Post-Operative Pain in Children Undergoing Tonsillectomy

Dr. Myer and his colleagues at Cincinnati Children’s Hospital have had good results with around-the-clock dosing with acetaminophen and ibuprofen and once-a-day dexamethasone for three post-operative days, and currently follow a protocol for post-operative pain management that incorporates this strategy (see “Protocol for Post-Tonsillectomy Pain Control,” p. 28)

Along with recommending ibuprofen at 10 mg per kilogram per dose for a maximum of two doses every 24 hours starting on day two, Dr. Sadhasivam said that the surgical staff he works with also are comfortable administering ibuprofen on the first day after surgery without significant concern of increased bleeding. They often do this because of the increased pain on post-operative day one. “Most physicians do not think that acetaminophen and ibuprofen will work well enough for pain management and [think] they have to give a stronger opioid to treat post-operative pain,” he said. “But if you give these non-opioid medications around the clock, they help reduce pain significantly, and you can avoid the risk of opioids by avoiding or reducing the opioid use.”

Since implementing this protocol more than a year ago, he and his staff have seen a reduction in pain, as evidenced by the fewer calls regarding pain concerns. In addition, they have not had any patient return to the emergency room due to increased pain or significant bleeding caused by ibuprofen or dexamethasone.

The use of ibuprofen in place of codeine is increasing. Concerns over an increased risk of bleeding after surgery have not been supported by evidence, which consistently shows no increased bleeding risk (Cochrane Database Syst Rev. 2005;(2):CD003591). Based on this evidence, the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Practice Guideline on Tonsillectomy in Children states that ibuprofen can be used safely for pain control after surgery (Otolaryngol Head Neck Surg. 2011;144(1S):S1-S30).

Further support from AAO-HNS on the use of ibuprofen, as well as caution regarding the use of narcotics, can be found on the AAO-HNS website in a Q&A with Dr. Messner and Dr. Tunkel (available at entnet.org).

Need to Adequately Manage Post-Operative Pain

Along with choosing the most effective and safe analgesic to manage post-operative pain, clinicians must also educate parents and caregivers on the importance of administering adequate pain medication. “We need to educate parents that it is okay to give children safe pain medication,” said Dr. Tunkel, who is also chair of the AAO-HNS Pediatric Otolaryngology Committee.