A Randomized Clinical Trial of the Efficacy of Scheduled Dosing of Acetaminophen and Hydrocodone for the Management of Postoperative Pain in Children After Tonsillectomy

Abstract

Objectives To determine the effectiveness of around-the-clock (ATC) analgesic administration, with or without nurse coaching, compared to standard care with PRN dosing in children undergoing outpatient tonsillectomy. Methods Children 6 to 15 years were randomized to receive acetaminophen and hydrocodone (167mg/2.5mg/5ml) for 3 days after surgery: Group A (N=39) – every 4 hours PRN, with standard postoperative instructions; Group B (N=34) – every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and Group C (N=40) – every 4 hours ATC, with standard postoperative instructions, with coaching. Parents completed a medication log, and recorded the presence and severity of opioid-related adverse effects and children's reports of pain intensity using a 0 to 10 numeric rating scale. Results No differences were found in analgesic administration or pain intensity scores between the 2 ATC groups. Therefore, they were combined for comparison with the PRN group. Children in the ATC group received more analgesic than those in the PRN group (p<0.0001). Children in the PRN group had higher pain intensity scores compared to children in the ATC group, both at rest (p=0.017) and with swallowing (p=0.017). Pain intensity scores for both groups were higher in the morning compared to the evening (p<0.0001). With the exception of constipation, scheduled analgesic dosing did not increase the frequency or severity of opioid-related adverse effects. Discussion Scheduled dosing of acetaminophen and hydrocodone is more effective than PRN dosing in reducing pain intensity in children following tonsillectomy. Nurse coaching does not impact parent's adherence to ATC dosing.

National Patterns of Codeine Prescriptions for Children in the Emergency Department

“…[25][26][27] Hydrocodone has also demonstrated efficacy as an analgesic agent with good safety profile in children. 28 The 3.9% of injury visits with acetaminophenhydrocodone prescriptions indicate that some providers are comfortable with this alternative, suggesting switching from acetaminophen-codeine to acetaminophen-hydrocodone as a potential provider behavior change. With regard to cough suppression, data indicate that codeine-containing products have no benefit over placebo.…”

Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial

“…16 Undertreatment is an important cause of inadequate postoperative analgesia. [17][18][19][20] Both ibuprofen 21,22 and oral morphine 22,23 have shown benefit in children with musculoskeletal injuries. Following deaths of children who received codeine postoperatively, 24,25 the United States Food and Drug Administration 26 and Health Canada 27 issued advisories.…”

Toward Adenotonsillectomy in Children

“…54,57 The benefit of fixed vs as-needed schedules for analgesics is unresolved, but results from one trial did demonstrate superior pain control with a fixed schedule. 58 Owing to the risk of oversedation, we do not advocate a fixed schedule with opioids. Opioid use should be limited in children following adenotonsillectomy.…”