***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Corticosteroids are commonly given to children undergoing tonsillectomy to reduce postoperative nausea and vomiting ; however , they might increase the risk of perioperative and postoperative hemorrhage . OBJECTIVE To determine the effect of dexamethasone on bleeding following tonsillectomy in children . DESIGN , SETTING , AND PATIENTS A multicenter , prospect i ve , r and omized , double-blind , placebo-controlled study at 2 tertiary medical centers of 314 children aged 3 to 18 years undergoing tonsillectomy without a history of bleeding disorder or recent corticosteroid medication use and conducted between July 15 , 2010 , and December 20 , 2011 , with 14-day follow-up . We tested the hypothesis that dexamethasone would not result in 5 % more bleeding events than placebo using a noninferiority statistical design . INTERVENTION A single perioperative dose of dexamethasone ( 0.5 mg/kg ; maximum dose , 20 mg ) , with an equivalent volume of 0.9 % saline administered to the placebo group . MAIN OUTCOME MEASURES Rate and severity of posttonsillectomy hemorrhage in the 14-day postoperative period using a bleeding severity scale ( level I , self-reported or parent-reported postoperative bleeding ; level II , required inpatient admission for postoperative bleeding ; or level III , required reoperation to control postoperative bleeding ) . RESULTS One hundred fifty-seven children ( median [ interquartile range ] age , 6 [ 4 - 8 ] years ) were r and omized into each study group , with 17 patients ( 10.8 % ) in the dexamethasone group and 13 patients ( 8.2 % ) in the placebo group reporting bleeding events . In an intention-to-treat analysis , the rates of level I bleeding were 7.0 % ( n = 11 ) in the dexamethasone group and 4.5 % ( n = 7 ) in the placebo group ( difference , 2.6 % ; upper limit 97.5 % CI , 7.7 % ; P for noninferiority = .17 ) ; rates of level II bleeding were 1.9 % ( n = 3 ) and 3.2 % ( n = 5 ) , respectively ( difference , -1.3 % ; upper limit 97.5 % CI , 2.2 % ; P for noninferiority < .001 ) ; and rates of level III bleeding were 1.9 % ( n = 3 ) and 0.6 % ( n = 1 ) , respectively ( difference , 1.3 % ; upper limit 97.5 % CI , 3.8 % ; P for noninferiority = .002 ) . CONCLUSIONS Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with excessive , clinical ly significant level II or III bleeding events based on not having crossed the noninferior threshold of 5 % . Increased subjective ( level I ) bleeding events caused by dexamethasone could not be excluded because the noninferiority threshold was crossed . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01415583 As part of a r and omized clinical trial that compared three different analgesic dosing regimens ( Sutters et al. , 2004 ) , the purpose of this study , in children who underwent tonsillectomy , was to determine whether around-the-clock ( ATC ) dosing of acetaminophen with codeine , compared with as-needed ( PRN ) dosing , increased the frequency of moderate-to-severe opioid-related side effects ( i.e. , daytime sedation , lightheadedness , nightmares , nausea , vomiting , and constipation ) in the first 3 days after surgery . Because no differences were found in pain intensity scores and in the amount of analgesic administered between the two ATC groups ( i.e. , with and without coaching ) , for these analyses , the two groups were combined ( n = 52 ) and compared with the PRN group ( n = 28 ) . Each side effect was recoded into a dichotomous response ( i.e. , 0 = did not have symptoms or had slight symptoms ; 1 = symptoms that were moderate , severe , or very severe ) to provide an adequate sample size in each cell for the statistical analyses . No differences were found in the frequency of moderate-to-severe side effects between the ATC and PRN groups at any of the postoperative assessment s. The number of children who reported moderate-to-severe daytime sedation decreased over time in both the PRN ( p = .02 ) and ATC groups ( p = .01 ) . Children in the ATC groups reported a statistically significant decrease over time in vomiting ( p = .001 ) and feeling lightheaded or dizzy ( p = .003 ) , and a significant increase in constipation ( p = .018 ) . Except for daytime sedation , changes , over time , in the frequency of moderate-to-severe side effects were not observed in the PRN group Objective The search for an effective post-tonsillectomy analgesic has been disappointing . This study tests the hypothesis that rofecoxib improves pain scores in children for 72 hours post-tonsillectomy when compared to hydrocodone with acetaminophen elixir . Study Design Prospect i ve , r and omized , double-blind , active comparison of postoperatively administered rofecoxib or hydrocodone with acetaminophen in 60 healthy children scheduled for elective tonsillectomy . Subjects and Methods Sixty ASA I and II children scheduled for elective tonsillectomy were enrolled to receive either rofecoxib or hydrocodone with acetaminophen , commencing at discharge from day surgery . Active and passive pain scores and side effects were assessed for 3 days . Results and Conclusion Rofecoxib significantly reduced active pain scores at all time intervals after 6 hours following surgery when compared to hydrocodone with acetaminophen without detectable differences in adverse effects . This difference was not apparent in passive pain scores . A review of analgesic strategies is presented . Study results and review of the literature support the development of pediatric formulations of NSAIDs with greater COX-2 selectivity to improve postsurgical pain relief for children & NA ; The purpose of this study was to determine whether around‐the‐clock ( i.e. ATC ) dosing of acetaminophen with codeine , with or without nurse coaching , compared to st and ard care with as needed ( i.e. PRN ) dosing : reduced children 's reports of pain intensity with and without swallowing ; increased pain relief , and increased analgesic consumption . Eighty children , 6–15 years , undergoing tonsillectomy were r and omized to one of three treatment groups to receive acetaminophen with codeine ( 120 mg/12 mg/5 ml ) for 3 days after surgery : PRN group (N=28)—every 4 h PRN , with st and ard postoperative instructions , without nurse coaching ; ATC group (N=26)—every 4 h ATC , with st and ard postoperative instructions , without nurse coaching ; and ATC+coaching group (N=26)—every 4 h ATC , with st and ard postoperative instructions and nurse coaching . In all three groups , significant decreases were found over time in pain intensity scores at rest ( P<0.0001 ) and with swallowing ( P<0.0001 ) . However , mean pain scores at rest and with swallowing were > 3/10 until the fourth evening after tonsillectomy . Children in both ATC dosing groups received significantly greater amounts of acetaminophen and codeine  than children in the PRN group ( P<0.003 ) . No significant differences were found in the amount of analgesic administered between the ATC dosing groups with and without nurse coaching . No significant differences were found in the amount of nausea and vomiting among the three groups . Scheduled dosing of acetaminophen with codeine did not provide adequate pain relief for children following tonsillectomy . Nurse coaching does not increase parent 's adherence with an ATC dosing schedule Objectives To determine the effectiveness of around-the-clock ( ATC ) analgesic administration , with or without nurse coaching , compared with st and ard care with as needed ( PRN ) dosing in children undergoing outpatient tonsillectomy . Methods Children 6 to 15 years of age were r and omized to receive acetaminophen and hydrocodone ( 167 mg/2.5 mg/5 mL ) for 3 days after surgery : Group A (N=39)—every 4 hours PRN , with st and ard postoperative instructions ; Group B (N=34)—every 4 hours ATC , with st and ard postoperative instructions , without nurse coaching ; and Group C (N=40)—every 4 hours ATC , with st and ard postoperative instructions , with coaching .  Parents completed a medication log , and recorded the presence and severity of opioid-related adverse effects and children 's reports of pain intensity using a 0 to 10 numeric rating scale . Results No differences were found in analgesic administration or pain intensity scores between the 2 ATC groups . Therefore , they were combined for comparison with the PRN group . Children in the ATC group received more analgesic than those in the PRN group ( P<0.0001 ) . Children in the PRN group had higher pain intensity scores compared to children in the ATC group , both at rest ( P=0.017 ) and with swallowing ( P=0.017 ) . Pain intensity scores for both groups were higher in the morning compared with the evening ( P<0.0001 ) . With the exception of constipation , scheduled analgesic dosing did not increase the frequency or severity of opioid-related adverse effects . Discussion Scheduled dosing of acetaminophen and hydrocodone is more effective than PRN dosing in reducing pain intensity in children after tonsillectomy . Nurse coaching does not impact parent 's adherence to ATC dosing & NA ; Chronic pain is associated with a range of other problems , including disturbed sleep , depression , anxiety , fatigue , reduced quality of life , and an inability to work or socialise . We investigated whether good symptom control of pain ( using definitions of moderate and substantial benefit ) is associated with improvement in other symptoms . Individual patient data from four r and omised trials in fibromyalgia ( 2575 patients ) lasting 8–14 weeks were used to calculate  percentage  pain reduction  for each completing patient ( 1858 ) , divided into one of five groups according to pain reduction , irrespective of treatment : substantial benefit – ≥50 % pain reduction ; moderate – 30 % to < 50 % ; minimal – 15 % to < 30 % ; marginal – 0 % to < 15 % ; worse – < 0 % ( increased pain intensity ) . We then calculated change from baseline to end of trial for measures of fatigue , function , sleep , depression , anxiety , ability to work , general health status , and quality ‐adjusted life year ( QALY ) gain over a 12‐month period . Substantial and moderate pain intensity reductions were associated with statistically significant reduction from baseline by end of trial in all measures , with values by trial end at or approaching normative values . Substantial pain intensity reduction result ed in 0.11 QALYs gained , and moderate pain intensity reduction in 0.07 QALYs gained over a 12‐month period . Substantial and moderate pain intensity reduction predicts broad beneficial outcomes and improved quality of life that do not occur without pain relief . Pain intensity reduction is a simple and effective predictor of which patients should continue treatment , and which should discontinue and try an alternative therapy CONTEXT Dexamethasone is widely used to prevent postoperative nausea and vomiting ( PONV ) in pediatric tonsillectomy . OBJECTIVE To assess whether dexamethasone dose-dependently reduces the risk of PONV at 24 hours after tonsillectomy . DESIGN , SETTING , AND PATIENTS R and omized placebo-controlled trial conducted among 215 children undergoing elective tonsillectomy at a major public teaching hospital in Switzerl and from February 2005 to December 2007 . INTERVENTIONS Children were r and omly assigned to receive dexamethasone ( 0.05 , 0.15 , or 0.5 mg/kg ) or placebo intravenously after induction of anesthesia . Acetaminophen-codeine and ibuprofen were given as postoperative analgesia . Follow-up continued until the 10th postoperative day . MAIN OUTCOME MEASURES The primary end point was prevention of PONV at 24 hours ; secondary end points were decrease in the need for ibuprofen at 24 hours and evaluation of adverse effects . RESULTS At 24 hours , 24 of 54 participants who received placebo ( 44 % ; 95 % confidence interval [ CI ] , 31%-59 % ) had experienced PONV compared with 20 of 53 ( 38 % ; 95 % CI , 25%-52 % ) , 13 of 54 ( 24 % ; 95 % CI , 13%-38 % ) , and 6 of 52 ( 12 % ; 95 % CI , 4%-23 % ) who received dexamethasone at 0.05 , 0.15 , and 0.5 mg/kg , respectively ( P<.001 for linear trend ) . Children who received dexamethasone received significantly less ibuprofen . There were 26 postoperative bleeding episodes in 22 children . Two of 53 ( 4 % ; 95 % CI , 0.5%-13 % ) children who received placebo had bleeding compared with 6 
    Output:
    
Mean pain intensity scores decreased over time , as did medication use .
However , children were still reporting pain at the final assessment , suggesting that no administration schedule provided adequate analgesia .
The studies reported adverse events that may have been related to the study medication , such as nausea and vomiting , and constipation , but no statistically significant differences were noted between the groups .
There was limited evidence available to draw any conclusions about the efficacy of PRN versus ATC analgesic administration for the management of postoperative pain in children