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8 Articles in this Series
Bench to Bedside: Clinical Tips From APS Poster Presentations
New Pain Research Underscores the Importance of Sufficient Rest
The Benefits of Exercise for Pain Management
Exercise as Postoperative Analgesic?
How Race Affects Pain
Increased Centralized Pain in African American Patients
Managing Post-Tonsillectomy Pain in Obese Children
Research Offers Insight Into Fibromyalgia and Pain

Managing Post-Tonsillectomy Pain in Obese Children

When treating an obese or overweight (OB/OW) child recovering from a tonsillectomy, determining the optimal analgesic regimen can be more difficult than other patient populations. This is partly because children with high Body Mass Index (BMI) scores appear to have increased early acute post-tonsillectomy pain (PTP),1 a phenomenon that currently lacks any solid explanation.

Further compounding this problem are the increased risks from obstructive sleep apnea (OSA) that are associated with OB/OW children. While there is a low risk of perioperative deaths in children with OSA,2 clinicians may cautiously restrict their analgesia following a post-tonsillectomy procedure due to those complicating factors and this could result in inadequate pain management in this patient group. Tonsillectomy represents about 15% of all surgical procedures performed on children annually in the US and approximately one-third of those children are OB/OW.

managing pain in obese children can be challengingManaging pain in obese children following a tonsillectomy can be challenging due to complicating factors such as the increased risk of obstructive sleep apnea. How clinicians specifically choose to handle PTP in OB/OW children is unknown. There is no professional standard and scarce research on the topic in general—both possible areas of concern. A recent literature review,3 which was presented at this year’s annual meeting of the American Pain Society (APS), took a comprehensive database search of CINAHL, Medline, and PubMed resources and investigated three separate questions:

  1. How do clinicians manage pain in OB/OW children?
  2. Are OB/OW children at increased risk of moderate to severe PTP?
  3. What do nurses know about the management of PTP in OB/OW children?

“There is a moral imperative to prevent and alleviate suffering in OB/OW children post-tonsillectomy, but scientific support for practice is sparse,” the researchers wrote. Indeed, two studies the researchers found had conflicting determinations concerning OB/OW and PTP in children.

No studies examining nursing knowledge of PTP management in OB/OW children were found. Typically, nurses and physicians calculate medication dose using age and weight as basic perimeters. However, the studies do not indicate whether nurses are trained to take into consideration associated factors like increased pain severity in the OB/OW pediatric patients.

One study the researchers found described a decision support tool developed for guiding medication administration to obese children in postoperative condition. Pain, being a subjective experience, can be especially hard for nurses to gauge in patients that are significantly younger and perhaps lack the maturity to clearly communicate their level of pain to the caregivers.

One study described the practical utility of two newly-developed pain scales—parents' post-operative pain measure (PPPM) and faces pain scale-revised (FPS-R)—and showed how they can be used to accurately quantify post-tonsillectomy pain in children.4 These new pain scales could also be very useful for future clinical research in this topic, since it appears many questions have yet to be answered concerning the pain mechanisms present in OB/OW children and the most optimal pain management necessary to treat them after surgery.

Optimizing Pre- and Post-Tonsillectomy Pain Management

The gap in the clinical knowledge could be filled through more inter-disciplinary research, the authors of the APS abstract noted. For instance, post-tonsillectomy bleeding is a serious concern following the tonsillectomy procedure and may lead practitioners to avoid ibuprofen. However, nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and acetaminophen, have been shown to be effective analgesics for post-operative pain management,5 especially when acetaminophen and ibuprofen are used in alternating doses.6

Other recent studies have found great success adding ketamine to midazolam during the pre-operative stage to help reduce agitation and post-operative pain in the first 30 minutes following surgery.7 Another supplemental approach—adding magnesium with metamizole—may help improve analgesia and lessen postoperative nausea and vomiting.8

Topical analgesics, particularly topical sucralfate, applied during the first week of post-tonsillectomy pain management could be beneficial, as it has been found to significantly reduce throat pain, decrease the need for analgesics, improve wellbeing in general, and get patients back to regular daily activities with no side effects from the treatment.9

The benefits of a wide range of non-pharmacological treatments for post-tonsillectomy pain management have also been explored in a crop of studies. Speech therapy, modified acupuncture, aromatherapy, and even simply chewing gum right after surgery have provided substantial pain relief from localized pain for some children. Eating honey during the first 5 postoperative days has also been shown to have an analgesic effect.10,11

But none of these aforementioned studies have been conducted in the OB/OW pediatric population, however. With more focus placed on optimizing pain management regimens specifically for OB/OW pediatric patients recovering from tonsillectomy, safer, more effective pain management approaches may be developed, tested, and supported.



  1. Nafiu OO, Shanks A, Abdo S, et al. Association of high body mass index in children with early post-tonsillectomy pain. Int J Pediatr Otorhinolaryngol. 2013;77(2):256-261.
  2. Coté CJ. Anesthesiological considerations for children with obstructive sleep apnea. Curr Opin Anaesthesiol. 2015;28(3):327-332.
  3. Martin S., Acute post-tonsillectomy pain management in obese and overweight children. Poster presented at: Annual Meeting of the American Pain Society; May 11- 14, 2016; Austin, TX. Poster #460.
  4. de Azevedo CB, Carenzi LR, de Queiroz DL, et al. Clinical utility of PPPM and FPS-R to quantify post-tonsillectomy pain in children. Int J Pediatr Otorhinolaryngol. 2014;78(2):296-299.
  5. Mattos JL, Robison JG, Greenberg J, et al. Acetaminophen plus ibuprofen versus opioids for treatment of post-tonsillectomy pain in children. Int J Pediatr Otorhinolaryngol. 2014;78(10):1671-1676.
  6. Liu C, Ulualp SO. Outcomes of an alternating ibuprofen and acetaminophen regimen for pain relief after tonsillectomy in children. Ann Otol Rhinol Laryngol. 2015;124(10):777-781.
  7. Bameshki SA, Salari MR, Bakhshaee M, et al. Effect of ketamine on post-tonsillectomy sedation and pain relief. Iran J Otorhinolaryngol. 2015; 27(83):429-34.
  8. Tugrul S, Degirmenci N, Eren SB, et al. Analgesic effect of magnesium in post-tonsillectomy patients: a prospective randomised clinical trial. Eur Arch Otorhinolaryngol. 2015;272(9):2483-2487.
  9. Siupsinskiene N, Žekonienė J, Padervinskis E, et al. Efficacy of sucralfate for the treatment of post-tonsillectomy symptoms. Eur Arch Otorhinolaryngol. 2015;272(2):271-278.
  10. Soltani R, Soheilipour S, Hajhashemi V, et al. Evaluation of the effect of aromatherapy with lavender essential oil on post-tonsillectomy pain in pediatric patients: a randomized controlled trial. Int J Pediatr Otorhinolaryngol. 2013;77(9):1579-1581.
  11. Fayoux P, Wood C. Non-pharmacological treatment of post-tonsillectomy pain. Eur Ann Otorhinolaryngol Head Neck Dis. 2014;131(4):239-241.
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