- 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).
is a dire need for an evidence-based non-codeine plan for children undergoing
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.
‘Tonsillectomy is one of the most commonly performed pediatric surgical procedure, with nearly 500,000 tonsillectomies performed on children every year in the United States.’
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
Pharmacologic Therapy for Treatment of Tonsillectomy Pain
- 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.
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
Non-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
- 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.
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
- IV dexamethasone is usually given for the
reduction of postoperative nausea, vomiting, and 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.
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.
behavioral pain management and distraction techniques include music, imagery,
and computer/video games.