# A breastfeeding mother of a 6-month-old infant calls the clinic. Her child just had an outpatient tonsillectomy and the surgeon prescribed codeine with acetaminophen elixir for the child and codeine for the mother. Which response by the nurse is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375165&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A breastfeeding mother of a 6-month-old infant calls the clinic. Her child just had an outpatient tonsillectomy and the surgeon prescribed codeine with acetaminophen elixir for the child and codeine for the mother. Which response by the nurse is most appropriate?

## Option

1. Halve the dose of both prescriptions and proceed.
2. Refuse to fill the mother prescription only and have the child take it as ordered.
3. Both prescriptions are unsafe; codeine has an FDA boxed warning against use in children under 12 years, after tonsillectomy/adenoidectomy in those under 18, and in breastfeeding because some people are ultra-rapid metabolizers (CYP2D6) and produce high morphine levels that can cause infant respiratory arrest; please contact the surgeon for an alternative such as acetaminophen and ibuprofen, or hydrocodone or oxycodone if an opioid is required. **✔ Correct answer**
4. It is safe; codeine is the mildest opioid and works well for both children and breastfeeding mothers.

**Correct answer: 3**

## Explanation

Codeine is a prodrug converted to morphine by the CYP2D6 enzyme. The amount produced varies dramatically by genotype: poor metabolizers get little analgesia, while ultra-rapid metabolizers convert codeine into very high morphine levels rapidly, with risk of life-threatening or fatal respiratory depression. The FDA has issued strict boxed warnings: (1) contraindicated in any child under 12 years for any indication; (2) contraindicated in any child under 18 years for postoperative pain after tonsillectomy or adenoidectomy because deaths have been reported even with usual doses; (3) contraindicated in breastfeeding women because morphine passes into breast milk and has caused infant deaths from respiratory arrest; (4) caution in adolescents 12 to 17 with obesity, sleep apnea, or severe lung disease because of overlapping respiratory risk; (5) tramadol carries an essentially identical pediatric and breastfeeding warning. Safer alternatives in these populations: acetaminophen, ibuprofen (over 6 months), or non-codeine opioids such as hydrocodone or oxycodone for short-term severe pain when needed. Halving doses, refusing only one of the two prescriptions, or accepting the prescription as written are unsafe. The nurse contacts the prescriber to communicate the boxed warning and request a change.

## In-depth explanation

Codeine for breastfeeding mom or child after tonsillectomy = boxed warning hard contraindication. Always think CYP2D6 ultra-rapid metabolizer when codeine appears in pediatric or lactation context.

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