AAP Strongly Advises Against Codeine for Children

The American Academy of Pediatrics (AAP) has recently released a Clinical Report strongly advising against codeine use in children. The rationale of the AAP is as follows:

“Codeine is a prodrug with little inherent pharmacologic activity and must be metabolized in the liver into morphine, which is responsible for codeine’s analgesic effects. However, there is substantial genetic variability in the activity of the responsible hepatic enzyme, CYP2D6, and, as a consequence, individual patient response to codeine varies from no effect to high sensitivity. Drug surveillance has documented the occurrence of unanticipated respiratory depression and death after receiving codeine in children, many of whom have been shown to be ultra-rapid metabolizers. Patients with documented or suspected obstructive sleep apnea appear to be at particular risk because of opioid sensitivity, compounding the danger among rapid metabolizers in this group.”

This statement strongly advises against the use of codeine both as an analgesic agent and as an antitussive agent. The AAP notes that an FDA advisory panel (in December 2015) recommended that the use of codeine for cough should be considered as contraindicated in all children under 18 years.

Texas Children’s Health Plan endorses the AAP and FDA recommendations and strongly advises providers NOT to prescribe codeine-containing medications for children.

Clinical Pearls for Analgesia

• Avoid the use of codeine containing products in children.
• Consider prescribing alternative analgesics such ibuprofen or acetaminophen.   If opioids are required, consider hydrocodone preparations.
• When prescribing opioids, use lowest effective dose for shortest period of time.
• Avoid prescribing opioids “round the clock”.
• Counsel patients and caregivers on how to recognize signs of opioid toxicity, and advise them to seek medical attention or call 911.

Harold J. Farber, MD, MSPH, FAAP, Associate Medical Director, Texas Children’s Health Plan

Joy P Alonzo, M.E., PharmD, Associate Pharmacy Director, Texas Children’s Health Plan

Source:

Tobias JD, Green TP, Coté CJ, AAP SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE, AAP COMMITTEE ON DRUGS. Codeine: Time To Say “No”. Pediatrics. 2016;138(4):e20162396

http://pediatrics.aappublications.org/content/pediatrics/early/2016/09/15/peds.2016-2396.full.pdf

Accessed September 21, 2016