September 21, 2016
2 min read

AAP urges restrictions on use of codeine in children

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Parents and health care providers are encouraged to stop administering codeine to children aged younger than 18 years as either an analgesic or antitussive, due to growing evidence linking the common painkiller to life-threatening or fatal respiratory reactions in pediatric settings, according to an AAP clinical report.

“Effective pain management for pediatric patients remains problematic, with studies showing that significant improvements and alterations in practice may be needed to provide safe and adequate analgesia,” Joseph D. Tobias, MD, FAAP, of Nationwide Children’s Hospital, and colleagues from the AAP’s Section on Anesthesiology and Pain Medicine and Committee on Drugs wrote.

While widely considered an optimal oral analgesic for outpatient pain treatment among children, codeine itself has no analgesic effect, but rather must be converted into morphine by the liver.

Due to the metabolic differences between patients, however, there can be considerable variability in the therapeutic response to the recommended codeine dosages. In particular, children and those with obstructive sleep apnea, can be “ultra-rapid metabolizers” and may experience unanticipated respiratory depression and death after receiving standard doses of codeine.

“Despite these concerns and the potential hazards, codeine continues to be widely available from many pharmacies and inpatient hospital formularies for use in outpatient pediatric settings and is commonly prescribed to pediatric patients,” the researchers wrote.

According to the AAP report, codeine is commonly prescribed to children after surgical procedures, such as tonsil and adenoid removal, and in one study, more than 800,000 patients aged younger than 11 years were prescribed codeine in 2011.

The most frequent health care prescribers of codeine/acetaminophen liquid formulations during 2007 to 2011, included:  

  • otolaryngologists (19.6%);
  • dentists (13.3%);
  • pediatricians (12.7%); and
  • general practice/family physicians (10.1%)

In addition to the AAP, several medical organizations and regulatory bodies, including WHO, the FDA, and the European Medicines Agency, have issued warnings regarding the occurrence of adverse effects of codeine in children — some have even considered a declaration of a contraindication for the use of codeine as either an analgesic or an antitussive.

“Improved education of parents and more formal restrictions regarding its use in children, regardless of age, are necessary,” Tobias and colleagues wrote. “Additional clinical research must extend the understanding of the risks and benefits of both opioid and nonopioid alternatives for orally administered, effective agents for acute pain.” – by Bob Stott

Disclosure: The researchers report no relevant financial disclosures.