A short course of oral dexamethasone after paediatric adenotonsillectomy cut opioid prescriptions

Design

parallel-design quadruple-blinded randomised placebo-controlled trial

Population

209 children aged 3-17 having adenotonsillectomy at one tertiary centre; 131 completed pain diaries

Primary outcome

mean pain score before analgesia on postoperative days 2-8

Effect

pain 0.72 points lower (95% CI 0-1.44); opioid prescription odds ratio 0.23 (0.06-0.84); emergency visit for pain 0.12 (0.003-0.91); no difference in haemorrhage or readmission

Children aged 3 to 17 having adenotonsillectomy at a single tertiary centre were randomised, quadruple-blinded, to oral dexamethasone 0.5 mg/kg (maximum 20 mg) or placebo on postoperative days 2, 4 and 6 - that is, a course after discharge, not the single intraoperative dose that is already standard. Two hundred and nine children were analysed for adverse events and health care use; 131 completed pain diaries for the primary pain outcome.

The pain result was modest and imprecise. Mean pain before analgesia on days 2 to 8 was 0.72 points lower with dexamethasone (95% CI 0 to 1.44), an interval touching zero, and the authors say plainly that baseline differences and wide intervals prevent a definitive conclusion. Later in recovery, on days 12 and 13, differences were larger (0.96 to 2.37 points). The findings that matter more are downstream: the odds of receiving an opioid prescription fell (odds ratio 0.23, 95% CI 0.06-0.84) and of an emergency department visit for pain (odds ratio 0.12, 0.003-0.91). Readmissions, nursing calls, post-tonsillectomy haemorrhage and return to normal diet did not differ - and the absence of a bleeding signal is the safety question this trial existed to answer.

In Indian practice the opioid endpoint translates poorly, since codeine is contraindicated in children after tonsillectomy and opioid prescribing to this group is uncommon anyway. What translates is the rest: a cheap, familiar drug, three doses, no increase in bleeding, and fewer children returning in pain. The intervals on those two outcomes are wide and one nearly touches zero, so this is a reason to consider a protocol change and audit it, not to declare the question settled.

• Consider adding oral dexamethasone 0.5 mg/kg on postoperative days 2, 4 and 6 to your adenotonsillectomy protocol, alongside the usual intraoperative dose
• Keep paracetamol and ibuprofen as the analgesic base - this is an adjunct, not a replacement
• Audit post-tonsillectomy haemorrhage if you make the change; the trial found no increase but was not powered to detect a small one
• Track unplanned returns for pain as the outcome most likely to move
• Note the primary pain outcome was not definitive - do not promise parents a large reduction in pain

Why it matters

It offers a cheap adjunct for the most painful week in paediatric ENT without the bleeding signal that has always been the objection.

Don't overread it

A single-centre trial whose primary pain outcome was not definitive, with wide intervals on the health care use findings and incomplete diary return.

The statistics, in plain English

The primary outcome, a 0.72-point pain reduction with a confidence interval of 0 to 1.44, is exactly the result that should not be over-claimed - the interval touches zero, so no effect remains compatible with the data. The downstream odds ratios look dramatic (0.23 for opioid prescription, 0.12 for an emergency visit) but their intervals are enormous, running to 0.84 and 0.91 respectively; that width comes from small numbers of events and means the direction is more trustworthy than the size. Note also that only 131 of 209 children completed pain diaries, so the pain analysis rests on the families organised enough to keep one.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.