On the list of priorities at most any children’s hospital, preventing and managing pain in the pediatric population ranks near the top. A recent study1 published in Journal of American Medical Association(JAMA) measures the benefits of administering intravenous acetaminophen, rather than morphine, to children recovering from surgery. The motivation to administer drugs such as acetaminophen in lieu of opioids such as morphine and hydrocodone is linked to the clinical concept of opiophobia – a reticence on the part of physicians to prescribe opioids due to concerns that patients may become addicts.
But is unnecessary pain the ultimate result for children receiving less potent medications? Kanwaljeet J. S. Anand, medical director of critical care at Le Bonheur Children’s Hospital and division chief of Pediatric Critical Care at the University of Tennessee Health Science Center, poses the question in an editorial to JAMA. Dr. Anand examines several facets of the Ceelie et al study, which showed clinically significant reductions in morphine use among neonates or infants receiving postoperative pain management.
Dr. Anand suggests that several factors warrant further evaluation. Those factors include the likelihood of developing opioid-induced increased sensitivity to pain (hyperalgesia) rather than opioid tolerance in the brief duration of the trial, the study’s focus on opioid-related adverse effects rather than the toxicity or possible adverse effects of acetaminophen, and the absence of studies evaluating the safety of intravenous acetaminophen. Dr. Anand also highlights the potential synergy between morphine and acetaminophen and genetic variations in our response to acetaminophen as topics for further study.
Dr. Anand cites a widespread reluctance among clinicians to treat pain in infants and children with adequately-dosed opioids. He suggests that managing morphine dosage precisely – based on pain scores – is more labor intensive than the common practice of slightly oversedating infants who require opioid relief for painful conditions, such as postoperatively.
“Busy clinical units will have to choose between the nursing resources required to follow such a labor-intensive protocol or to tolerate a rel
atively low incidence of oversedation and opioid-related effects,” said Dr. Anand. “Theoretically elegant approaches have little value in clinical practice if they are not practically feasible in the clinical settings for which they were designed.”
Dr. Anand is professor of Pediatrics, Anesthesiology, Anatomy and Neurobiology at the University of Tennessee Health Science Center.
- Ceelie I, de Wildt SN, van Dijk M, et al. Effect of intravenous paracetamol on postoperative morphine requirements in neonates and young infants undergoing major noncardiac surgery: a randomized controlled trial. JAMA. 2013;309(2):149-154.
- Anand KJS. Pain panacea for opiophobia in infants? JAMA. 2013;309(2):183-184.