefore useful not only to clarify what is currently supported and where evidence is still indirect or heterogeneous, but also to show more concretely how multimodal elements can be assembled into evidence-based practice. In practical terms, this means linking age-appropriate pain assessment, foundational non-opioid therapy, selective regional techniques, individualized rescue opioids, family-centered education, and structured follow-up within an auditable perioperative pathway rather than treating each component in isolation.

Objective

This review summarizes research progress and practice implications in multimodal pediatric postoperative pain management. The discussion is organized into five parts: the rationale for multimodal care, pharmacologic and opioid-sparing strategies, non-pharmacologic and theory-guided interventions, evidence-based implementation pathways, and future directions toward precision and technology-enabled pain management. Throughout, we emphasize how these elements may be translated into practical perioperative care plans by combining assessment, risk-benefit judgment, standardized pathway structure, family engagement, and technology-supported follow-up, as shown in Figure 1. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0363/rc).

Figure 1 Conceptual framework of multimodal pediatric postoperative pain management across the perioperative continuum.

Methods

A literature review was conducted using the PubMed database with the keywords “Pediatric postoperative pain”, “Multimodal analgesia”, “Opioid-sparing care”, “Non-pharmacologic intervention”, “Family-centered care”, “Evidence-based practice”, and “Digital health”, focusing on studies published between 2010 and 2025. Eligible studies were identified based on predefined inclusion and exclusion criteria. Table 1 summarizes our search strategy, which aimed to identify previously published journal articles that had conducted research, analysis, and discussion on pain after pediatric surgery, including studies reporting pain intensity, opioid use, functional recovery, caregiver-related outcomes, and broader adverse-event profiles rather than only a narrow set of predefined complications.

Pharmacologic foundations and opioid-sparing multimodal analgesia

Construction of multimodal analgesic regimens

The pharmacologic foundation of pediatric postoperative pain management increasingly relies on multimodal design rather than isolated drug selection. Multimodal analgesia combines agents and techniques acting at different points in the nociceptive pathway in order to improve analgesic efficacy while reducing opioid dose requirements and opioid-related harms (10,12,13,22). In pediatric perioperative care, this usually involves scheduled non-opioid baseline therapy, selective use of regional or neuraxial techniques, and carefully titrated rescue opioids when needed (2,14,15).

This strategy is particularly relevant in children because procedure type, age, and recovery setting substantially influence analgesic needs. Reviews of pediatric cleft, spinal, and other postoperative populations suggest that well-designed multimodal pathways can support better pain control, earlier feeding and mobilization, and reduced opioid exposure without sacrificing comfort (2,14,15). At the same time, regimen construction should not be equated with simply adding more medications. The value of multimodal care depends on rational selection, dose adjustment, safety monitoring, and procedure-specific integration (12,13).

Core role of non-opioid analgesics

Non-opioid analgesics form the foundation of most contemporary multimodal protocols. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are widely recognized as core agents because they provide effective baseline analgesia, are familiar to clinicians and caregivers, and reduce the need for rescue opioids in many postoperative settings (10,11,13,23). In pediatric practice, these agents are especially valuable because they can often be scheduled early and continued through the transition to home recovery (1,2).

NSAIDs are central to multimodal pathways because they target inflammatory mechanisms that contribute to postoperative pain. Narrative reviews and practice primers indicate that non-opioid, multimodal regimens using NSAIDs can provide effective first-line analgesia in many surgical populations while supporting opioid-sparing goals (11,13). Intravenous NSAIDs, including ibuprofen, may be particularly useful when oral intake is delayed and have been associated with reduced opioid consumption and improved pain outcomes in perioperative care (24,25). In parallel, acetaminophen remains an important baseline medication because of its broad applicability, favorable tolerability, and compatibility with other components of multimodal care (23,26,27).

The opioid-sparing significance of these medications is not merely pharmacologic but practical. Studies of postoperative prescribing change in pediatric orthopedic and otolaryngologic settings suggest that reducing opioid exposure is feasible when non-opioid regimens are standardized and implemented consistently (11,18,28). This is particularly important for common procedures where pain remains substantial after discharge and caregiver-administered treatment determines much of the recovery experience (1,6,18), as shown in Table 2.

Precision use of regional and neuraxial techniques

Regional and neuraxial analgesic techniques are important adjuncts in pediatric multimodal care because they can reduce systemic opioid exposure and improve procedure-specific pain control (23,29-32). Peripheral nerve blocks, fascial plane blocks, and neuraxial strategies allow the clinician to target pain pathways more selectively than systemic medication alone. In principle, this fits well with pediatric analgesic goals: maximize comfort while limiting oversedation and other opioid-related complications.

Among regional approaches, the transversus abdominis plane block has received attention as part of opioid-sparing postoperative care for abdominal surgery and related procedures (29,33). Peripheral block strategies are also discussed as alternatives or supplements when neuraxial techniques are not suitable (31). However, the literature also suggests that regional techniques should be incorporated thoughtfully rather than automatically. A more explicit risk-benefit framework is helpful here. The potential benefits include superior procedure-specific analgesia, lower systemic opioid exposure, less nausea or oversedation, and possibly easier mobilization or feeding when pain is better controlled. These advantages must be weighed against risks and burdens such as block failure, local anesthetic systemic toxicity, motor weakness, urinary retention in some neuraxial contexts, need for technical expertise, monitoring requirements, and the possibility that an additional block may add little benefit when an existing multimodal regimen is already well optimized (29,31,34-37). This reinforces a broader principle of pediatric multimodal care: appropriateness depends on the match between the procedure, patient profile, and baseline pathway.

Neuraxial techniques remain highly effective in selected major surgeries and continue to inform perioperative pain practice more broadly (23,32,35). Their relevance to pediatric care lies less in routine universal application and more in the demonstration that high-quality postoperative analgesia often depends on combining central, regional, and systemic approaches when clinically justified. In all cases, safety requires procedure-specific judgment, attention to contraindications, and close postoperative monitoring, because the decision to use regional or neuraxial analgesia is fundamentally a clinical risk-benefit decision rather than a default component of every multimodal pathway (32,35-37).

Preventive analgesia and perioperative opioid stewardship

Preventive or preemptive analgesia aims to reduce postoperative pain by intervening before or around the onset of surgical nociceptive input. This concept aligns closely with multimodal pediatric care because it shifts the focus from reactive rescue treatment toward pathway-based prevention (26). Preoperative acetaminophen and other multimodal measures have been associated with lower postoperative pain scores and reduced rescue analgesic requirements in broader perioperative literature, supporting their inclusion in structured pain protocols (23,26,27).

At the same time, opioid stewardship has become a defining theme in postoperative pain management. Stewardship does not mean eliminating opioids in all cases; rather, it means reserving them for appropriate indications, minimizing excess exposure, standardizing prescribing, and embedding opioids within a broader non-opioid strategy (10,12,18,38). Pediatric orthopedic and tonsillectomy-related studies have shown that standardized protocols can markedly reduce opioid prescribing without worsening pain-related revisits, suggesting that many older prescribing patterns were more liberal than necessary (18,28).

The stewardship perspective is important in children because perioperative opioid exposure often extends into the home environment, where adherence, storage, and rescue decisions are managed by caregivers (1,6,7). Therefore, the quality of opioid stewardship depends not only on intra-hospital prescribing but also on discharge instructions, parental understanding, and follow-up support. A rational pediatric pathway should thus combine effective non-opioid foundations, clear rescue thresholds, and family education regarding medication use and monitoring (6,7,20), as shown in Table 3.

Current limitations and safety considerations

Despite the strength of the multimodal concept, pharmacologic care in children still faces important limitations. Much of the perioperative literature remains procedure-specific, institution-specific, or partly extrapolated from adult populations (12,13,21). Even when evidence is favorable, translation requires attention to developmental pharmacology, adverse-event surveillance, and the realities of outpatient recovery. Families may underdose scheduled medications, delay rescue treatment, or avoid opioids even when they are indicated, while clinicians may vary in comfort with standardized opioid-sparing pathways (1,6,17).

Accordingly, the current evidence supports not a single universal analgesic formula but a structured approach: combine non-opioid foundational agents, use regional or neuraxial strategies selectively, individualize opioid rescue, and monitor both efficacy and safety over time (2,10,11,18). This principle provides the bridge from pharmacologic theory to broader multimodal practice.

Non-pharmacologic and theory-guided supportive interventions

Distraction-based and immersive interventions

Non-pharmacologic strategies are increasingly recognized as meaningful contributors to pediatric postoperative pain relief because they address attentional, emotional, and behavioral dimensions of pain that medications alone cannot fully resolve (19,39-41). Children are particularly responsive to interventions that redirect attention, reduce procedural fear, and make the perioperative experience feel more predictable or controllable. These effects are clinically relevant because pain and anxiety often amplify one another during recovery.

Among distraction-based approaches, virtual reality (VR) has emerged as one of the most visible innovations. Recent reviews and perioperative studies suggest that VR may reduce pain intensity, procedural distress, and anxiety by immersing children in engaging multisensory environments (19,40,41). Although the literature is still developing, the appeal of VR lies in its compatibility with pediatric care: it is adaptable to developmental level, can be individualized, and may be integrated into perioperative education as well as postoperative support (19,40). More conventional distraction-based interventions, including activity-oriented engagement and child-centered creative approaches, may also improve comfort and recovery experience (39).

Complementary and physical adjuncts

Complementary and supportive physical interventions continue to attract interest, although the evidence base is more heterogeneous than for core pharmacologic care. Reviews discussing non-pharmacologic pain management have included techniques such as acupuncture, breathing exercises, relaxation training, massage, and other supportive approaches (21,42-44). These interventions may offer additional benefit when they are embedded in a structured multimodal plan, particularly for children with high distress, strong anxiety components, or limited tolerance for medication escalation.

However, the available evidence warrants cautious interpretation. Some techniques appear promising in principle but remain under-supported in procedure-specific pediatric postoperative contexts. For example, psychological or relaxation-based interventions may depend heavily on timing, training intensity, developmental appropriateness, and family participation (43,44). This means that the question is often not whether a technique is theoretically beneficial, but whether it can be delivered in a sufficiently structured and reproducible way to change outcomes in real-world pediatric surgical care (21,44).

Theory-guided nursing models

Nursing theory provides an important conceptual framework for pediatric postoperative pain management because pain in children is never purely a physiologic event. Caring-based models help organize interventions that address comfort, trust, fear, communication, and the therapeutic environment alongside medication administration. Recent evidence suggests that theory-guided nursing interventions can reduce pain intensity and medication requirements in children after surgery (16).

In particular, caring models informed by Watson’s Theory of Human Caring emphasize the therapeutic value of presence, empathy, healing environment, and relationship-centered care (16,45,46). When translated into pediatric postoperative practice, this orientation encourages nurses to move beyond task-based monitoring and instead coordinate reassurance, family engagement, symptom interpretation, and individualized comfort measures. Such models are especially relevant in children because fear, unfamiliarity, and dependence on adults may magnify suffering even when nociceptive input is moderate (16,45).

Family-centered pain management

Family-centered pain management is a defining feature of pediatric care because much of recovery occurs in the presence of caregivers, and many analgesic decisions after discharge are made by parents rather than professionals (1,6,7,20). Studies from different settings indicate that parental attitudes toward pain medication, confidence in pain management, and understanding of non-pharmacologic options directly influence postoperative care quality (6,7). Caregiver anxiety also matters because parental distress may amplify the child’s anxiety and alter how pain behaviors are interpreted or managed (4,5).

These findings support a family-centered model in which parents are not passive observers but active members of the pain-management team. Effective education should therefore include pain assessment principles, scheduled versus rescue medication use, red flags, realistic recovery expectations, and practical non-pharmacologic strategies that can be applied at home (6,7,20,43). This is also where digital tools may be particularly useful, because they can reinforce guidance after discharge and support longitudinal monitoring (20,43), as shown in Table 4.

Evidence gaps in supportive interventions

The major limitation across supportive interventions is not the absence of clinical rationale, but the variability of the evidence base. Many studies use small samples, mixed procedures, different outcome definitions, or short follow-up periods (21,40,41,44). Some interventions are studied mainly in perioperative anxiety rather than postoperative pain itself, while others are evaluated as add-ons without enough detail to determine how they should be integrated into routine care (43,44). As a result, the most defensible current position is that non-pharmacologic and theory-guided interventions are valuable components of multimodal care, but they should complement rather than replace evidence-based pharmacologic and pathway-based management.

Evidence-based practice translation: standardized pathways, family engagement, and emerging technologies

Standardized perioperative pain pathways and quality improvement

The translation of multimodal pain care into routine pediatric practice depends heavily on standardized pathways. Quality-improvement studies in pediatric tonsillectomy and orthopedic care suggest that protocolized prescribing and structured multimodal regimens can reduce opioid exposure substantially while maintaining clinically acceptable pain control (18,28). These findings matter because they move the discussion from theoretical analgesic superiority to actual change in prescribing behavior, complication rates, and implementation consistency.

Standardized pathways are particularly useful in pediatric care because they reduce avoidable variability across providers and create a shared framework for nurses, surgeons, anesthesiologists, and families. They can specify baseline non-opioid therapy, rescue thresholds, discharge instructions, and reassessment expectations, thereby improving both safety and predictability (17,18,28). However, implementation is rarely frictionless. Interprofessional differences in assumptions about pain, opioids, and assessment tools can become barriers if pathway adoption is not supported by communication, training, and feedback (17).

Continuous pain monitoring and patient-reported outcomes

An evidence-based pathway is only as strong as its monitoring strategy. Pediatric postoperative pain management requires repeated assessment using age-appropriate tools, with particular attention to children who cannot provide reliable self-report (2,33). In practice, this means combining validated behavioral scales, self-report tools when developmentally appropriate, and family observations that capture changes in comfort, sleep, feeding, and function after discharge (1,6,7,20). At the same time, the limitations of pain intensity scores should be recognized more explicitly. Numeric and faces-based tools are essential, but they do not fully capture pain interference, movement-related pain, affective distress, or analgesic side effects, and observer-based tools may be influenced by caregiver anxiety, clinician interpretation, or developmental uncertainty. Accordingly, optimization depends not only on using pain scores but on using them within a broader functional and contextual assessment strategy.

Patient-reported and caregiver-reported outcomes are especially important because they reflect the lived experience of recovery more directly than readmission or emergency-visit rates alone. Ongoing monitoring can identify undertreated pain, adverse effects, and children at risk of more persistent postoperative symptoms (3,47). This is clinically relevant because acute postoperative pain should not be viewed only as a short-term event; for a subset of children, poorly controlled early pain may contribute to longer-term pain vulnerability, pain-related fear, impaired function, and more difficult recovery trajectories (3,48,49). This possibility strengthens the rationale for repeated monitoring and early adjustment of multimodal plans rather than treating pain assessment as a one-time postoperative task.

Digital health and technology-enabled care

Digital tools are emerging as important enablers of evidence-based pediatric postoperative pain management because they can extend support beyond the hospital and reinforce family-centered care (20,43). Mobile applications, symptom monitoring systems, and digital counseling interventions can help caregivers track pain trajectories, improve adherence to analgesic guidance, and identify when professional review is needed (20). These tools are particularly useful in ambulatory surgery and short-stay pathways, where most pain management occurs at home.

Digital innovation also intersects with non-pharmacologic care. VR can be viewed not only as an intervention in itself but as part of a broader shift toward personalized, technology-enabled symptom management (19,40,41). Digital counseling for parents has similarly shown potential to improve the use of non-pharmacologic pain-relief strategies in pediatric day surgery (43). The next challenge is not only to show that digital approaches are feasible, but to determine how clinical teams can use them to build and refine more consistent multimodal pathways across institutions. In practice, most postoperative teams already use multimodal pathways, yet these pathways are rarely uniform. Broader collaboration across centers, specialties, and professional groups is therefore needed to define shared pathway elements, outcome metrics, and implementation standards while still allowing procedure-specific adaptation, as shown in Figure 2.

Figure 2 Translational pathway from evidence-based pain assessment to personalized and technology-enabled pediatric pain care. FLACC, Face, Legs, Activity, Cry, Consolability.

Multidisciplinary collaboration and implementation barriers

High-quality pediatric postoperative pain management is inherently multidisciplinary. Surgeons, anesthesiologists, nurses, psychologists, rehabilitation professionals, and caregivers all influence the child’s pain experience and recovery trajectory (17,50). This interdependence is a strength when collaboration is effective, but it also creates implementation barriers when communication is inconsistent or professional priorities differ. It also highlights a broader systems issue: although multimodal pathways are widely used in postoperative care, they remain highly variable across institutions and are rarely developed through fully shared national or international frameworks.

Interprofessional studies have highlighted barriers related to knowledge gaps, divergent opioid attitudes, uncertainty regarding standardized assessment, and the challenge of maintaining protocol adherence in busy clinical environments (17). Nursing knowledge and attitudes also remain important because nurses often serve as the most continuous evaluators of postoperative pain and are central to translating protocols into daily care (51). Therefore, education is necessary but not sufficient; sustainable improvement also requires workflow support, institutional commitment, feedback loops, and a culture that treats pain management as a shared quality target rather than an isolated medication task (17,21,50). More broadly, the field would benefit from multicenter and cross-disciplinary collaboration aimed at defining which multimodal pathway elements should be standardized, which should remain procedure-specific, and how digital tools can support implementation without adding fragmentation, as shown in Table 5.

Future directions toward precision pain management

The next stage of pediatric postoperative pain research is likely to move from broad multimodal principles toward precision-oriented care. Recent reviews on personalized pain assessment and multimodal intervention planning suggest that future pathways may incorporate richer preoperative risk profiling, procedure-specific prediction, and stratified intervention intensity (49). This could eventually help clinicians identify children at higher risk of severe acute pain, prolonged recovery, or persistent postsurgical pain, and intervene earlier with targeted support (48,49).

At the same time, future progress will depend on implementation science as much as on analgesic innovation. Pediatric pain care improves when the strongest available evidence is translated into practical workflows that clinicians can follow and families can sustain (17,18,20,28). Therefore, the most valuable future models are likely to be those that connect individualized risk assessment, multimodal therapy, family-centered education, and digital monitoring within a coherent and auditable pathway (20,22,43,49). In practical terms, this means future multimodal or precision-based plans should specify who assesses risk, how baseline analgesics and rescue thresholds are selected, when regional techniques are favored, how families are prepared for home management, and how follow-up signals prompt pathway adjustment rather than leaving implementation at a purely conceptual level.

Conclusions

Pediatric postoperative pain management has entered a stage in which effective care can no longer be understood as simple opioid administration or isolated symptom relief. The current literature supports a broader multimodal model built on age-appropriate assessment, non-opioid foundational analgesics, selective regional techniques, family-centered education, supportive non-pharmacologic measures, and standardized perioperative pathways (2,6,7,10,11,13,16-20). This integrated approach is especially important in children because pain intensity, anxiety, medication response, and recovery behavior are shaped simultaneously by developmental, relational, and organizational factors.

The strongest practical message from the available evidence is that opioid-sparing care is feasible when it is implemented through structured protocols rather than ad hoc substitution (10,11,18,28). Non-pharmacologic and theory-guided interventions further strengthen this model by addressing fear, distress, and caregiver participation, even though their evidence base remains more heterogeneous than that of pharmacologic strategies (16,19,21,40,41,43,44). In this sense, high-quality pediatric postoperative pain care depends on combining technical analgesia with supportive nursing and family partnership.

Future work should focus on implementation-ready precision models that can identify children at greater risk of severe or persistent postoperative pain, match them to tailored multimodal strategies, and maintain follow-up beyond the immediate hospital stay (20,22,43,48,49). If this direction is pursued successfully, pediatric postoperative pain management will become not only more effective but also safer, more individualized, and more sustainable across the perioperative continuum.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0363/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0363/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0363/coif). The authors have no conflicts of interest to declare.

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