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What to Give a Child for Pain

What to Give a Child for Pain

Learn how to decipher mixed messages on children and opioids.

The American Academy of Pediatrics (AAP) has published a warning against giving the opioid codeine to children in the journal Pediatrics, published in September 2016. An opioid, codeine has the potential to suppress breathing and cause death. The report found 64 cases of suppressed breathing and two dozen deaths—mostly in children under 12—from 1965 to 2015.

Despite its potential for injury and death, codeine remains a popular drug. It’s found in a number of over-the-counter cough medicines, and one study cited in the report estimated that codeine was prescribed more than 800,000 times to children under age 11 in 2011.

Codeine is popular because it is less potent than other opioids, so it can be used for mild to moderate pain instead of something more potent—and potentially habit forming. But if it’s less potent than alternatives, how does it have the potential to kill?

How Codeine Can Be Dangerous
The body turns codeine into morphine—and gives it its painkilling effect—with the help of an enzyme produced in the liver called CYP2D6. A certain gene tells the liver to produce the enzyme. Some people, called ultra-rapid metabolizers, have two or more copies of that gene, which makes their bodies convert codeine to morphine in higher amounts than other people.   

Molecules of opioids, like morphine, attach themselves to parts of a cell called opioid receptors, which are found in brain, spine and other cells in the body. They block pain signals, but when there’s too much opioid in the system, it suppresses the urge to breathe. For children who are ultra-rapid metabolizers, even the correct dosage can cause this reaction.

Alternatives to Codeine
According to a 2011 report from the Food and Drug Administration, a codeine-acetaminophen mixture was most often used in children after surgery. Ear, nose and throat doctors, dentists, pediatricians and primary care physicians were most likely to prescribe it.

The AAP offered few good alternatives in its report. Oxycodone and hydrocodone, two more powerful opioids, may also pose a risk to ultra-rapid metabolizers. The authors floated the idea of oral morphine, but said it is too untested to recommend. Another opioid, called tramadol, is converted to morphine by a similar process, but different enzyme; the authors suggested the potential for the same dangers as codeine. Tapentadol is another option, they said, but there have been no studies about using it to treat children.

Non-Opioid Options
The AAP report recommends non-opioid drugs for pain management. It cites acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin, as substitutes to codeine.  

“It is clear that one of the keys to improving [pain relief] and reducing opioid-related adverse effects is both provider and parental education regarding the effective use of nonopioid [painkillers],” wrote the authors. “The answer may not lie in using more medication or different medications but merely using more effectively other options that are currently available.”

Medically reviewed in December 2018.

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