Pediatric Pain and Opioids: How to Respond When a Patient Is Still in Pain After a Tonsillectomy

Overall, Dr. Walz said, the message from the evidence is that there’s a statistically significant association between PTH and the use of ibuprofen, but with a small effect size. “I would consider choosing an opioid versus ibuprofen analgesic strategy that’s specific to the patient,” he said.

Christina J. Yang, MD, attending physician in otorhinolaryngology–head and neck surgery at Montefiore Medical Center in the Bronx, N.Y., reviewed literature on other steps that can be taken to avoid opioids. In one study published in 2021, 120 patients were randomized to receive standard alternating ibuprofen and acetaminophen, or the standard care plus dexamethasone on the third day after adenotonsillectomy. The dexamethasone group had better pain scores on the third, fourth and fifth day after surgery, a decrease in pain medication use on day five, and fewer caregiver phone calls, Dr. Yang said (Otolaryngol Head Neck Surg. 2021;165:83-88).

Ninety percent of patients are not going home with an opioid now. That translates into 1,800 fewer prescriptions of opioids that are being given out per year. —Christina J. Yang, MD

Another study looked at a pediatric post-tonsillectomy protocol, with the electronic health record restricting opioids in patients under 7 years old. The practice resulted in a reduction in opioid prescriptions from 82% to 15%, with no increase in emergency room or urgent care visits, or in bleeds, Dr. Yang said (Otolaryngol Head Neck Surg. 2016;154:720-724).

But another survey of opioid use among otolaryngology patients found that 80% of them had leftover opioids after the episode of care, and that 72% of the patients kept the extra opioids that they hadn’t used (Laryngoscope. 2020;130:1913-1921).

The guidelines that address pain control in children show the need for continued work in this area, Dr. Yang said. “They have identified a need to continue in research endeavors to evaluate and compare oral postoperative pain medications so that we have as many potential strategies and alternatives at our disposal as possible.”

The panelists also described systematic steps taken to lower the amount of opioids prescribed after tonsillectomy. At Nationwide Children’s Hospital, for instance, they use an opioid consent system meant to increase education and limit abuse, and it has increased its threshold for opioid prescriptions to 4 years old.

“With these interventions we’ve been able to have a pretty significant impact. Ninety percent of patients are not going home with an opioid now. That translates into 1,800 fewer prescriptions of opioids that are being given out per year.”