Children prescribed codeine despite safety concerns

Although significant concerns have been raised about the safety and benefits of codeine-containing medications for children, there's been only a slight decline in hospital emergency department prescriptions for the drugs over the past decade, a new study finds.

"There's been growing evidence that codeine is metabolized very differently in different children, with a small portion of them being at risk for potentially fatal side effects," says pediatrician Sunitha Kaiser, an assistant clinical professor at the University of California-San Francisco, and lead author of the study published online Monday in Pediatrics.

And 1 in 3 children "metabolize it in a way that they get no effect at all" when it's taken to relieve pain or to shorten or reduce the severity of cough and cold, says Kaiser. "The expense and time of going to get it may not even be worthwhile for a large proportion of children," she says.

That evidence aside, the new study shows that "hundreds of thousands of kids are still being prescribed codeine every year," most often for coughs and colds and to treat injury pain, Kaiser says

Using data from the nationally representative National Hospital and Ambulatory Medical Care Survey, researchers analyzed the equivalent of 189,028,628 emergency room visits for patients ages 3 to 17 between 2001 and 2010 and found:

• 577,270 prescriptions for codeine written in 2010, down from 644,394 in 2001.

• Codeine was prescribed in 2.9% of visits in 2010, down from 3.7% of visits in 2001 .

• Children ages 8 to 12 and 13 to 17 were more likely to be prescribed codeine than were younger kids, ages 3 to 7. Although there was no statistically significant change in prescribing rates for older children, the percentage of prescriptions for the youngest age group decreased from 3.8% to 3.0% during the 10-year study period.

The study notes that guidelines from the American Academy of Pediatrics, issued in 1997 and reaffirmed in 2006, warn about codeine's potential dangers and lack of documented effectiveness in children who have coughs or upper respiratory infections.

The Food and Drug Administration issued a warning against codeine-use after pediatric tonsillectomy and/or adenoidectomy for obstructive sleep apnea. In 2012, FDA reported that three children had died and one child experienced a non-fatal but life-threatening case of respiratory depression after taking the narcotic for pain-relief following the surgeries.

In an editorial in Pediatrics, physicians Alan Woolf and Christine Greco of Boston Children's Hospital write that "some remedies have long outlived their usefulness," and that "there are good reasons why we should encourage all pediatric clinicians to give up their codeine-prescribing habit."

It cites an "inordinately high number of adverse effects," including allergic reactions, constipation, nausea and vomiting, the fact that "there is no evidence that codeine shortens the duration or reduces the severity of pediatric coughs," that it is "an ineffective analgesic in many pediatric patients," and is often "diverted for recreational drug use by substance abusers."

The high number of emergency room prescriptions for codeine does not surprise Shan Yin, a pediatric emergency room physician and medical director of the Drug and Poison Information Center at Cincinnati Children's Hospital Medical Center. He was not involved in the new study.

"In emergency rooms we see a lot of children with cough caused by viral illnesses and often there's some expectation by parents that we do something," Yin says. "I've personally never given codeine for cough, but I wouldn't be surprised that prescribers have done that."

Although the study examines codeine prescriptions only for children in emergency departments, it's equally as important for codeine use to decrease in other settings such as hospitals, urgent care clinics and primary care clinics," Kaiser says. "It's not a good drug for children in any setting."