Despite warnings from the United States Food and Drug Administration (FDA) 7 years ago, clinicians continue to prescribe perioperative opioids for children undergoing tonsillectomy and adenoidectomy.1-3 The FDA warned clinicians in 2012 that codeine posed a higher risk than other analgesics in causing respiratory depression in children.2

In addition to prescribing codeine for analgesia, clinicians used it as an off-label cough suppressant.2,4 Two years ago, the FDA added tramadol to the list of contraindicated drugs for children 12 years old and younger.2,5

The warnings come as understanding of the metabolism of these opioids in children has evolved. While most children metabolize codeine through the UGT2B7 pathway, about 10% metabolize the opioid through the CYP2D6 pathway, converting the codeine into high-dose morphine.2 Likewise, in some children who metabolize via the CYP2D6 pathway, tramadol converts to O-desmethyltramadol, which can also lead to oversedation, respiratory depression, and death.2

Particularly troubling in pediatric patients undergoing a tonsillectomy is that the surgery already compromises the airways.2 In addition, children are more susceptible to respiratory depression than adults.

Despite Warnings, Clinician Inertia

In a retrospective chart study of more than 362,000 children, pediatric researcher Kao-Ping Chua, MD, PhD, from the University of Michigan, Ann Arbor, and colleagues found that 1 in 20 clinicians continued to prescribe perioperative codeine for children undergoing tonsillectomy and adenoidectomy from 2010 to 2015.3 The 5-year study examined the prescribing patterns for privately insured children (49.9% aged 0-5 years; 48.7% girls).

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While codeine prescribing declined from 31% to 5% during the study period, more concerning is that 3% of children with obstructive sleep apnea were still prescribed codeine, even though obstructive sleep apnea is a known risk for inducing respiratory depression.3 When clinicians substituted alternatives, they were most often hydrocodone or oxycodone.3