Management of Post-Tonsillectomy Pain in Children in the Post-codeine Era

• Life threatening respiratory failure and death has been reported following the use of codeine in certain children after tonsillectomy
• FDA issued a black box warning on the use of products containing codeine in children after tonsillectomy and adenoidectomy (surgical removal of adenoids).
• There is a dire need for an evidence-based non-codeine plan for children undergoing tonsillectomy.

Tonsillectomy is a medical procedure, performed with or without adenoidectomy, for removal of tonsils to treat recurring severe tonsillitis or complications arising from enlarged tonsils. The pain associated with this procedure is reported to be moderate-to-severe. There is some discrepancy regarding the safety and efficacy of some analgesic agents which are used in patients after the surgery.

Reports of rare but life-threatening respiratory failure and cases of death were reported in few children who had received codeine after tonsillectomy.

Following this, the Food and Drug Administration (FDA) issued a new black box warning and contraindication for use of products containing codeine in children after tonsillectomy and adenoidectomy.

Possible Reasons for Codeine-related Fatalities

• Some children were found to be ultra-rapid metabolizers of substrates of isoenzyme CYP2D6 including codeine, causing the liver to metabolize it to large amounts of morphine in the body, which could be life-threatening or fatal.
• Codeine-related fatalities were mainly seen in children with obstructive sleep apnea (OSA) who had received codeine postoperatively for pain relief since they are reportedly more sensitive to opioids and would need lower doses of analgesia.
• Other co-existing medical conditions such as asthma, bronchopneumonia, craniofacial disorders and respiratory tract infections coupled with possible swelling after surgery could exacerbate the respiratory effects of opioids.

Pharmacologic Therapy for Treatment of Tonsillectomy Pain

• Acetaminophen is recommended as the first-line medication in children after tonsillectomy and adenoidectomy. Rectal administration of acetaminophen could be considered if oral route is not feasible.
• Ibuprofen could also be used concomitantly or as a second line agent, however, should be avoided in cases of dehydration due to possible renal toxicity.
• Opioids such as hydrocodone and oxycodone are commonly used as analgesics in adult patients following tonsillectomy and adenoidectomy, however, there is limited evidence to support their use in children. Hence, they should be used with caution in children following tonsillectomy, especially those with OSA.
• Opioids should not be given to children who are excessively sleepy, lethargic, have difficulty in breathing, unarousable or incoherent following tonsillectomy and adenoidectomy.
• IV dexamethasone is usually given for the reduction of postoperative nausea, vomiting, and pain

Non-pharmacologic Therapy for Treatment of Tonsillectomy Pain

• Educating the family about various aspects such as anesthesia and postoperative pain management techniques prior to the surgery results in better and faster healing.
• Presence of parents or a guardian is necessary to provide a comforting atmosphere and reduce any anxiety associated with the surgery and postoperative pain.
• Eating soft or cold foods such as ice cream or popsicles, drinking plenty of fluids, not talking too much, applying cold packs also helps in faster recovery.
• Cognitive behavioral pain management and distraction techniques include music, imagery, and computer/video games.

Source-Medindia