Stop the codeine — opioids and acute pain medicines

The codeine prescription is a medication-safety error. Codeine is contraindicated in children under 12 years and for postoperative pain after tonsillectomy or adenoidectomy in children under 18 years. This four-year-old, post-tonsillectomy child meets both contraindications. The instruction to the nurse is: do not give the codeine; I will rewrite the chart. [1] [2]

I would prescribe scheduled paracetamol and ibuprofen as the non-opioid foundation, with oral morphine 0.2 to 0.5 milligram per kilogram every four hours as rescue (about 3 to 8 milligrams per dose for 16 kilograms) — or intravenous morphine 0.1 to 0.2 milligram per kilogram titrated if he cannot tolerate oral. I would add a prophylactic stimulant laxative from the first dose. Because he has obstructive sleep apnoea and is opioid-naive, I would monitor him overnight with continuous oximetry and hourly pain and sedation scoring, use the smallest effective opioid dose, avoid any background infusion, and keep naloxone at the bedside. If he becomes over-sedated with slow breathing, I would stimulate him, support his airway, and give naloxone 10 microgram per kilogram intravenously, repeated every two to three minutes, titrated to his respiratory rate. I would counsel his parents about over-sedation and airway obstruction, document the codeine error, and submit an incident report. [6] [9] [11]