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Key messages
1. Non‐selective NSAIDs do not increase the risk of reoperation for bleeding after
tonsillectomy in paediatric patients (R) (Level I [Cochrane Review]).
2. Dexamethasone reduces post‐tonsillectomy pain and postoperative nausea and vomiting
(N) (Level I) but high doses may increase the risk of bleeding (N) (Level II).
3. Paracetamol and non‐selective NSAIDs are effective for moderately severe pain and
decrease opioid requirements after major surgery (U) (Level II).
4. The efficacy of oral codeine in children is variable, individual differences in the ability to
generate active metabolites may reduce efficacy (U) (Level II) or increase side effects (N)
(Level IV).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Safe dosing of paracetamol requires consideration of the age and body weight of the child,
and the duration of therapy (U).
Aspirin should be avoided in children, but serious adverse events after non‐selective
NSAIDs are rare in children over 6 months of age (U).
10.6 OPIOID INFUSIONS AND PCA
10.6.1 Opioid infusions
The safety and efficacy of IV opioid infusion for the management of acute postoperative pain
are well established for children of all ages (van Dijk et al, 2002 Level II). Further procedure‐
specific evidence and dose recommendations are available (Howard et al, 2008). As intermittent
IM injections are distressing for children, the IV route is preferred, but if peripheral perfusion
is normal, the SC route can be used for continuous infusion (McNicol, 1993 Level IV) or for PCA,
with similar safety and efficacy to the IV route (Doyle, Morton et al, 1994 Level II).
Differences between intermittent bolus doses and continuous infusions of opioid relate more
to the total dose given than to the method of administration (Lynn et al, 2000 Level III‐2).
Comparison of the same total dose of morphine given via infusion (10 mcg/kg/hr) or bolus
(30 mcg/kg every 3 hours) found no difference in pain scores (COMFORT scale and observer
VAS) (van Dijk et al, 2002 Level II) or stress response to surgery (Bouwmeester et al, 2001 Level II)
in neonates and young infants. However, these doses were inadequate in older children CHAPTER 10
(1 to 3 years of age) who required additional bolus doses and the 3‐hourly interval was less
effective (possibly due to more rapid clearance) (van Dijk et al, 2002 Level II).
In ventilated preterm neonates, opioid infusions have limited efficacy for control of acute
procedural pain (Bellu et al, 2008 Level I). Initial associations between routine morphine infusion
and improved neurological outcome were not confirmed in a subsequent large multicentre
study (Anand et al, 2004 Level II). A subsequent meta‐analysis found no statistically significant
differences in mortality, duration of ventilation, or improvements in short or long‐term
neurological outcomes with routine use of opioid infusions in ventilated neonates (Bellu et al,
2008 Level I). Prolonged sedation may have detrimental effects in preterm neonates (Anand et
al, 1999 Level II), but no association with poor 5‐year neurological outcome has also been
reported (Roze et al, 2008 Level II), as studies vary in the degree and manner of correction for
confounding factors.
Acute pain management: scientific evidence 353
