Codeine is not for children

The Pediatric Insider

© 2016 Roy Benaroch, MD

Codeine is a terrible choice for treating children’s pain and cough, and we ought to just stop using it. It’s like an old yogurt container, way at the back of your fridge — sure, it was once tasty, and then for a while you held on to it for sentimental reasons. “Remember that yogurt?” you’d say to your spouse. But it’s well past time to throw that stinky stuff away.

For a long time, codeine was thought to be safer than other opiate-based pain medications. It’s a naturally occurring form of morphine with good oral bioavailability (that means you can swallow it in pill or liquid form.) But codeine, the molecule itself, has no biologic activity or drug effect on its own. It has to be converted, in the liver, to an active “metabolite” to have any effect on your body. And that’s the problem: the “activation” step. It turns out that different people have a huge variability in how quickly they activate codeine, which can lead to all kinds of problems.

Some people are “fast metabolizers” — meaning they very rapidly activate codeine. If you’re one of these people, the effects and side effects of codeine will be much higher than expected. There have been about 64 cases of severe respiratory depression reported in children taking “normal” doses of codeine, and many of these children died.

On the other hand, some people are “slow metabolizers”. They can take a dose of codeine, and their liver just sits there, twiddling its liver thumbs. Nothing happens. There’s no therapeutic effect of even very high codeine doses in these people, because their bodies don’t activate the drug.

A slew of international smart-guys has already begun to limit the use of codeine, especially in children. The US FDA slapped a black box warning against its use in post-op children, the Europeans issued a report suggesting that we stop using codeine entirely in children less than 12, and Health Canada even joined the fun, calling codeine “a big hoser of a mistake, eh?”

So, if not codeine, what else can we safely use to treat serious pain in children? Oxycodone (found in Percocet and other products), should have much less variability, though there will still be some added risk to fast metabolizers. The best option, really, might be to go back to using straight-up morphine, but there aren’t great studies looking at its absorption in children.

Non-opiate pain medicines work well, too — in many cases, as well as opiates, if used correctly. These medications, including acetaminophen and ibuprofen, can very effectively relieve even serious, post-op pain, if they’re given in advance and on schedule. Even if they can’t relieve pain completely, they can be used to reduce the doses of opiates needed. There are also IV preparations of acetaminophen and some NSAIDs.

We also need to be very careful about the kind of pain we’re treating. Acute serious pain, from surgery or a broken bone, can and should be safely treated with a combination approach that often includes opiates in the short run. But chronic or recurrent pain (including backaches and migraines) should not be treated with opiates. In the long run, these medicines actually increase the body’s sensitivity to pain, potentially leading to a cycle of dependence and addiction.

Sometimes, codeine is also used as a cough suppressant. The same risks for high- or low- metabolizers are there, and in fact there are no studies showing that codeine is even effective for cough in children. You’ve got all the risk for potentially zero benefit.

Codeine is an old medicine that’s way past its prime. We’ve got better drugs to choose from. If your doc offers a codeine prescription for your child, it’s time to say “no.”

Growing pains

The Pediatric Insider

© 2010 Roy Benaroch, MD

OK, I’ll admit it, this time I just made up a question. If you’ve got something you want me to write about, submit it under the “topic suggestions” thread via the link over there on the right. Please keep your questions short. I will not address very specific, individual medical problems here—this isn’t the place for me to diagnose your own child’s problems. Aim for more general-interest stuff that your friends and neighbors would want to read. Thanks!

Begonia Payne wrote in: “My 5 year-old-son has a lot of pains at night. He goes back to sleep, but I think there really is something hurting him. Is this ‘growing pains’”?

It could be, yes, but there are a few other questions I’d like to ask to make sure it’s not something else.

“Growing pains” are common and benign, and can usually be diagnosed based only on the pattern of pain. They occur a little more commonly in boys than girls, most typically starting at 4 to 8 years of age. The pain is almost always limited to the night-time hours, often waking children from sleep. During the day, children with growing pains do not limp or complain of pain. At night, they’ll usually complain of pain in one or both legs, and in a vague location that varies from side to side and site to site on subsequent nights. When children are asked to point at where it hurts, they’ll rub over an area rather than point specifically at one exact point.

It’s important to stress that the pain itself is very real—“growing pains” is not a euphemism for “faking it.” These kids are genuinely uncomfortable, and often scared. We don’t know, honestly, what causes growing pains, or if they actually have anything at all to do with growing. Still, “growing pains” is a good-enough name that seems to have stuck.

Fortunately, it’s easy to treat. Gentle massage or a heating pad can work very well. Use the safer kind of heating pad that you gently warm in the microwave, rather than the electric kind. A single dose of a pain medicine like ibuprofen or acetaminophen can also help. Though children with growing pains can be very uncomfortable, they’ll feel better in 20 to 30 minutes, so everyone can go back to sleep.

Recent research has shown that vitamin D deficiency can contribute to night-time muscle and bone pains in some children. Parents of children with apparent growing pains may want to try a vitamin D supplement, 400 IU per day (that’s the usual concentration in most children’s vitamins.)

Growing pains ought to fit a specific pattern, and should not be accompanied by other signs of illness. Beware of the following “red flags” that may mean something else may be causing pain in your child:

• Pain or limp during the day.
• Pain that persistently affects one specific joint or place.
• Associated fever, weight loss, or other symptoms of potentially serious disease.
• Pain that’s becoming more and more intense as weeks go by.

Growing pains are common, and though the pain is real they’re easy to treat. Kids with growing pain do not continue to have symptoms as they grow older, and there are no lasting effects. Speak with your child’s pediatrician to review the patterns of pain to ensure that nothing more needs to be done, and stock up on massage oil to help get through those painful, wakeful nights.

Acetaminophen safety alert

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kelly posted, “After the FDA’s recent announcement about the dangers of acetaminophen overdose, I now think twice before using it for me or my family.  What’s your take on whether the drug is safe in the prescribed dosages – particularly for kids?”

In June, 2009 the FDA released information from an advisory committee studying the safety of medications containing acetaminophen (most commonly known by the brand name Tylenol.) They pointed out that acetaminophen can cause acute and chronic liver injury, which can be fatal. Since then, the manufacturer has started an advertising campaign defending the safety of their product. So who to believe?

Acetaminophen is very, very safe—when taken correctly by people who are not already at risk for liver problems. But it turns out in practice that many, many people have been injured because they didn’t take the medicine right, or didn’t realize that acetaminophen isn’t always safe for everyone.

Who shouldn’t take acetaminophen? Anyone with chronic liver damage or liver disease. The main group are adults who consume too much alcohol. It turns out that not everyone tells their doctor about their alcohol habits, so doctors haven’t necessarily warned people about this. Other causes of chronic liver problems are obesity (so-called “fatty liver” has become the most common cause of liver disease in adolescents), the use of other medicines that affect the liver, and hepatitis. For most children (excluding overweight adolescents), the chance of having liver disease is very, very small.

How do you take acetaminophen correctly? Read the label. Use the included dosing device, and if you’re not sure how to use it, ask your doctor or pharmacist. Don’t combine multiple medications that contain acetaminophen, and make sure that if your child does take other medicines every day, you know if there are interactions between that and acetaminophen (or any other over-the-counter meds you might try.)

One specific recommendation from the FDA committee was to insist that all children’s and infant’s acetaminophen products be sold at the same concentration, simplifying dosing instructions. Right now there are several different strengths of liquids, chewables, and “Junior” tablets that are unnecessary and confusing.

Also, don’t use acetaminophen (or any other medicine) unless you really need to. Fever itself doesn’t necessarily need to be treated with medication (see here and here), but if your child feels lousy, you ought to try to help her feel better.

Alternatives to Tylenol include Motrin or Advil (both are brands of ibuprofen, see here for comparisons), or a non-medical approach like cool towels to reduce a fever, or a gentle heating pad to reduce ear pain.

If your child is in pain or has a fever, acetaminophen is a good safe medication to use. Just use it carefully and correctly, and check with your doctor or pharmacist if there’s any reason to think that your child has liver disease or is on any other chronic daily medication.

Tylenol versus Motrin

Katherine asks a question that comes up a lot in practice: “I am wondering when it is best to use Motrin and when to use Tylenol with my children. I brought my son to the doctor recently for a virus causing a bad sore throat with low grade fever. I told the doctor I had been using Tylenol and she said I should be using Motrin. Is Motrin/ibuprofen better for pain relief? If so, in which situations should I should be using Tylenol? Also I have heard about switching between the two drugs – is there any merit to that?”

First, to clear up the names: Tylenol is the most common brand name of acetaminophen; Motrin and Advil are two brands of ibuprofen. Any brand or generic is fine. Avoid the “combo” products, like “Motrin Cold” or “Tylenol with Vodka.”*  These are confusing to use, and are very rarely helpful.

Both ibuprofen and acetaminophen are effective at relieving both pain and fever. For pain, ibuprofen is probably a little more effective; for fever, they work equally well. However, ibuprofen lasts longer, about six hours against acetaminophen’s four. That might make a big difference in the middle of the night.

Ibuprofen should not ordinarily be used in a baby under six months of age. Acetaminophen is safe at any age, even newborns.

For fever, remember that the reason you’re treating fever is to help the child feel better. Fever itself is not harmful. But often children with fever feel achy and miserable, and treatment with acetaminophen or ibuprofen can help them feel better.

Some people suggest “alternating” ibuprofen and acetaminophen. There is one study from Israel that did show using them alternating every three hours seemed to provide better relief than using one medicine alone; but in that study the doses were different from what’s typically used in the United States, so it’s hard to know for sure. If you do alternate the meds, you ought to keep a chart so you and other caretakers don’t end up giving extra doses of the wrong medicine.

Acetaminophen and ibuprofen are both quite safe if dosed correctly. Be especially careful if you’re using both medicines together, using them for more than a few days, or if your child is dehydrated. Any of these circumstances will increase the risk for dangerous side effects.

I like to keep things simple. In my home, since all of my children are over six months, I use generic ibuprofen for pain or fever. IF a child has a return of these symptoms and it hasn’t been six hours since the last dose of ibuprofen, I use acetaminophen as a “pinch hitter” to give an early dose, then resume the ibuprofen if symptoms come back again.

* – OK, I made this one up. But it sounds like a good idea for parents with headaches. I ought to patent that….

Ice v Heat for injuries

Mark wants to know how to treat injuries: “Why do doctors say to alternate between applying heat and ice? Since these are opposites, how could they both help?”

Heat and ice do two different things after an injury. Knowing which one is more suitable depends on what you’re trying to accomplish.

Ice numbs tissue, so it reduces pain. It can also reduce bleeding and bruising. Coldness also helps prevent or treat swelling, which is important—swollen joints have altered mechanics, so they don’t work right, and are prone to re-injury. A swollen, painful joint will also change the way a person walks and moves, which can create a risk for further injury at other body parts. Immediately following a musculoskeletal injury, ice is often one of the best ways to help. Ice itself can be uncomfortably cold, especially in children, so a better option might be ice wrapped in a towel, or a cool wet washcloth from the refrigerator. Don’t leave bare ice on a body part for more than 15 minutes to avoid frostbite, and check any area that’s being iced frequently—the skin can feel cool, but should never be close to frozen.

Warmth works in a different way. It relaxes muscles that often tense up after an injury, and it feels good. Warmth is usually used the day after an injury, when swelling is less of a problem. It’s great for pulled muscles, whiplash, and other injuries that don’t typically involve a broken bone. Warmth can make swelling, bruising, and bleeding worse. Electric heating pads should not be used on unsupervised children. Instead, use one of those warm-up things you put in the microwave, and check carefully that it isn’t too hot before putting it on a child. Topical heating creams smell kind of weird, but do help muscle injuries feel better. They’re hard to remove if a child objects to the warmth or smell.

I can’t think of a time when I’ve ever suggested alternating heat and ice after an injury—when did a doctor suggest that to you? It doesn’t make sense to me, either!

Reducing the pain and anxiety of immunizations

From DMM, on the Topics Suggestions page: “Any ideas for a kid scared of immunizations. I have a 5 year old who needs his kindergarten shots before August. He has anxiety issues.. He is now able to go to the Pediatrician and trusts her, but he knows that he will need to get some shots before school. Some of his friends have gotten them, and just the mention of them sends my son into meltdown/anxiety attack mode.
Any ideas on how to make this a doable situation for us all?”

I agree that the pre-kindergarten visit can be rough on the kids. The good news is that we can protect our children and their classmates from serious infections. The bad news is for the child himself: that’s 3 or 4 booster shots. Though many kids take this in stride, it can be a scary experience for many children.