Post-Operative Pain in Children Undergoing Tonsillectomy

According to Charles Monroe Myer III, MD, professor of otolaryngology-head and neck surgery at Cincinnati Children’s Hospital Medical Center, the only way to ensure the safe use of codeine and other opioids in children is to identify those who are rapid metabolizers. Although genetic testing that can identify patients with CYP2D6 is available, it is currently too expensive—approximately $400—to be used widely or as a screening tool.

To find a cheaper and more accessible way of identifying patients, Dr. Sadhasviam and colleagues are currently studying the risk factors for opioid-related complications in children who are fast metabolizers to identify problems prior to surgery or before administering post-operative pain medication.

Dr. Myer emphasized that finding an easier and cheaper way to identify children at risk of opioid-related complications would also help identify the subgroup of children who are slow metabolizers of codeine and other opioids and who therefore do not receive adequate pain relief when treated with these drugs.

Along with ultra-metabolizers of CYP2D6, children in whom opioids should be used with care or not at all are those undergoing tonsillectomy for sleep apnea. Dr. Sadhasivam emphasized the need for extreme care in using opioids in these children, who are at increased risk of respiratory depression.

Changing Practice: Alternatives to Narcotics

“Most people feel that narcotics will give better pain relief than a non-narcotic,” said Dr. Myer, “so the assumption is that acetaminophen with codeine must be better pain management than acetaminophen alone.” Evidence does not bear this out, he said.

A randomized study published in 2002 that evaluated the efficacy of acetaminophen alone or with codeine in children after tonsillectomy found no difference in the level of pain control between the two treatments (Laryngoscope. 2000;110(11):1824-1827). In addition, the study found that children treated with acetaminophen alone consumed a significantly higher percentage of a normal diet during the first six days after surgery.

Dr. Messner, the senior author of the study, said that she and her colleagues have not used codeine for a long time because of these results. “At our institution, we don’t give narcotics to kids younger than age 7,” she said, adding that they do consider hydrocodone with acetaminophen for older children who have a T&A for the diagnosis of sleep apnea.

In place of codeine, she and her colleagues routinely use acetaminophen alone, administering 15 mg per kilogram per dose every four hours. Alternately, patients also may switch between acetaminophen and ibuprofen every three hours. She emphasized that this is not an evidence-based approach to treatment, but is one with which they have had good results.