Pediatric contraindications, age limits, toxicities and dangerous combinations that Prometric questions are built on.
Rule: avoid aspirin (and hidden salicylates) for fever/pain in anyone <16 years (UK) / children and teenagers (US), especially with influenza or varicella.
Child on long-term aspirin: give annual inactivated influenza vaccine (not LAIV); consider stopping/switching aspirin during influenza or varicella exposure; avoid ibuprofen (blocks aspirin's antiplatelet effect).
| Ingested dose | Expected toxicity |
|---|---|
| <150 mg/kg | Mild/none |
| >150 mg/kg | Toxic |
| >300 mg/kg | Severe, potentially fatal |
Avoid intubation if possible; if needed, keep hyperventilation (loss of respiratory compensation → acidemia → collapse).
Mechanism: both are prodrugs activated by CYP2D6. Ultra-rapid metabolizers (common in Middle East/North Africa populations) make large amounts of morphine/active metabolite → respiratory depression and death.
| Situation | FDA / EMA position |
|---|---|
| Age <12 years | Contraindicated (pain and cough) |
| Post-tonsillectomy/adenoidectomy <18 years | Contraindicated (OSA children most vulnerable) |
| 12–18 years with obesity, OSA, severe lung disease | Avoid |
| Opioid cough/cold medicines | Not for <18 years (FDA) |
| Breastfeeding mothers | Avoid (infant deaths from morphine in milk) |
Instead: mild–moderate pain → paracetamol and/or ibuprofen; severe pain (fracture, post-op, pancreatitis) → IV morphine 0.05–0.1 mg/kg titrated with monitoring (WHO two-step ladder).
Tramadol also lowers the seizure threshold and causes serotonin syndrome with SSRIs.