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Post-Operative Pain in Children Undergoing Tonsillectomy

by Mary Beth Nierengarten •

The importance of including parents in the successful management of pain is highlighted in the AAO-HNS guidelines, in which a number of recommendations are provided to caregivers on helping to manage pain in their children (see “Parent Education: Post-Tonsillectomy Pain Management Guidelines for Caregivers,” p. 26).

Dr. Tunkel emphasized that parents often do not provide adequate pain medication to their children despite rating their children’s pain as very high, furthering the need for clear communication from otolaryngologists and other physicians regarding the importance of compliance with the prescribed pain medications.

The Bottom Line

Adequate pain control in children after tonsillectomy is critical to ensure proper hydration and a return to normal eating after surgery. The once well-established use of acetaminophen and codeine has come under scrutiny following an increasing number of codeine-related fatalities in young children undergoing tonsillectomy. Until a good way to screen children who are at risk of opioid-related complications is available, many physicians recommend against the use of narcotics in young children—particularly those undergoing tonsillectomy for sleep apnea.

Alternative strategies using around-the-clock dosing of acetaminophen and ibuprofen have shown good results without the risks of opioids or increased bleeding risk with ibuprofen. Although this approach to pain management is not yet an established evidence-based strategy, it has received endorsement by the AAO-HNS as a viable option. Along with choosing the safest and most effective pain analgesic, compliance with safe pain medications is also critical, and parents must be educated on the importance of adequate pain control for their children.

Parent Education: Post-Tonsillectomy Pain Management Guidelines for Caregivers

  1. Throat pain is greater the first few days following surgery and may last up to two weeks.
  2. Encourage your child to communicate with you if he or she experiences significant throat pain, because pain that is not expressed may not be recognized promptly.
  3. Discuss strategies for pain control with your health care provider before and after surgery; realize that antibiotics after surgery do not reduce pain and should not be given routinely for this purpose.
  4. Make sure that your child drinks plenty of fluids after surgery. Staying well hydrated is associated with less pain.
  5. Ibuprofen can be used safely for pain control after surgery.Pain medicine should be given as directed by your health care provider. For the first few days following surgery, it should be given often.
  6. Many clinicians do not recommend waiting until your child complains of pain. Instead, give the pain medication on a regular schedule.
  7. Expect your child to complain more about pain in the mornings—this is normal.
  8. Rectal administration is an option for children refusing to take pain medication orally. Call your health care provider if you are unable to adequately control your child’s pain.

Protocol for Post-Tonsillectomy Pain Control

Protocol for Post-Tonsillectomy Pain Control

All ages

  • Acetaminophen q5 hour dosing
  • Dexamethasone 0.5 mg/kg, maximum 20 mg, day of surgery and POD 3
  • Ibuprofen 10 mg/kg/dose, maximum of three doses in 24 hours, beginning POD 2

Ages ≥ 6 years

  • Same as above
  • Acetaminophen with codeine q5 hour dosing for rescue only

Ages 3 to 5 years

  • Consider testing for CYP2D6 genotype if available

Ages <3 years

  • No narcotics