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Postoperative pain management in pediatric tonsillectomy patients


Inadequate postoperative pain management may cause morbidity in the pediatric patient after tonsillectomy in the form of decreased oral intake, dysphagia, dehydration, and weight loss1.  Historically, codeine was often used for pain management in these patients typically in the form of acetaminophen with codeine.  However, there is no difference between acetaminophen and acetaminophen with codeine in pain control after pediatric tonsillectomy, and oral intake is actually significantly greater in patients treated with only acetaminophen2.  Also, there is a Boxed Warning for codeine-containing products used for post-tonsillectomy pain management in pediatric patients due to rare, but life-threatening, respiratory depression stemming from genetic variation in the metabolism of codeine3.  Acetaminophen alone will not provide adequate pain relief postoperatively in the pediatric patient4.

            Previously, there was often concern about giving non-steroidal anti-inflammatory drugs (NSAIDs) postoperatively due to these medications interfering with platelet function and leading to a possible increased hemorrhage risk.  However, a Cochrane review showed NSAID use does not increase perioperative bleeding and may decrease postoperative vomiting in pediatric tonsillectomy patients5.  This suggests NSAIDs may be safely used postoperatively in these patients for analgesia.

            Evidence is currently lacking for one specific regimen for analgesia in the pediatric tonsillectomy patient.  However, we currently advocate for around-the-clock dosing of acetaminophen and ibuprofen. 


Recommended dosing: acetaminophen 10 mg/kg PO q4h and ibuprofen 5-10 mg/kg PO q6h.



1. Baugh et al. Clinical Practice Guideline:  Tonsillectomy in Children.  AAOS-HNS. 2011; 144(IS)S1-S30.

2.  Moir et al. Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy.  Laryngoscope. 2000; 1000:1824-1827

3.  U.S. Food and Drug Administration.  Codeine Use in Certain Children After Tonsillectomy and/or Adenoidectomy: Drug Safety Communication – Risk of Rare, But Life-Threatening Adverse Events or Death.  Last Updated Feb. 2013.  Accessed from on January 22, 2014.

4. Anderson et al. Perioperative pharmacodynamics of acetaminophen analgesia in Children.  Anesthesiology. 1999; 90(2):411-421

5. Lewis et al.  Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy.  The Cochrane Collaboration. 2013; 7.


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