Pediatric Pain Control After Tonsillectomy: Opioids or NSAIDs?
Kelly LE, Sommer DD, Ramakrishna J, et al. Morphine or ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics. 2015;135(2):307-313.
More than 500,000 tonsillectomies are performed on children every year in the United States. Pediatric post-tonsillectomy care guidelines generally focus on maintaining hydration and managing and assessing analgesia. Selecting the most effective and safest pain medication is an important aspect of these practice guidelines.
In 2012, the U.S. Food and Drug Administration mandated the addition of a boxed warning to the label of codeine-containing products cautioning against the use of codeine for post-tonsillectomy analgesia in children due to the associated risk of life-threatening respiratory failure.1 Concern also exists about the use of nonsteroidal anti-inflammatory drugs (NSAIDs) after tonsillectomy due to the increased possibility of bleeding, although a recent meta-analysis did not observe an increased risk of bleeding with post-tonsillectomy NSAID use.2
With concerns about safe and effective pediatric pain control in mind, a group of researchers in Canada reviewed the safety and effectiveness of post-tonsillectomy analgesia with either oral morphine plus acetaminophen or oral ibuprofen plus acetaminophen in children with sleep disordered breathing.3
This randomized controlled trial enrolled 91 healthy children aged 1 to 10 years who had a diagnosis of sleep disordered breathing and who had been scheduled for tonsillectomy. The participants’ parents were taught to use a pulse oximeter to monitor their child’s respiratory status before and after the procedure, were taught how to make basic pain assessments using the Objective Pain Scale and the Faces Pain Rating Scale, and were asked to monitor for adverse events. Families gave the children acetaminophen and age-appropriate doses of either morphine or ibuprofen. The parents were not blinded to the randomized choice as they were administering the medication.
On the first postoperative night, 68% of the children receiving ibuprofen had an improvement in the number of oxygen desaturations, while only 14% of the children receiving morphine showed improvement. In fact, the desaturation events per hour increased significantly in the morphine group on the first postoperative night. No significant difference was found between the ibuprofen and morphine groups in reported pain control. A similar number of episodes of tonsillar bleeding were reported—3 children who received ibuprofen, and 2 who received morphine. One child receiving morphine experienced a severe drug reaction and required admittance to an intensive care unit. In light of these early definitive results, the study was halted at what was to have been the interim analysis period.
Because children with sleep disordered breathing already are at elevated risk for obstructive sleep apnea and respiratory depression, choosing postoperative analgesia that does not contribute to potential adverse respiratory effects is extremely important. Accordingly, the researchers concluded that the ibuprofen is as effective as and safer than morphine for post-tonsillectomy analgesia in children, without a higher risk of postoperative hemorrhage. As with codeine, morphine is best avoided for pain relief in children after tonsillectomy.
Jessica Tomaszewski, MD, is an assistant clinical professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.
Charles A. Pohl, MD—Series Editor, is a professor of pediatrics, senior associate dean of student affairs and career counseling, and associate provost for student affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.
References
1. Food and Drug Administration. FDA drug safety communication: safety review update of codeine use in children; new boxed warning and contraindication on use after tonsillectomy and/or adenoidectomy. http://www.fda.gov/Drugs/DrugSafety/ucm339112.htm. February 20, 2013. Accessed March 4, 2015.
2. Riggin L, Ramakrishna J, Sommer DD, Koren G. A 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of nonsteroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy. Clin Otolaryngol. 2013;38(2):115-129.
3. Kelly LE, Sommer DD, Ramakrishna J, et al. Morphine or ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics. 2015;135(2):307-313.