Background Tonsillectomy is a common procedure in children, with approximately 18,000 carried out per year in the UK. It is a painful procedure with children requiring post-operative analgesia to take home following the surgery. In July 2013 the Medicines and Healthcare Products Regulatory Agency (MHRA) altered the licence status of codeine following reports of deaths in children who had undergone tonsillectomy, removing it as a treatment option for children less than 12 years old, and contraindicating it in children with obstructive sleep apnoea. Prior to this, codeine represented a breakthrough pain relief agent for many centres nationally in children in the post-operative period. Given the lack of robust data on the efficacy and safety of the alternatives (morphine, tramadol, dihydrocodeine) we were concerned that children would be exposed to variable practice across the country.

Methods An electronic survey of post-operative pain relief in UK centres carrying out tonsillectomy was carried out. The paediatric pharmacist at each site was contacted for the information.

Results Twenty one UK centres were contacted, with responses received from 10. 6/10 units reported changing their practice following the MHRA decision. A wide variety of practice was noted. All except one centre used paracetamol and ibuprofen but at various doses and durations and in one centre diclofenac is used in place of ibuprofen. For additional (breakthrough) pain relief codeine remained in use in 2 units, morphine in 2, dihydrocodeine in 1 and tramadol in 2, while 3 centres did not use any additional analgesia and 1 centre did not have standardised take home pain relief. These results cover centres across the UK and represent approximately 25% of the tonsillectomies in children per year.

Discussion & conclusions There is little evidence available for the efficacy and safety of the replacement agents being used for breakthrough pain relief in children undergoing tonsillectomy. Although it is not possible to say how uniform the post-operative analgesia practice was prior to the MHRA decision, there is now considerable variation in practice across the UK. A prospective RCT to determine efficacy and safety of post-operative analgesia is required.