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may cause gastrointestinal bleeding, but this risk is very small. These agents
also cause renal and hepatic dysfunction; therefore, they should be used with
caution in children with renal or hepatic disease. They may prolong bleeding
time, but their effect on platelets (inhibition of aggregation) is reversible.
There is some concern that NSAIDs may adversely affect bone fracture
healing, but to date there is no definite evidence to support this.
Aspirin is one of the oldest analgesic medications, but it is rarely used
now because of the better side effect profile of other analgesics and the
perceived risk of Reye syndrome related to aspirin.
Ibuprofen is the most commonly used oral NSAID. Ibuprofen is as
effective as oxycodone for analgesia. Ibuprofen is available in liquid form,
making it suitable for use in children older than 6 months. The
recommended dosage of ibuprofen is 8 to 10 mg/kg given every 6 hours. The
recommended dosage for ibuprofen in older children is 200 to 400 mg/dose
given every 6 hours (maximum 40 mg/kg/day) for mild to moderate pain. As
with acetaminophen, there are several different formulations of ibuprofen, so
parents should be advised carefully about how to properly measure doses for
their child.
Selective COX-2 inhibitors have not been shown to be more effective than
nonselective NSAIDs, they are less likely to impair platelet function and
cause gastritis, however data in children are limited. These medications are
most useful for older children who have a hypersensitivity to NSAIDs. There
is concern in adults that COX-2 inhibitors increase the risk of thrombotic
cardiovascular events and they should be used with caution. Currently, these
medications are recommended for those who require long-term NSAID
administration for chronic pain syndromes.

Opioids
Codeine is an orally administered narcotic analgesic used for minor pain.
Significant effort has been invested in uncovering the pharmacogenetic
effects of codeine in children. When given the same dose, some children will

have a suboptimal response, others will respond well and still others will
have toxic manifestations. In 2013, after several deaths in children receiving
codeine for pain after tonsillectomy and adenoidectomy, the FDA placed a
black box warning recommending that codeine be avoided in this
population. The children who died were found to be ultrarapid metabolizers