Appropriateness of postoperative analgesic doses among pediatric surgical patients in a teaching hospital in Northwest Nigeria

  • Ibrahim Abayomi Ogunyinka
  • Kazeem Adeola OshikoyaEmail author
  • Ahmed Olowo-okere
  • Christopher Suiyel Lukong
  • Comfort Adamaigbo
  • Adekunle Azeez Adebayo
Original Research Article



The inappropriate and suboptimal use of analgesic drugs is a global problem, and is an area of concern with regard to the management of postoperative pain, particularly in children. Information relating to the management of postoperative pain in children is generally limited, particularly in low- and middle-income countries, and is unavailable in Northwest Nigeria.


The aim of this study was to describe the types of analgesics used postoperatively in children, evaluate the appropriateness of their doses compared with best practice, and determine risk factors for underdosing of analgesics.


We performed a retrospective chart review of patients administered analgesics after surgery between 1 January 2015 and 31 December 2017. The appropriateness of the analgesic doses was categorized as underdose, normal dose, or overdose. Simple descriptive and comparative statistical analyses were performed. Logistic regression was used to build an analgesic underdose risk-prediction model.


Overall, 194 patients received a total of 281 prescriptions for seven different analgesics, with 112 (57.7%), 77 (39.7%), and 5 (2.6%) patients receiving one, two, and three analgesics, respectively. Of the 281 analgesic prescriptions, paracetamol accounted for 148 (52.7%) and pentazocine accounted for 77 (27.4%), and there were 64 cases of overdosing (22.8%) and 89 of underdosing (31.7%). There was a statistically significant association between analgesic type and category of dose appropriateness (p < 0.001). The risk of underdosing was not predicted by any of the patient demographic characteristics or by the number of analgesics used.


Inappropriate use of analgesics (overdosing or underdosing) is common and is found across all analgesic types and all age groups. A substantial number of children were underdosed, suggesting undertreatment of pain.


Compliance with ethical standards


This work was self-sponsored and no external funding was received.

Ethical approval

The Ethics and Research Committee of the UDUTH approved this study.

Conflicts of interest

Ibrahim Abayomi Ogunyinka, Kazeem Adeola Oshikoya, Ahmed Olowo-okere, Christopher Suiyel Lukong, Comfort Adamaigbo, and Adekunle Azeez Adebayo have no relevant conflicts of interest to declare.


  1. 1.
    International Association for the Study of Pain, Subcommittee on Taxonomy. Pain terms: a list with definitions and notes on usage. Pain. 1979; 6:249–52.Google Scholar
  2. 2.
    Apfelbaum JL, Chen C, Mehta SS, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534–40.Google Scholar
  3. 3.
    Kulshrestha A, Bajwa SJS. Management of acute postoperative pain in pediatric patients. Anaesth Pain Intensive Care. 2014;18(1):101–5.Google Scholar
  4. 4.
    Segerdahl M, Warrén-Stomberg M, Rawal N, et al. Children in day surgery: clinical practice and routines. The results from a nation-wide survey. Acta Anaesthesiol Scand. 2008;52(6):821–8.Google Scholar
  5. 5.
    Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manage. 2008;13:25–32.Google Scholar
  6. 6.
    Lee JY, Jo YY. Attention to postoperative pain control in children. Korean J Anesthesiol. 2014;66(3):183–8.Google Scholar
  7. 7.
    Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Task Force on Pain in Infants, Children, and Adolescents, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108:793–7.Google Scholar
  8. 8.
    Andrews K, Fitzgerald M. Cutaneous flexion reflex in human neonates: a quantitative study of threshold and stimulus-response characteristics after single and repeated stimuli. Dev Med Child Neurol. 1999;41:696–703.Google Scholar
  9. 9.
    Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349:599–603.Google Scholar
  10. 10.
    Sharrock NE, Cazan MG, Hargett MJ, et al. Changes in mortality after total hip and knee arthroplasty over a ten-year period. Anesth Analg. 1995;80(2):242–8.Google Scholar
  11. 11.
    Katz J, Jackson M, Kavanagh BP, et al. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12:50–5.Google Scholar
  12. 12.
    Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001;87(1):62–72.Google Scholar
  13. 13.
    Boric K, Dosenovic S, Jelicic Kadic A, et al. Interventions for postoperative pain in children: an overview of systematic reviews. Paediatr Anaesth. 2017;27(9):893–904.Google Scholar
  14. 14.
    Anand KJS. Pain, plasticity, and premature birth: a prescription for permanent suffering? Nat Med. 2000;6(9):971–3.Google Scholar
  15. 15.
    Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998;152(2):147–9.Google Scholar
  16. 16.
    Walther-Larsen S, Pedersen MT, Friis SM, et al. Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals. Acta Anaesthesiol Scand. 2017;61:328–37.Google Scholar
  17. 17.
    Friedrichsdorf SJ, Postier A, Eull D, et al. Pain outcomes in a US children’s hospital: a prospective cross-sectional survey. Hosp Pediatr. 2015;5:18–26.Google Scholar
  18. 18.
    Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manag. 2008;13:25–32.Google Scholar
  19. 19.
    Groenewald CB, Rabbitts JA, Schroeder DR, et al. Prevalence of moderate-severe pain in hospitalized children. Paediatr Anaesth. 2013;22:661–8.Google Scholar
  20. 20.
    Birnie KA, Chambers CT, Fernandez CV, et al. Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag. 2014;19:198–204.Google Scholar
  21. 21.
    Shomaker K, Dutton S, Mark M. Pain prevalence and treatment patterns in a US children’s hospital. Hosp Pediatr. 2015;5:363–70.Google Scholar
  22. 22.
    Oshikoya KA, Edun B, Oreagba IA. Acute pain management in children with sickle cell anaemia during emergency admission to a teaching hospital in Lagos, Nigeria. S Afr J Child Health. 2015;9(4):119–23.Google Scholar
  23. 23.
    Faponle AF, Soyannwo OA, Ajayi IO. Postoperative pain therapy: a survey of prescribing patterns and adequacy of analgesia in Ibadan, Nigeria. Cent Afr J Med. 2001;47:70–4.Google Scholar
  24. 24.
    Morriss WW, Roques CJ. Pain management in low- and middle-income countries. BJA Educ. 2018;18(9):265e270.Google Scholar
  25. 25.
    Vittinghoff M, Lönnqvist PA, Mossetti V, et al. Postoperative pain management in children: guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth. 2018;28(6):493–506.Google Scholar
  26. 26.
    Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131–57.Google Scholar
  27. 27.
    Federal Ministry of Health, Nigeria. Guidelines for the treatment of pain in Nigeria, 2018. Available at Accessed 5 Nov 2018.
  28. 28.
    Nasir AA, Ameh EA, Abdur-Rahman LO, et al. Postoperative pain management in children: a survey of practices of pediatric surgeons in Nigeria. J Clin Sci. 2017;14:138–43.Google Scholar
  29. 29.
    Chan E, Bucevska M, Verchere C. Minor surgery procedures: a retrospective review and prospective survey in a pediatric population. Plast Surg (Oakv). 2015;23(3):189–94.Google Scholar
  30. 30.
    Rabbitts JA, Aaron RV, Fisher E, et al. Long-term pain and recovery after major pediatric surgery: a qualitative study with teens, parents, and perioperative care providers. J Pain. 2017;18(7):778–86.Google Scholar
  31. 31.
    British National Formulary for Children: 2018–2019.  London: British Medical Journal Group, Pharmaceutical Press, and Royal College of Paediatrics and Child Health; 2018.Google Scholar
  32. 32.
    Osifo OD, Aghahowa SE. Hazards of pentazocine for neonatal analgesia: a single-centre experience over 10 years. Ann Trop Paediatr. 2008;28:205–10.Google Scholar
  33. 33.
    Drugs and Diseases. Pentazocine (Discontinued). Medscape. Available at Accessed 3 Sep 2018.
  34. 34.
    Hamunen K, Olkkola KT, Seppälä T, et al. Pharmacokinetics and pharmacodynamics of pentazocine in children. Pharmacol Toxicol. 1993;73:120–3.Google Scholar
  35. 35.
    Dix P, Prosser DP, Streete P. A pharmacokinetic study of piroxicam in children. Anaesthesia. 2004;59(10):984–7.Google Scholar
  36. 36.
    Woldehaimanot TE, Eshetie TC, Kerie MW. Postoperative pain management among surgically treated patients in an Ethiopian hospital. PLoS One. 2014;9(7):e102835.Google Scholar
  37. 37.
    Salaudeen GO, Afuwape OO, Eyelade OR, et al. Effectiveness of postoperative analgesia in the management of acute pain in day-case surgeries. Ann Afr Med. 2018;17:140–4.Google Scholar
  38. 38.
    Baum C, Hsu JP, Nelson RC. The impact of the addition of naloxone on the use and abuse of pentazocine. Public Health Rep. 1987;102:426–9.Google Scholar
  39. 39.
    Ray AD, Gupta M. Clinical trial of pentazocine as analgesic in paediatric cases. J Indian Med Assoc. 1994;92:77–9.Google Scholar
  40. 40.
    Pandey N, Jain A, Mishra A. Comparative efficacies of pentazocine, fentanyl, tramadol and ketorolac: an experimental study using ketorolac as a standard drug. Riga: Lambert Academic Publishing; 2013.Google Scholar
  41. 41.
    Size M, Soyannwo OA, Justins DM. Pain management in developing countries. Anaesthesia. 2007;62(Suppl 1):38–43.Google Scholar
  42. 42.
    Matthews ML. Management of postoperative pain in Children. US Pharm. 2008;33(3):HS10–HS15.Google Scholar
  43. 43.
    Riordan M, Rylance G, Berry K. Poisoning in children 2: painkillers. Arch Dis Child. 2002;87(5):397–9.Google Scholar
  44. 44.
    Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287–98.Google Scholar
  45. 45.
    Brandsborg B, Dueholm M, Nikolajsen L, et al. A prospective study of risk factors for pain persisting 4 months after hysterectomy. Clin J Pain. 2009;25(4):263–8.Google Scholar
  46. 46.
    Thomazeau J, Rouquette A, Martinez V, et al. Predictive factors of chronic post-surgical pain at 6 months following 46 knee replacement: influence of postoperative pain trajectory and genetics. Pain Physician. 2016;19(5):E729–41.Google Scholar
  47. 47.
    Niraj G, Kelkar A, Kaushik V, et al. Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center. J Clin Anesth. 2017;36:174–7.Google Scholar
  48. 48.
    Benini F, Castagno E, Barbi E, et al. Multicentre emergency department study found that paracetamol and ibuprofen were inappropriately used in 83% and 63% of paediatric cases. Acta Paediatr. 2018;107(10):1766–74.Google Scholar
  49. 49.
    Mezdrzycka-Dazbrowska W, Dazbrowski S, Basinski A. Problems and barriers in ensuring effective acute and postoperative pain management: an international perspective. Adv Clin Exp Med. 2015;24:905–10.Google Scholar
  50. 50.
    Rabbitts JA, Groenewald CB, Rasanen J. Geographic differences in perioperative opioid administration in children. Pediatr Anesth. 2012;22:676–81.Google Scholar
  51. 51.
    Hines RN. Ontogeny of human hepatic cytochromes P450. J Biochem Mol Toxicol. 2007;21(4):169–75.Google Scholar
  52. 52.
    Lu H, Rosenbaum S. Developmental pharmacokinetics in pediatric populations. J Pediatr Pharmacol Ther. 2014;19(4):262–76.Google Scholar
  53. 53.
    Adudu OP, Isa I, Longway FO. Trends in intraoperative pain relief in anesthesized Nigerian pediatric patients: implications for a developing economy. Ann Afr Med. 2011;10(3):233–7.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Ibrahim Abayomi Ogunyinka
    • 1
  • Kazeem Adeola Oshikoya
    • 2
    Email author
  • Ahmed Olowo-okere
    • 3
  • Christopher Suiyel Lukong
    • 4
  • Comfort Adamaigbo
    • 1
    • 5
  • Adekunle Azeez Adebayo
    • 6
  1. 1.Department of Clinical Pharmacy and Pharmacy PracticeUsmanu Danfodiyo UniversitySokotoNigeria
  2. 2.Department of Pharmacology, Therapeutics and ToxicologyLagos State University College of MedicineIkejaNigeria
  3. 3.Department of Pharmaceutics and Pharmaceutical MicrobiologyUsmanu Danfodiyo UniversitySokotoNigeria
  4. 4.Paediatric Surgery Unit, Department of PaediatricsUsmanu Danfodiyo University Teaching HospitalSokotoNigeria
  5. 5.Department of PharmacyUniversity of Benin Teaching HospitalBeninNigeria
  6. 6.Department of AnaesthesiaLagos State University College of MedicineIkejaNigeria

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