Although rare, there has been an increasing number of case reports describing children who have died after receiving codeine for post-operative pain, particularly after tonsillectomy. The most recent report published in 2012 documented the cases of three children who died after receiving standard treatment with tylenol with codeine after tonsillectomy between 2010 and 2011. However, these are only the known documented cases.
Given how rare, changing prescribing patterns may not be warranted... BUT...
What about the possibility that there may be numerous other cases which are not documented or close-calls? As we all know, for every documented case, there's probably numerous other undocumented cases.
To investigate this possibility, a close proxy would be to look at malpractice lawsuits after tonsillectomy. This report did just that looking closely at lawsuits stemming from tonsillectomy complications between 1984 and 2010 and found that the incidence of codeine-related deaths was much higher than the researchers expected. They found that 18 percent of death claims and 5 percent of injury claims resulted from the use of opioids, largely codeine. Indeed, after bleeding, opioid usage was the second most common cause of death in patients after tonsillectomy.
Additionally, death and anoxic brain injury claims associated with narcotic usage were associated with the greatest indemnity with a median payment of more than $900,000 per case.
Though likely impossible to do retrospectively, it would have been interesting to see whether all these children in these lawsuits had multiple CYP2D6 copies or not.
Alternatives to Narcotics
First, there is the question whether tylenol with codeine even helps with pain. Apparently not according to one study. In fact, children who took tylenol alone resumed a normal diet more quickly than kids who received codeine.
In fact, tylenol with codeine is associated with adverse side effects (nausea, dizziness, vomiting, etc) in up to 79% of children who take it [link].
Ibuprofen may also be given for pain control. Though ibuprofen theoretically can increase risk of bleeding due to its anti-platelet activity, numerous studies have not found this to be true.
Given codeine helps minimally with pain and tylenol alone seems to provide adequate pain control, why even given narcotics, especially given the small but significant risk of death associated with this drug?
Pain Control Protocol
Based on all these findings, we feel that narcotics for pain control after tonsillectomy for kids under 7 years of age is not recommended.
Rather, the following protocol is what we will now be implementing:
Tylenol and Ibuprofen over-the-counter as needed to help with pain control. The dosing is weight-based and exact dosing for a given child can be found on the bottle. These medications can be given alternating between Tylenol and ibuprofen every 3-4 hours (Tylenol first, followed by ibuprofen 3-4 hours later, followed by Tylenol 3-4 hours after that, etc). A prescription for a single dose of steroids is also provided which is meant as a one-time dose that can be given anytime 3 days after surgery if the child suddenly seems to have significantly more pain that is not controlled with Tylenol and ibuprofen. Pain in this scenario is often due to inflamed tissues that can be quickly minimized with steroids.
FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. FDA 8/15/12
Post-Operative Pain in Children Undergoing Tonsillectomy. ENT Today. Sept 2012.
FDA Investigates Codeine Safety After Children’s Deaths. ABC News. 8/15/12
Ibuprofen with Acetaminophen for Postoperative Pain Control following Tonsillectomy Does Not Increase Emergency Department Utilization. Otolaryngol Head Neck Surg. 2014 Sep 9. pii: 0194599814549732. [Epub ahead of print]
More codeine fatalities after tonsillectomy in North American children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9.
Preventing opioid-related deaths in children undergoing surgery. Pain Med. 2012 Jul;13(7):982-3; author reply 984. doi: 10.1111/j.1526-4637.2012.01419.x. Epub 2012 Jun 13.
Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope. 2012 Jan;122(1):71-4. doi: 10.1002/lary.22438. Epub 2011 Nov 10.
Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope. 2000 Nov;110(11):1824-7.
Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591.
Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial. Published online January 26, 2015 (doi: 10.1542/peds.2014-1906)
Outcomes of an Alternating Ibuprofen and Acetaminophen Regimen for Pain Relief After Tonsillectomy in Children. Ann Otol Rhinol Laryngol. 2015 Apr 22. pii: 0003489415583685. [Epub ahead of print]