Clinicians are being asked to rethink post-operative care for children with sleep apnea, and avoid prescribing morphine, following clinical trials that revealed the drug can cause life-threatening breathing problems.
Midway through 2014, researchers from Toronto's Hospital for Sick Children and Hamilton's McMaster University halted trials about the adverse effects of morphine as a pain reliever for children who had their tonsils or adenoids (commonly called a nose tonsil) removed after one child needed to be resuscitated because of a lack of oxygen.
Each hospital's ethics board, as well as Health Canada, was notified as a result. The general findings showed the adverse affects of morphine, and an alternative that managed pain just as effectively.
Researchers found morphine should not be given to children following sleep apnea operations, except in monitored or extreme cases, and that standard doses of ibuprofen and acetaminophen helped ward off pain in the three weeks of discomfort children tend to have after the operation.
"It is safer, treats the pain just as well and should be considered the main treatment," Dr. Doron Sommer, clinical professor of surgery at McMaster’s Michael G. DeGroote School of Medicine and a surgeon at McMaster Children’s Hospital, said of the alternatives.
Alternative pain management sought
Sommer and researchers from the Hospital for Sick Children were looking into alternative pain management options for children getting tonsillectomies.
Some 14,000 tonsillectomies are performed in Ontario every year, and according to Sommer, many are to prevent sleep apnea in children.
In 2009 and 2012, major studies revealed codeine caused adverse reactions and even death when used in pediatric post-operative care for sleep apnea patients, suppressing the brain's signalling to breathe while sleeping. It's one part of what causes apnea, along with physical blockages in the breathing pathway.
"It works on the brain directly to decrease the respiratory drive," Sommer said.
Since codeine is metabolized into morphine in the body, Sommer said, researchers looked at removing the metabolic stage to give a more uniform pain management delivery, essentially skipping the middle man. However, similar negative effects were found when morphine was give to children following surgery.
"The evidence here clearly suggests children with obstructive sleep apnea should not be given morphine for post-operative pain. We already know that they should not get codeine, either," says Dr. Gideon Koren, another author of the study and senior scientist at the Hospital for Sick Children.
"The good news is that we now have evidence that indicates ibuprofen is safe for these kids, and is just as effective in controlling their pain, so there’s a good alternative available for clinicians to prescribe."