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of substrates of cytochrome CYP2D6. The FDA further revised this black
box warning in 2017 listing age <12 years as a contraindication to codeine
administration as well as a warning against use in children aged 12 to 18
years who have obesity, obstructive sleep apnea, or severe lung disease.
Codeine should be avoided as there are other alternatives with a better safety
profile.
Oxycodone and hydrocodone are oral analgesics that are more potent than
codeine and have less associated nausea and vomiting. Oxycodone is about
one-third as potent and hydrocodone is equipotent to oral morphine as
analgesics and respiratory depressants. They retain about 60% of their
efficacy when given orally. Oxycodone is often combined with nonopioid
medications such as aspirin (Percodan), acetaminophen (Percocet, Tylox), or
ibuprofen. One study found that oxycodone was no more effective than
ibuprofen in reducing pain related to orthopedic injuries in children and
combining oxycodone with ibuprofen did not add further pain relief.
Sustained-release oxycodone should not be used for acute pain management.
Table 129.6 summarizes the advantages and disadvantages of these
analgesics for treating minor pain in children.

SUMMARY
It is common to encounter children in pain in the pediatric ED. It is often
difficult, but not impossible, to avoid inflicting pain on some children in this
setting. Management should be accomplished with nonpharmacologic
techniques such as hypnosis and distraction, along with various narcotic and
nonnarcotic analgesics, local and topical anesthetics, and sedative-hypnotics.
Other agents, such as N2 O, ketamine, dexmedetomidine, and propofol, play
a more limited role in reducing pain and distress in the pediatric patient.
Gentle restraint is needed occasionally and reassurance is of paramount
importance.
Suggested Readings and Key References
Pain in Children

Alexander J, Manno M. Underuse of analgesia in very young pediatric
patients with isolated painful injuries. Ann Emerg Med 2003;41:617–622.