Doctors should stop giving children codeine, according to a report by the American Academy of Pediatrics (AAP) published in the journal Pediatrics.

That’s because of its ability to suppress respiratory function, just like all opioids have the ability to do (codeine is metabolized as morphine through the liver, the study explains). Some children are more susceptible to its potentially negative effects than others, but it’s nearly impossible to figure out who (though it appears people from different ancestral groups could metabolize the drug differently). Kids who show symptoms of sleep apnea could be at higher risk for adverse respiratory effects.

Codeine is often prescribed to children due to a lack of options for administering strong pain relief or anti-cough medicine to kids, according to the researchers. In fact, in 2011, more than 800,000 children under the age of 11 were prescribed codeine, most commonly after getting their tonsils removed or visiting the dentist.

According to U.S. Food and Drug Administration (FDA) findings, 64 children in the U.S. experienced codeine-related respiratory depression between 1965 and 2015, and 24 of them died. Most were taking recommended doses at approved schedules.

The study authors pointed out that several drug-regulation bodies around the world have become skeptical of codeine’s safety in recent years. The FDA, the European Medicines Agency, Health Canada and the World Health Organization have all expressed concerns over the drug’s use in children between 2011 and 2015.  

Physicians have begun to look elsewhere for a codeine alternative in pediatric cough suppression and pain relief. But potentially promising drugs such as tramadol and tapentadol aren’t as well understood and could be dangerous in their own rights—there is not enough data to make recommendations either way, according to the researchers. Drugs dextromethorphan and dexmedetomidine need more research, the study authors said. And while drugs like acetaminophen and ibuprofen are other options, there are still concerns that NSAIDs would be a bad choice for bleeding-prone children needing post-operative pain relief.

The authors wrote, “It is clear that one of the keys to improving analgesia and reducing opioid-related adverse effects is both provider and parental education regarding the effective use of nonopioid analgesics. The answer may not lie in using more medication or different medications but merely using more effectively other options that are currently available.”

And as for codeine as a cough suppressant—the study authors warn against the drug’s regular side effects, plus call into question the usefulness of suppressing a cough in the first place.