AAP: “Time to Say No” to Codeine for Children

September 19, 2016

AAP: “Time to Say No” to Codeine for Children

  1. Cara Adler, MS and
  2. John D. Cowden, MD, MPH

In a clinical report, the American Academy of Pediatrics outlines the risks of codeine for management of pain and cough in children and adolescents.

  1. Cara Adler, MS and
  2. John D. Cowden, MD, MPH

Citing risk for respiratory depression or death, the American Academy of Pediatrics, in a clinical report, urges clinicians and parents to stop giving codeine to children. Highlights of the report include:

  • Genetic variation in codeine metabolism can lead to excessive morphine levels in some children, and is a particular concern in those with sleep-disordered breathing. From 1965 to 2015, the FDA Adverse Event Reporting System recorded 64 children with severe respiratory depression and 24 deaths (most in children younger than 12 years) associated with use of codeine.

  • Despite warnings against its use from the FDA (Physician's First Watch Dec 11 2015), World Health Organization, and European Medicines Agency, codeine continues to be widely used for management of pediatric pain and cough in the U.S. In 2011, codeine was prescribed to more than 800,000 children younger than 11 years. Codeine is currently available in over-the -counter cough medicines in 28 states.

  • Among the limited alternatives for pediatric analgesia, other opioids are not recommended due to similar safety concerns or insufficient evidence about safety in children. Nonopioid options, chiefly nonsteroidal anti-inflammatory agents and acetaminophen, may be effective for mild to moderate pain.

Comment

The movement to eliminate pediatric codeine use continues in this AAP report, with a concise summary of the growing evidence of risk and a review of recommendations from prominent professional organizations. Though provider and parent education might move us closer to replacing codeine with alternative pain control options, significant progress will depend on formal restriction of its use in children.

Editor Disclosures at Time of Publication

  • Disclosures for John D. Cowden, MD, MPH at time of publication Leadership positions in professional societies Co-Chair, Culture, Ethnicity, and Health Care Special Interest Group, Academic Pediatric Association

Citation(s):

Reader Comments (3)

JOSE GROS-AYMERICH Physician, Family Medicine/General Practice, INSS -retired

A very appropriate study and conclusion, I'd add that Codeine exerts its action by being metabolized into Morphine inside the body, that many differences in metabolism and Opioid receptors exist from person to person, and that some became addict to opiates after the first single dose, the conclusion would be that Codeine is never a drug acceptable for pediatric patients, also never to be dosed to woman who could become pregnant, risks of priming or triggering an addiction seem unacceptable

Joseph Soler Physician, Emergency Medicine, ER

Could my Pediatric colleagues suggest an alternative to codeine for pain control? It seems unreasonable to ban and then have very limited alternatives. Perhaps dose codeine at a lower mg/kg?

OWEN SHEEKEY Physician, Internal Medicine, Vineland, New Jersey

“In (the US) in 2011, codeine was prescribed to more than 800,000 children younger than 11 years.” Though not a pediatrician this seems to be a marker for a major need for relief of pain and cough in children. Further it suggests that the alternatives are inadequate. “From 1965 to 2015 (50 years), the FDA Adverse Event Reporting System recorded 64 children with severe respiratory depression and 24 deaths (most in children younger than 12 years) associated with use of codeine.” The phrase associated with the use of codeine does not necessarily equate with the alternate phrase caused by the use of codeine. Life is risky and most of us drive on highways because of the great benefits but children die daily in motor vehicular accidents. Unfortunately in this world in which we live these are the prices we pay. Though a laudable goal it is just not possible to live our lives completely risk free and the statistics will always bear that out. Finally there seems to be a lot of moralizing about opioids these days which tends to cloud the discussions. It is not “time to say no” but time to be more cautious and continue to look for alternatives.

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