Tonsillectomy is one of the most common surgeries performed in children, successfully treating both chronic infections and nighttime airway obstruction like obstructive sleep apnea, says Aldo Londino, MD,  Assistant Professor of Pediatric Otolaryngology at the Mount Sinai Health System and Chief of the Division of Pediatric Otolaryngology at the Mount Sinai Kravis Children’s Hospital.

While parents are typically happy with post-surgery results once the child has completely recovered, they are often surprised at how trying the recovery period can be. After tonsillectomy surgery, parents should expect their child to have a very bad sore throat for at least one week, and often up to two weeks. “I provide detailed discharge instructions to all parents outlining tricks for keeping their child as comfortable as possible and reducing the risk of returning to the hospital for dehydration because it hurts too much to swallow,” says Dr. Londino.  Despite these efforts, Dr. Londino receives multiple post-surgery calls from parents struggling to control their child’s pain and prevent dehydration. With the science behind appropriate pain management in children evolving, misinformation is rampant:  “Information on the internet, even sometimes on medical sites, is often in conflict with my written instructions to families.”

FDA Warning for Tylenol With Codeine

In August 2012, the Food and Drug Administration (FDA) issued a safety announcement regarding the use of Tylenol with Codeine after tonsillectomy and adenoidectomy in children, prompted by several incidents, including three deaths in children using the drug after surgery. This was followed up with a boxed warning and contraindication in February 2013, after concerns about prescribing the drug for children were substantiated. In April 2017, the FDA required that medicines which contain codeine—or tramadol—have a label indicating they should not be used in children under 12. Codeine is metabolized by the liver into morphine, which then provides pain relief. Unfortunately, individuals metabolize codeine at different rates; some do it too slowly, not getting enough pain control, while others are ultrafast metabolizers of codeine. For these people, codeine is dangerous, as too much morphine in the body can cause a person to stop breathing.

Until this warning was issued, many doctors felt Tylenol with Codeine was a safer, gentler narcotic than most and was particularly appropriate for use in children. Other narcotics, such as oxycodone, were reserved for adult patients. The FDA warning left many ear, nose, and throat surgeons scrambling to find safe, yet effective alternatives to Tylenol with Codeine.

Ibuprofen and Bleeding

Doctors have known for years that non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen provide good pain relief and help decrease inflammation and swelling after an injury. However, most doctors have had concerns about using NSAIDs before or after surgery as they also affect blood clotting. This is important because about three percent of children having a tonsillectomy are at risk for bleeding during the recovery.

Initially, there was significant concern that using ibuprofen for pain would increase the risk of bleeding after tonsillectomy. Fortunately, multiple studies have now shown that these concerns are not warranted: there is no increased risk of a post-tonsillectomy bleed with ibuprofen. However, online sources, and even some ear, nose, and throat surgeons who perform the procedure, will advise against its use, creating confusion for parents trying to provide appropriate care for their child post-surgery. “I’ve had many parents call with concerns about uncontrolled pain after surgery and have found that they have not given ibuprofen as instructed because of this well-intentioned, but unfounded, concern,” says Dr. Londino.

What Is the Best Way to Control Pain After My Child’s Surgery?

Talk to your child’s surgeon about the right medicines for your child. With ongoing interest in pain control for children and new protocols being implemented every year, Dr. Londino offers clear advice to parents of her patients: “My current approach is to have parents alternate regular over-the-counter liquid acetaminophen (Tylenol) with over-the-counter liquid ibuprofen (Motrin or Advil) at the appropriate dose on the bottle for the child’s weight,” says Dr. Londino. “Both medications can be given every six hours and, if alternated, the child can have something for pain as frequently as every three hours.”

This method keeps most children under 12 years old comfortable enough to drink and stay hydrated. Parents should remember that it is not uncommon for children to need pain medicine through the second week after the surgery. “Children have a good reason to be uncomfortable,” notes Dr. Londino. “It is okay to keep using these medicines for the entire recovery period, if necessary.”

For those children who are not comfortable enough, despite alternating the acetaminophen and ibuprofen, a steroid can be prescribed for a short period (one to two days). This decreases swelling and increases the child’s appetite. It is important to note that these tricks work for most, but not all, children. While it is rare, some parents do need to take their child to the emergency room due to dehydration.

A narcotic other than codeine can be safely prescribed to adults and children over 12 years of age. Dr. Londino often recommends the same alternating use of acetaminophen and ibuprofen to older individuals to reduce the need for narcotics. Additionally, there is some evidence to suggest that a medication called sucralfate (Carafate) can coat the raw areas of the throat, helping to increase the healing rate and decrease pain. While Dr. Londino does not routinely prescribe sucralfate for children, she does recommend its use in older children and adults.