Post-Operative Pain in Children Undergoing Tonsillectomy

For the many children who undergo tonsillectomies each year, management of post-operative pain remains a challenge. Among the obstacles is finding the best post-operative medical strategy to control pain with minimal side effects, as well as working with parents and other caregivers to ensure that children receive adequate pain medications. Adequate pain control is critical to ensure that children remain hydrated and resume regular eating as soon as possible after surgery.

Tonsillectomy is an operation that is uncomfortable and affects children profoundly for a few days after surgery,” said David E. Tunkel, MD, director of pediatric otolaryngology at Johns Hopkins Children’s Center in Baltimore, Md. “The problem is that there is no perfect analgesic strategy.” The other problem, he said, is that parents and caregivers often don’t administer adequate doses of pain medication after surgery due to concerns about giving these medications to children.

This concern is not without warrant. An increasing number of reports of fatalities associated with codeine, one of the most time-honored drugs used to treat post-operative pain in children following

tonsillectomy, is prompting clinicians to rethink the medical strategy to control pain in this setting.

Although many otolaryngologists and other physicians have already changed their practice to omit the use of codeine and other narcotics, their use remains widespread in the post-operative pain management of children, according to Anna Messner, MD, professor and vice chair in the department of pediatric otolaryngology-head and neck surgery at Lucile Packard Children’s Hospital, Stanford University Medical Center, Stanford, Calif. “Codeine has been used for a long time, so it is hard to change established practice,” she said.

Time for a Change?

For many years, acetaminophen combined with codeine has been used to treat post-operative pain in children undergoing tonsillectomy or other otolaryngologic procedures. For many children, this is a safe and effective treatment.

The safety of codeine use in some children has been questioned over the past few years, however, with an increasing number of case reports describing children who have died after receiving codeine for post-operative pain, particularly after tonsillectomy (Pain Med. 2012;13(7):982-983). The latest report, published in 2012, documented the cases of three children who died after receiving standard treatment with codeine-acetaminophen after tonsillectomy between 2010 and 2011 (Pediatrics. 2012;129(5):e1343-1347).

FDA Warns of Codeine Death Risk

On August 15, the U.S. Food and Drug Administration issued a warning of a potentially fatal risk associated with codeine use in children following tonsillectomy and adenoidectomy. For more information, visit and click on “News & Events.”