{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T16:19:16Z","timestamp":1772468356905,"version":"3.50.1"},"reference-count":26,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,2,28]],"date-time":"2026-02-28T00:00:00Z","timestamp":1772236800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background: In adults, the forces generated during Boyle\u2013Davis Gag suspension correlate with postoperative pain, but no data are available in pediatrics. This study investigates the force metrics and postoperative opioid consumption, pain, emergence delirium (ED), and hypoactive delirium in children. Methods: Children undergoing elective partial or total adenotonsillectomy or adenoidectomy were enrolled. Intraoperative maximum and average forces, suspension time, total impulse (area under the curve of force vs. time), and postoperative opioid consumption, pain, ED, and hypoactive delirium were assessed. Results: Data from 43 children were analyzed. Force metrics were not associated with postoperative opioid consumption, ED, or hypoactive delirium. Compared to no pain, total impulse decreased with mild (mean difference 2.3 kN\u00b7s; 95% CI, 3.8 to 4.2; p = 0.02), moderate (mean difference 2.8 kN\u00b7s; 95% CI, 5.4 to 3.9; p = 0.011), and severe pain (mean difference 2.3 kN\u00b7s; 95% CI, 7.6 to 3.9; p = 0.005). Suspension time was negatively correlated with pain score (r = \u22120.32, p = 0.041). Conclusions: The force metrics are low and not associated with opioid consumption, ED, or hypoactive delirium. Suspension correlates weakly with postoperative pain in children.<\/jats:p>","DOI":"10.3390\/children13030353","type":"journal-article","created":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T14:55:01Z","timestamp":1772463301000},"page":"353","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Force Metrics During the Boyle\u2013Davis Gag in Children Undergoing Adenotonsillectomy"],"prefix":"10.3390","volume":"13","author":[{"given":"Enriqueta Arevalo","family":"Asensio","sequence":"first","affiliation":[{"name":"Division of Pediatric Anesthesia, Montreal Children\u2019s Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anelise","family":"Schifino Wolmeister","sequence":"additional","affiliation":[{"name":"Division of Pediatric Anesthesia, Montreal Children\u2019s Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3954-5820","authenticated-orcid":false,"given":"Thomas","family":"Engelhardt","sequence":"additional","affiliation":[{"name":"Division of Pediatric Anesthesia, Montreal Children\u2019s Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"},{"name":"Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9698-9519","authenticated-orcid":false,"given":"Sam J.","family":"Daniel","sequence":"additional","affiliation":[{"name":"Department of Pediatric Surgery, Montreal, Children\u2019s Hospital, McGill University, Montreal, QC H4A 3J1, Canada"},{"name":"Department of Otolaryngology-Head and Neck Surgery, Montreal Children\u2019s Hospital, McGill University, Montreal, QC H4A 3J1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4918-6603","authenticated-orcid":false,"given":"Samuel D. F.","family":"Wasserman","sequence":"additional","affiliation":[{"name":"Division of Pediatric Anesthesia, Montreal Children\u2019s Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"},{"name":"Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6585-5809","authenticated-orcid":false,"given":"Gianluca","family":"Bertolizio","sequence":"additional","affiliation":[{"name":"Division of Pediatric Anesthesia, Montreal Children\u2019s Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"},{"name":"Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/j.pcl.2021.12.008","article-title":"Tonsillectomy and Adenoidectomy\u2014Pediatric Clinics of North America","volume":"69","author":"Nguyen","year":"2022","journal-title":"Pediatr. Clin. N. Am."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1093\/bja\/aeq264","article-title":"Safety implications of the Boyle-Davis mouth gag and tracheal tube position in tonsillectomy","volume":"105","author":"Fennessy","year":"2010","journal-title":"Br. J. Anaesth."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1111\/pan.12327","article-title":"Effective postoperative pain management in children after ambulatory surgery, with a focus on tonsillectomy: Barriers and possible solutions","volume":"24","author":"Dorkham","year":"2014","journal-title":"Paediatr. Anaesth."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1016\/j.ijporl.2015.01.016","article-title":"Swedish guidelines for the treatment of pain in tonsil surgery in pediatric patients up to 18 years","volume":"79","author":"Ericsson","year":"2015","journal-title":"Int. J. Pediatr. Otorhinolaryngol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e819","DOI":"10.1097\/PR9.0000000000000819","article-title":"A descriptive analysis of pediatric post-tonsillectomy pain and recovery outcomes over a 10-day recovery period from 2 randomized, controlled trials","volume":"5","author":"Postier","year":"2020","journal-title":"Pain. Rep."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2563","DOI":"10.1002\/lary.27827","article-title":"Laryngeal force sensor metrics are predictive of increased perioperative narcotic requirements","volume":"129","author":"Feng","year":"2019","journal-title":"Laryngoscope"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1177\/0194599818768482","article-title":"Laryngeal Force Sensor: Quantifying Extralaryngeal Complications after Suspension Microlaryngoscopy","volume":"159","author":"Feng","year":"2018","journal-title":"Otolaryngol. Head. Neck Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"768","DOI":"10.1177\/000348940311200905","article-title":"Morphological comparison between neonatal and adult human tongues","volume":"112","author":"Iskander","year":"2003","journal-title":"Ann. Otol. Rhinol. Laryngol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1138","DOI":"10.1097\/00000542-200405000-00015","article-title":"Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale","volume":"100","author":"Sikich","year":"2004","journal-title":"Anesthesiology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1111\/pan.14122","article-title":"An observational study of hypoactive delirium in the post-anesthesia recovery unit of a pediatric hospital","volume":"31","author":"Reade","year":"2021","journal-title":"Paediatr. Anaesth."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1177\/0194599820982635","article-title":"Laryngeal Force Sensor for Suspension Microlaryngoscopy: A Prospective Controlled Trial","volume":"165","author":"Feng","year":"2021","journal-title":"Otolaryngol. Head. Neck Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1016\/j.jvoice.2019.10.017","article-title":"Force Metrics and Suspension Times for Microlaryngoscopy Procedures","volume":"35","author":"Feng","year":"2021","journal-title":"J. Voice"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1007\/s00540-023-03303-3","article-title":"Association of preoperative neutrophil-lymphocyte ratios with the emergence delirium in pediatric patients after tonsillectomy and adenoidectomy: An observational prospective study","volume":"38","author":"Feng","year":"2024","journal-title":"J. Anesth."},{"key":"ref_14","first-page":"42","article-title":"The importance of maintaining normal perioperative physiological parameters in children during anaesthesia","volume":"17","author":"Aamri","year":"2021","journal-title":"Signa Vitae"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"23779608251389303","DOI":"10.1177\/23779608251389303","article-title":"Peri-Operative Nurses\u2019 Experiences of Recognizing and Responding to Post-Anesthetic Pediatric Emergence Delirium: A Narrative Review","volume":"11","author":"Moyo","year":"2025","journal-title":"SAGE Open Nurs."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1056","DOI":"10.1111\/pan.14259","article-title":"Behavioral changes after hospital discharge in preschool children experiencing emergence delirium after general anesthesia: A prospective observational study","volume":"31","author":"Kim","year":"2021","journal-title":"Paediatr. Anaesth."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Somaini, M., Engelhardt, T., and Ingelmo, P. (2023). Emergence from General Anaesthesia: Can We Discriminate between Emergence Delirium and Postoperative Pain?. J. Pers. Med., 13.","DOI":"10.3390\/jpm13030435"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1016\/j.bja.2024.03.022","article-title":"Comparison of postoperative pain in children after maintenance anaesthesia with propofol or sevoflurane: A systematic review and meta-analysis","volume":"133","author":"Abdallah","year":"2024","journal-title":"Br. J. Anaesth."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1016\/S2352-4642(19)30377-3","article-title":"Delirium in hospitalised children","volume":"4","author":"Dechnik","year":"2020","journal-title":"Lancet Child. Adolesc. Health"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"110225","DOI":"10.1016\/j.ijporl.2020.110225","article-title":"Grisel\u2019s syndrome post otolaryngology procedures: A systematic review","volume":"137","author":"Altheyab","year":"2020","journal-title":"Int. J. Pediatr. Otorhinolaryngol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1093\/bja\/aev552","article-title":"Emergence delirium or pain after anaesthesia\u2014How to distinguish between the two in young children: A retrospective analysis of observational studies","volume":"116","author":"Somaini","year":"2016","journal-title":"Br. J. Anaesth."},{"key":"ref_22","first-page":"45","article-title":"Coblation versus traditional tonsillectomy: A double blind randomized controlled trial","volume":"17","author":"Omrani","year":"2012","journal-title":"J. Res. Med. Sci."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"103782","DOI":"10.1016\/j.amjoto.2022.103782","article-title":"Reproducibility of laryngeal force sensor measurements","volume":"44","author":"Wang","year":"2023","journal-title":"Am. J. Otolaryngol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"830","DOI":"10.1111\/pan.13481","article-title":"Cervical instability in patients with Trisomy 21: The eternal gamble","volume":"28","author":"Bertolizio","year":"2018","journal-title":"Paediatr. Anaesth."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.ijporl.2018.08.029","article-title":"Iatrogenic neurological injury in children with trisomy 21","volume":"114","author":"Husnudinov","year":"2018","journal-title":"Int. J. Pediatr. Otorhinolaryngol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"10","DOI":"10.3171\/2017.5.SPINE17189","article-title":"Intubation biomechanics: Validation of a finite element model of cervical spine motion during endotracheal intubation in intact and injured conditions","volume":"28","author":"Gadomski","year":"2017","journal-title":"J. Neurosurg. Spine"}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/3\/353\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T15:30:13Z","timestamp":1772465413000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/3\/353"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,28]]},"references-count":26,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["children13030353"],"URL":"https:\/\/doi.org\/10.3390\/children13030353","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,28]]}}}