Management of Abdominal Pain After Adenoidectomy in Children
Treat this as postoperative pain requiring multimodal analgesia with NSAIDs and paracetamol as first-line therapy, while remaining vigilant for surgical complications that would require urgent evaluation.
Initial Assessment and Red Flags
Before initiating pain management, rapidly assess for surgical complications versus expected postoperative discomfort:
- Examine for peritonitis signs: rigid abdomen, rebound tenderness, guarding, or fever suggesting perforation or intra-abdominal catastrophe 1
- Check for bleeding complications: tachycardia, pallor, or hematemesis from adenoidectomy site that could cause referred abdominal pain from swallowed blood 2
- Assess pain characteristics: diffuse cramping pain with nausea suggests swallowed blood irritating the stomach, while localized severe pain with peritoneal signs requires surgical consultation 1, 3
First-Line Multimodal Analgesia
Combine NSAIDs with paracetamol as the foundation of pain management:
Basic Level Approach (Most Settings)
- Oral or IV paracetamol: 10-15 mg/kg every 6-8 hours (maximum 60 mg/kg/day) 4, 5
- Oral or IV NSAID (ibuprofen 10 mg/kg every 8 hours or ketoprofen as studied) 4, 2
- Avoid rectal paracetamol due to erratic absorption and poor bioavailability requiring 20-40 mg/kg loading doses versus 10-15 mg/kg oral 6
The combination of paracetamol and NSAIDs is essential and may eliminate the need for opioid rescue 4. Evidence from adenoidectomy studies demonstrates that ketoprofen (either IV or rectal) significantly reduces rescue analgesic requirements compared to placebo, with 65% versus 84% of children requiring rescue analgesia 2.
Intermediate/Advanced Level
- IV paracetamol: 15-20 mg/kg loading dose, then 10-15 mg/kg every 6-8 hours if oral route not feasible 5, 7
- IV NSAID: preferred over rectal formulations for reliable bioavailability 6
- Metamizole: loading dose IV if available in your region 4
- Transition to oral route as soon as the child tolerates oral intake 5
Rescue Analgesia for Breakthrough Pain
If multimodal non-opioid therapy is insufficient:
- Fentanyl IV: 0.5-1 mcg/kg in divided doses with pulse oximetry monitoring 4, 2
- Tramadol: oral, rectal, or IV as alternative opioid if available 4
- Morphine IV: with adequate monitoring including pulse oximetry 4
The need for multiple doses of rescue opioids in the immediate postoperative period correlates with higher pain intensity at home, so aggressive multimodal analgesia early is critical 8.
Adjunctive Strategies
Consider at all levels of care:
- Dexamethasone or methylprednisolone: reduces postoperative swelling and inflammation 4, 7
- Intraoperative ketamine: as co-analgesic if not already administered 4
Common Pitfalls to Avoid
- Do not rely on rectal paracetamol alone: it has poor bioavailability and unpredictable absorption 6
- Do not use oral liquid formulations rectally: this is not recommended due to pharmaceutical and bioavailability concerns 6
- Do not miss surgical emergencies: while most abdominal pain post-adenoidectomy is from swallowed blood or referred pain, appendicitis and other surgical conditions remain the most common surgical causes of acute abdominal pain in children 1
- Do not continue IV paracetamol unnecessarily: transition to oral route once the child tolerates oral intake 5
Expected Course and Follow-up
Pain intensity in hospital does not reliably predict pain duration at home, though rescue analgesic requirements do correlate with home pain intensity 8. Pre-emptive analgesia during surgery does not modify pain at home, emphasizing the importance of continued multimodal analgesia after discharge 8.
Discharge with oral NSAIDs and paracetamol scheduled around-the-clock for 24-48 hours, not just as-needed 2, 8.