What medications are recommended for post-operative pain management in pediatric patients undergoing adeno-tonsillectomy, particularly those with a history of sleep apnea or recurrent infections?

Post-Adenotonsillectomy Medication Regimen

All pediatric patients undergoing adenotonsillectomy should receive scheduled (not as-needed) acetaminophen and ibuprofen as baseline therapy, combined with a single intraoperative dose of intravenous dexamethasone, with opioids reserved strictly as rescue medication. 1, 2

First-Line Analgesic Regimen

Acetaminophen (Paracetamol)

• Administer on a scheduled basis starting pre-operatively or intra-operatively and continue postoperatively 1, 2, 3
• Scheduled dosing is superior to as-needed administration, with only 20% of patients requiring rescue analgesia versus 75% with on-demand dosing 3
• Continue for the expected pain duration of 11-12 days 4

NSAIDs (Ibuprofen)

• Combine ibuprofen with acetaminophen unless contraindicated 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation for ibuprofen use 1
• Weight-based dosing: 5-10 mg/kg per dose, not exceeding 3200 mg total daily dose in adults 5, 6
• Previous concerns about increased bleeding risk with NSAIDs are not substantiated by recent meta-analyses 1, 7
• Contraindications include active GI bleeding, peptic ulcer disease, renal insufficiency, and jaundiced breastfeeding infants 5

Intraoperative Dexamethasone

• Administer a single intraoperative dose of intravenous dexamethasone 1, 2
• Provides both analgesic and anti-emetic effects 1
• Does not increase risk of post-tonsillectomy bleeding 7

Absolute Contraindications

Codeine - NEVER USE

• Clinicians must not administer or prescribe codeine or any codeine-containing medication to children younger than 12 years 1, 8
• This is a strong recommendation against use due to risk of life-threatening respiratory depression from variable metabolism 8

Perioperative Antibiotics - DO NOT USE

• Do not administer or prescribe perioperative antibiotics 1, 8
• Strong recommendation against use - provides no benefit in reducing bleeding or infection rates 8

Second-Line Options (When First-Line Contraindicated)

Gabapentinoids

• Consider pre-operative gabapentin (at least 600 mg in adults) or pregabalin (at least 150 mg in adults) when NSAIDs are contraindicated 1, 2
• Side effects include sedation and dizziness at effective doses 1

Ketamine (Pediatric Patients Only)

• Intra-operative intravenous ketamine may be considered in children when baseline regimen is contraindicated 1, 2
• Administer as single IV dose at beginning of procedure 1
• Associated with hallucinations, agitation, and sedation 1

Dexmedetomidine

• Alternative when first-line analgesics contraindicated 1
• Provides analgesic effect for approximately 30 minutes post-surgery 1
• Risks include sedation, hypotension, and bradycardia 1

Adjunctive Therapies (Optional)

Honey

• Postoperative honey reduces pain scores and analgesic consumption with no side effects 1, 2
• Additional benefit of improved wound healing 1
• Low-grade recommendation due to small sample sizes 1

Acupuncture

• Intra-operative and postoperative acupuncture reduces pain and analgesic requirements 1, 2
• No complications reported 1
• Requires specific training, limiting widespread use 1

Opioid Use - Rescue Only

When to Use Opioids

• Reserve opioids strictly as rescue analgesics when baseline regimen is insufficient 1, 2, 8
• Avoid in children with obstructive sleep apnea due to risk of arterial oxygen desaturation and respiratory depression 1

Specific Considerations for Sleep Apnea Patients

• Children under 3 years or those with severe OSA (AHI ≥10 events/hour, oxygen saturation nadir <80%) require overnight inpatient monitoring 1, 8
• Exercise extreme caution with any opioid use in this population 7
• Risk of postoperative nausea and vomiting must be prevented 1

Critical Implementation Points

Timing and Administration

• Start analgesics pre-operatively or intra-operatively, not after pain develops 1, 3
• Scheduled dosing is superior to as-needed dosing - 65% of patients on scheduled regimen could eat solid food before discharge versus 37% on as-needed 3

Patient Education

• Counsel patients and caregivers that significant pain lasting 11-12 days is expected and requires proactive management 1, 8, 4
• Emphasize the importance of anticipating, reassessing, and adequately treating pain 1, 8
• More than 50% of patients need 1-3 rescue analgesic doses daily during the first week 4

Hydration and Nutrition

• Minimize fasting time to 4 hours for solids and 2 hours for liquids 2
• Ice popsicles provide temporary pain relief 2
• No benefit to restricting diet to liquids or cold foods only 2

Common Pitfalls to Avoid

• Do not prescribe codeine to children under 12 years - this is an absolute contraindication 1, 8
• Do not use as-needed dosing for baseline analgesics - scheduled administration is significantly more effective 3
• Do not avoid NSAIDs due to bleeding concerns - recent evidence does not support increased bleeding risk 1, 7
• Do not prescribe perioperative antibiotics - they provide no benefit 1, 8
• Do not discharge high-risk patients (age <3 years or severe OSA) without arranging overnight monitoring 1, 8