Use of Codeine on Children

Analgesics, including opioids, are drugs often administered to patients for pain relief in the rehabilitation setting (Ciccone, 2013, p. 183). In my practice as a pediatric physical therapist, my experience is limited regarding the effects of analgesics in children with disabilities (CWD). This isn’t because the patient population I cater to has no need for pain relief via pharmacological intervention. It is because the CWD who I see in the clinic are most often, if not always, cleared for therapy when the symptoms of post-operative pain medication no longer restrict physical therapy. Ciccone (2013) listed codeine among the opioid analgesics which are effective at managing pain of moderate intensity.

Garetz et al. (2015) stated that obstructive sleep apnea is a condition which affects approximately 1-3% of children, and that adenotonsillectomy (AT) is the surgical treatment of choice for it. Some of the CWD who I see for physical therapy have had this procedure done in the past. Codeine by itself, or in combination with other pain medications, is a commonly prescribed analgesic (Kelly, 2013). Tremlett, Anderson, and Wolf (2010) further specified that managing postoperative pain using codeine is widely accepted by the medical community (as cited in Prows et al., 2014). It is alarming to know however that the use of codeine in some children after a tonsillectomy and/or adenoidectomy has resulted in their deaths (United States Food and Drug Administration [FDA], 2013). The FDA (2013) also noted that children who have an inherited genetic ability to convert codeine into fatal amounts of morphine can die after postsurgical administration of codeine for pain management; therefore, its use following the aforementioned procedures should be discontinued. Not all children have this genetic characteristic however the FDA generalized the non-utilization of codeine in the management of postoperative pain in children after AT because even those who do not have the cytochrome P450 2D6, which is responsible for the rapid metabolism of codeine, may also do so (Kuehn, 2013). These findings alerted me to the fact that the children under my care who have sleep apnea are especially susceptible to the adverse, and fatal, effect of codeine use post-surgically.

I am glad that the FDA has made this information public. The FDA (2013) also highlighted the role of health care professionals in prescribing alternative analgesics for postoperative pain after AT, and that caregivers of children who take codeine for other types of pain must immediately seek medical attention when unusual sleepiness and/or difficulty in breathing are/is observed. My role as a pediatric physical therapist includes medication management. My plan of care not only consists of a child’s physical rehabilitation through therapeutic strategies, but it should also take into consideration the effects of pharmacologic intervention. My evidence-based research on codeine has also made me more aware of the importance of caregiver education and family communication. If family members are unaware of the adverse effects that certain medications may cause their children, then medical emergencies which warrant immediate intervention may not be addressed.

References

Ciccone, C. D. (2013). Davis’s drug guide for rehabilitation professionals. Philadelphia, PA. F.A. Davis Company

Garetz, S. L., Mitchell, R. B., Parker, P. D., Moore, R. H., Rosen, C. L., Giordani, B., & … Redline, S. (2015). Quality of life and obstructive sleep apnea symptoms after pediatric adenotonsillectomy. Pediatrics, 135(2), e477-e486. doi:10.1542/peds.2014-0620

Kelly, P. A. (2013). Pharmacogenomics: Why standard codeine doses can have serious toxicities or no therapeutic effect. Oncology Nursing Forum, 40(4), 322-324. doi:10.1188/13.ONF.322-324

Kuehn, B. M. (2013). FDA: No codeine after tonsillectomy for children. Journal of the American Medical Association, 309(11), 1100. doi:10.1001/jama.2013.2403

Prows, C. A., Zhang, X., Huth, M. M., Zhang, K., Saldaña, S. N., Daraiseh, N. M., & … Sadhasivam, S. (2014). Codeine-related adverse drug reactions in children following tonsillectomy: A prospective study. Laryngoscope, 124(5), 1242-1250. doi:10.1002/lary.24455

United States Food and Drug Administration (FDA). (2013, February 20). FDA Drug Safety Communication: Safety review update of codeine use in children; new boxed warning and contraindication on use after tonsillectomy and/or adenoidectomy. Retrieved from http://www.fda.gov/downloads/Drugs/DrugSafety/UCM339116.pdf