February 4, 2015
Morphine Dangerous for Children After Sleep
Apnea Surgery

Toronto, Ontario—Prescribing morphine to children for postoperative pain after removal of their tonsils and/or adenoids can cause life-threatening respiratory problems in some children, according to a new study.

Since both the FDA and Health Canada issued warnings about the risks of using codeine for pain in those children, some surgery centers have turned to morphine as a “more predictable” alternative, according to the study, co-conducted by the Motherisk Program at The Hospital for Sick Children (SickKids) and by McMaster University and McMaster Children's Hospital.

The report, published in the journal Pediatrics, warns of breathing disruption with home-administered morphine after the surgery, which is commonly and effectively used to treat childhood sleep apnea. Instead, the authors suggest that ibuprofen is a safe and effective alternative.

A 2009 Motherisk study and a 2012 study by the two groups found that codeine administered for postoperative pediatric pain in patients undergoing the procedures could cause respiratory problems and fatal outcomes for children who are genetically ultra-rapid metabolizers of codeine. Until that point, codeine had been considered standard treatment for that postoperative pain in North America.

In the aftermath of the 2009 report, the FDA gave pediatric codeine a "Boxed Warning" as well as a contraindication. No official recommendation of a safe and effective alternative was made, according to the authors, who note that many centers opted to use morphine in codeine’s stead.

For the new prospective, randomized clinical trial, 91 children between the ages of 1 and 10 were randomly assigned to receive postoperative painkillers at home following their outpatient tonsillectomy surgery to treat obstructive sleep apnea between September 2012 and January 2014.

Parents were given a prescription to fill and were instructed about the use of a home pulse oximeter to measure oxygen saturation and apnea events the night before and the night after surgery. The caregivers also were taught to use the Objective Pain Scale and Faces Scale to assess their children's pain levels on postoperative Days 1 and 5.

While one group of children was given postoperative standard doses of oral morphine (0.2 to 0.5 mg/kg) and acetaminophen (10-15 mg/kg) every 4 hours to treat pain, the other group was prescribed standard doses of oral ibuprofen (10 mg/kg) every 6 hours and acetaminophen (10-15 mg/kg) every 4 hours.

Pain was effectively managed and comparable in both groups, but, on the first postoperative night, 68% of children in the ibuprofen group showed improvement in oxygen desaturation incidents, but only 14% of children in the morphine group had the same result.

In the short term, according to the authors, the condition of the children in the morphine group worsened, with about 11 to 15 desaturation events per hour.

Last year, the study was halted early after one child suffered a life-threatening adverse drug reaction, including oxygen desaturation, after being treated with morphine.

“The evidence here clearly suggests children with obstructive sleep apnea should not be given morphine for post-operative pain. We already know that they should not get codeine either,” said corresponding author Gideon Koren, MD, director of the Motherisk Program and senior scientist at SickKids. “The good news is that we now have evidence that indicates ibuprofen is safe for these kids, and is just as effective in controlling their pain, so there's a good alternative available for clinicians to prescribe.”

Coauthor Doron Sommer, MD, a clinical professor of surgery at McMaster, suggested that clinicians should “re-evaluate their post-tonsillectomy pain treatment regimen. Due to the unpredictable respiratory side-effects of morphine, its use as a first-line treatment with current dosage ranges should be discontinued for outpatient tonsillectomy.”


U.S. Pharmacist Social Connect