Ibuprofen provides analgesia equivalent to acetaminophen-codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial

Comparison of analgesic efficacy of ibuprofen and dexketoprofen in pain management of long bone fractures: a prospective, randomized, double-blind study

INTRODUCTION

Long bone fractures (LBF) often cause severe pain, impacting patients' quality of life. This prospective, randomized, double-blind study aimed to compare the analgesic efficacy of dexketoprofen (Dex) and ibuprofen (Ibu) in LBF patients in the emergency department.

METHODS

Conducted between August 10, 2023, and January 17, 2024, the study included 100 eligible patients randomized into Dex and Ibu groups. Visual analog scale (VAS) scores were measured at baseline and at 30, 60, and 120 min. DeltaVAS (ΔVAS) values and ΔVAS percentages (ΔVAS%) were calculated. Primary endpoints were ΔVAS scores (ΔVAS 30-60-120) and ΔVAS% for comparative analysis.

RESULTS

Statistical analysis showed no significant difference in ΔVAS30 (p = 0.359). However, ΔVAS60 exhibited a significant difference (p = 0.027), as did ΔVAS120 (p = < 0.001). ΔVAS%30 showed no significance (p = 0.224), but ΔVAS%60 and ΔVAS%120 were clinically and statistically significant (p = 0.017 and p = < 0.001, respectively).

CONCLUSION

Ibuprofen 800 mg demonstrated superior analgesic efficacy at 60 and 120 min compared to Dex in long bone fractures. These findings suggest ibuprofen's potential as an effective pain management option in emergency departments.

Oral analgesic for musculoskeletal injuries in children: A systematic review and network meta-analysis

OBJECTIVE

Pain in pediatric musculoskeletal (MSK) injuries can lead to increased anxiety, fear, and avoidance of medical care, making analgesic management critical. Therefore, we evaluated analgesic efficacy and adverse effects to select the optimal analgesic agent in pediatric patients with MSK injuries.

METHODS

Four databases were searched from inception to March 2023 for peer-reviewed, open randomized controlled trials (RCTs). Inclusion criteria were: (1) trials with RCT design, (2) children aged 1 month-18 years with MSK injury, (3) outpatient setting, (4) interventions and control, (5) primary outcome of pain score at 60 and 120 min and secondary outcome of adverse effects, and (6) full-text and peer-reviewed articles. Two reviewers screened, extracted data, and assessed the risk of bias. A frequentist random-effects network meta-analysis (NMA) was performed. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach.

RESULTS

We included eight trials comprising 1645 children. Ibuprofen was significantly associated with pain reduction at 120 min, compared with acetaminophen (SMD 0.31 [95% CI 0.11-0.51]; moderate certainty) and opioids (SMD 0.34 [95% CI 0.20-0.48]; moderate certainty). Compared with opioids alone, ibuprofen-opioid combination was significantly associated with pain reduction at 120 min (SMD 0.19 [95% CI 0.03-0.35]). No significant differences were found in pain interventions at 60 min. Ibuprofen had statistically fewer adverse events than opioids (RR, 0.54 [95% CI 0.33-0.90]; moderate certainty) and ibuprofen with opioids (RR 0.47 [95% CI 0.25-0.89]; moderate certainty). In terms of limitations, the eight RCTs included had relatively small sample sizes; only two were high-quality RCTs.

CONCLUSIONS

Our NMA found ibuprofen to be the most effective and least adverse analgesic in pediatric patients with MSK injuries.

Oral ibuprofen versus oral ketorolac for children with moderate and severe acute traumatic pain: a randomized comparative study

This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4-6) and severe (NRS 7-10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0-4.0) for ibuprofen and 1.0 (IQR 1.0-3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623.

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.

AIM

To assess whether NSAID exposure is a risk factor for fracture nonunion in children.

METHODS

We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.

RESULTS

A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.

CONCLUSION

This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Background

Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria.

Methods

Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients.

Results

Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed.

Conclusion

In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Influence of ketamine versus fentanyl on pain relief for pediatric orthopedic emergencies: A meta-analysis of randomized controlled studies

INTRODUCTION

The comparison of ketamine with fentanyl for pain control of pediatric orthopedic emergencies remains controversial. We conduct a systematic review and meta-analysis to explore the influence of ketamine versus fentanyl on pain management among pediatric orthopedic emergencies.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2020 for randomized controlled trials assessing the effect of ketamine versus fentanyl on pain management for pediatric orthopedic emergencies.

RESULTS

Five randomized controlled trials are included in the meta-analysis. Overall, compared with fentanyl for pediatric orthopedic emergencies, ketamine led to similar change in pain scores at 15 to 20 minutes (standard mean difference = -0.05; 95% confidence interval [CI] = -0.38 to 0.28; P = .77) and 30 minutes (standard mean difference = 0.11; 95% CI = -0.20 to 0.42; P = .49), as well as rescue analgesia (RR = 0.90; 95% CI = 0.54 to 1.51; P = .69), but revealed the increase in nausea/vomiting (RR = 2.65; 95% CI = 1.13 to 6.18; P = .02) and dizziness (RR = 3.83; 95% CI = 1.38 to 10.60; P = .01).

CONCLUSIONS

Ketamine may be similar to fentanyl in terms of the analgesic efficacy for pediatric orthopedic emergencies.

[Volatile anesthetics for prehospital analgesia by paramedics-An overview]

Treatment of acute pain is a central task in emergency medicine. Yet, prehospital pain relief is often insufficient or delayed since the administration of potent intravenous analgesic drugs (such as opioids) is mostly limited to physicians due to legal restrictions or training deficiencies in Germany and Austria. Frequently, prehospitally operating emergency physicians have to be demanded later for anguished patients limiting disposability of physicians for patients who are in a potentially life-threatening condition. Thus, inhaled analgesics could represent an interesting alternative.A mixture of 50% nitrous oxide and 50% oxygen (N₂O, Livopan®) has been available in Germany and Austria for several years; however, prehospital use of Livopan has been merely realized and only one trial has been published. In addition, methoxyflurane (Penthrop®), a volatile anesthetic from the group of the dialkyl esters (2-dichloro-1:1-difluoroethyl-methyl-ester) was approved for the treatment of moderate to severe pain following trauma in adults in many European countries in recent years and was brought onto the market in Austria in 2018. Several in-hospital trials demonstrated high effectiveness in this setting.This article discusses the effects and prehospital areas of application of both substances in the light of the existing literature. We provide a narrative overview of the current study situation and report on a recently performed prehospital application study of methoxyflurane (Penthrop®) from Austria.The need for pressurized gas cylinders for the use of N₂O represents a certain limitation in prehospital use. Furthermore, in certain injuries such as of the inner ear or a pneumothorax N₂O should not be used and the risk of diffusion hypoxemia has to be addressed. Users should be particularly careful and limit the use in alcohol addicts and vegans. The advances of N₂O are that it is odorless, has a fast onset of action, the usability in patients over 1 month old and has stabilizing effects on the circulation. Plenty of literature regarding prehospital as well as in-hospital use of nitrous oxide in emergency, obstetric and pediatric settings show its effectiveness as a single drug as well as in combination with other analgesics, such as paracetamol or various opioids. Its long tradition in Anglo-American countries is also based on its safety and low rate of side effects.Methoxyflurane is easier to store and handle and may be slightly more effective in severe pain after trauma; however, its approval is restricted to adults, where it works significantly better with increasing age, based on the declining minimal alveolar concentration (MAC) of all inhaled anesthetics with increasing age. Furthermore, decades of use of inhaled methoxyflurane in Australia have shown the drug is effective, safe and low in side effects and has a broad spectrum of applications. The use of methoxyflurane is limited in patients with severe hepatic or renal insufficiency and the characteristic odor has been described as unpleasant by some patients. In Europe, three large in-hospital trials showed strong pain relief in trauma patients, even comparable to opioids.Overall, based on the current evidence, the use of nitrous oxide and even more of methoxyflurane may be recommended also for prehospital use by skilled paramedics.

Need for pharmacological analgesia after cast immobilisation in children with bone fractures: an observational cross-sectional study

BACKGROUND

Bone fractures are a common reason for children and adolescents to seek evaluation in the ED. Little is known about the pain experienced after cast immobilisation and discharge from the ED and its optimal management. We aimed to investigate the administration of pharmacological analgesia in the first days after cast immobilisation and to identify possible influencing variables.

METHODS

A prospective observational cross-sectional study was conducted at the ED of the children's hospital, Institute for Maternal and Child Health of Trieste, Italy, from October 2019 to June 2020. Patients aged 0-17 years with bone fractures were included. The primary outcome was the administration of analgesia during the 10 days following discharge, while secondary outcomes were the associated variables, including age, gender, fracture type and location, the mean limitation in usual activities and the frequency of re-evaluation at the ED for pain. Data were recorded through a questionnaire, completed by caregivers and collected by the researchers mainly through a telephone interview. The primary endpoint was evaluated as the ratio between the number of children who took at least one analgesic dose and the total enrolled children, while Χ² or Fisher's exact tests were used to assess secondary outcomes.

RESULTS

During the study period, 213 patients, mean age 10 years (IQR: 8-13), were enrolled. Among them, 137 (64.3%) did not take any analgesic during follow-up. Among children who were administered analgesia, 22 (28.9%) received it only on the first day, and 47 (61.8%) for less than 5 days. One hundred and sixty one patients (75.6%) did not report any limitation in usual activities because of pain. The administration of analgesia was not related to the child's age, gender or fracture site. Displaced fractures were associated with significantly more frequent analgesia being taken (OR 5.5, 95% CI 1.4 to 21.0).

CONCLUSION

Although some studies recommend scheduled analgesic treatment after discharge for bone fractures, this study would suggest analgesia on demand in children with non-displaced fractures, limiting scheduled analgesia to children with displaced fractures.

A randomized controlled trial of oxycodone/acetaminophen versus acetaminophen alone for emergency department patients with musculoskeletal pain refractory to ibuprofen

BACKGROUND

Use of oral opioids does not result in more pain relief than nonopioid alternatives when administered to patients as first-line treatment for acute musculoskeletal pain. This study compared the efficacy of oxycodone/acetaminophen to that of acetaminophen alone as second-line treatment for patients with acute musculoskeletal pain who were administered prescription-strength ibuprofen and reported insufficient relief 1 h later.

METHODS

A randomized, double-blind study was conducted in two urban emergency departments. Opioid-naïve patients ≥ 18 years with an acute musculoskeletal injury were administered ibuprofen 600 mg as part of the study protocol. Those who reported insufficient relief 1 h later were randomized (1:1 ratio) to oxycodone 10 mg/acetaminophen 650 mg or acetaminophen 650 mg. The primary outcome was improvement in 0 to 10 pain scale between randomization and 2 h later. We also assessed medication-associated adverse events. A sample size calculation, built around a minimum clinically important difference of 1.3 units, determined the need for 154 patients.

RESULTS

We screened 924 patients and enrolled 393. All 393 received ibuprofen. A total of 159 (40%) patients reported inadequate relief after 1 h had elapsed. A total of 154 of these were randomized, 77 to oxycodone/acetaminophen and 77 to acetaminophen. Baseline characteristics were comparable. Among patients randomized to oxycodone/acetaminophen, mean (±SD) improvement in 0 to 10 pain scale was 4.0 (±2.6) versus 2.9 (±2.4) in the acetaminophen arm. The 95% confidence interval (CI) for the mean difference of 1.1 was 0.3 to 1.9. Among patients who received oxycodone/acetaminophen, 26 of 76 (34%) reported any medication-related adverse event versus seven of 74 (9%) participants who received acetaminophen. The 95% CI for the between-group difference of 25% was 12% to 37%).

CONCLUSION

Among patients with acute musculoskeletal pain refractory to oral ibuprofen, oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen, but this was associated with more medication-related adverse events.

Efficacy and safety of ibuprofen in children with musculoskeletal injuries: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the analgesic efficacy and safety of ibuprofen in children with musculoskeletal injuries.

METHODS

PubMed, EMBASE, Web of science, and the Cochrane Central register of Controlled Trials (CENTRAL) were systematically searched to identify eligible randomized controlled trials (RCTs) that compared ibuprofen with other analgesics for pain relief in children with musculoskeletal injuries. Primary outcomes included change of visual analog scale (VAS) scores from baseline to post-medication, the proportion of patients achieving adequate analgesia, and the proportion of patients requiring additional analgesia. Secondary outcome was the incidence of adverse effects. Data analysis was performed using RevMan 5.3 software.

RESULTS

Five RCTs involving 1034 patients were included in this meta-analysis. Compared to the control group, change of VAS scores was greater in ibuprofen group at 60 min (standardized mean difference [SMD] = 0.28; 95% confidence intervals [CI], 0 to 0.57; P = .05), 90 min (SMD = 0.38; 95% CI, 0.17 to 0.59; P = .0005), and 120 min (SMD = 0.4; 95% CI, 0.23 to 0.57; P < .00001) after treatment. No difference was found in the change of VAS scores at 30 min (SMD = 0.07; 95% CI, -0.08 to 0.22; P = .36) after treatment. The proportion of patients who received adequate analgesia was higher in the ibuprofen group (risk ratios [RR] = 1.36; 95% CI, 1.20 to 1.56; P < .00001). The proportion of patients that required additional analgesia was lower in the ibuprofen group (RR = 0.7; 95% CI, 0.53 to 0.92; P = .01). The incidence of total adverse effects was lower in the ibuprofen group (RR = 0.59; 95% CI, 0.45 to 0.79; P = .0002).

CONCLUSIONS

Ibuprofen provides a better pain relief with a lower incidence of adverse effects in children with musculoskeletal injuries as compared to other analgesics.

PROSPERO REGISTRATION NUMBER

CRD42021231975.

Pain Management in Children: NSAID Use in the Perioperative and Emergency Department Settings

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used for pediatric pain management in the emergency setting and postoperatively. This narrative literature review evaluates pain relief, opioid requirements, and adverse effects associated with NSAID use. A PubMed search was conducted to identify randomized controlled trials evaluating the use of conventional systemic NSAIDs as pain management for children in the perioperative or emergency department (traumatic injury) setting. Trials of cyclooxygenase-2 inhibitors ("coxibs") were excluded. Search results included studies of ibuprofen (n = 12), ketoprofen (n = 5), ketorolac (n = 6), and diclofenac (n = 4). NSAIDs reduced the opioid requirement in 10 of 13 studies in which this outcome was measured. NSAID use did not compromise pain relief; NSAIDs provided improved or similar pain scores compared with opioids (or other control) in 24 of 27 studies. Adverse event frequencies were reported in 26 studies; adverse event frequencies with NSAIDs were lower than with opioids (or other control) in three of 26 studies, similar in 21 of 26 studies, and more frequent in two of 26 studies. Perioperative and emergency department use of NSAIDs may reduce opioid requirements while maintaining pain control, with similar or reduced frequencies of opioid-associated adverse events.

Reducing Opioid Doses Prescribed From a Pediatric Emergency Department

BACKGROUND

Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months.

METHODS

Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time.

RESULTS

Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back.

CONCLUSIONS

We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.

[Analgesia for trauma patients in emergency medicine]

Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to <5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.

Efficacy of ibuprofen in musculoskeletal post-traumatic pain in children: A systematic review

Musculoskeletal (MSK) injuries are one of the most frequent reason for pain-related evaluation in the emergency department (ED) in children. There is still no consensus as to what constitutes the best analgesic for MSK pain in children. However, ibuprofen is reported to be the most commonly prescribed analgesic and is considered the standard first-line treatment for MSK injury pain in children, even if it is argued that it provides inadequate relief for many patients. The purpose of this study was to review the most recent literature to assess the efficacy of ibuprofen for pain relief in MSK injuries in children evaluated in the ED. We performed a systematic review of randomized controlled trials on pharmacological interventions in children and adolescents under 19 years of age with MSK injuries according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome was the risk ratio for successful reduction in pain scores. Six studies met the inclusion criteria and provided data on 1028 children. A meta-analysis was not performed since studies were not comparable due to the different analgesic treatment used. No significant difference in term of main pain score reduction between all the analgesics used in the included studies was noted. Patients who received oral opioids had side effects more frequently when compared to children who received ibuprofen. The combination of effect on pain relief and tolerability would suggest ibuprofen as the initial drug of choice in providing relief from mild-to-moderate MSK pain in children in the ED. The results obtained in this review and current research suggest that there’s no straightforward statistically significant evidence of the optimal analgesic agent to be used. However, ibuprofen may be preferable as the initial drug of choice in providing relief from MSK pain due to the favorable combination of effectiveness and safety profile. In fact, despite the non-significant pain reduction as compared to children who received opioids, there are less side effect associated to ibuprofen within studies. The wide range of primary outcomes measured in respect of pain scores and timing of recorded measures warrants a future standardization of study designs.

Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis

OBJECTIVE

Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain.

METHOD

This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity.

RESULTS

Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min.

CONCLUSION

NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.

Non-steroidal or opioid analgesia use for children with musculoskeletal injuries (the No OUCH study): statistical analysis plan

Background

Pediatric musculoskeletal injuries cause moderate to severe pain, which should ideally be addressed upon arrival to the emergency department (ED). Despite extensive research in ED-based pediatric pain treatment, recent studies confirm that pain management in this setting remains suboptimal. The No OUCH study consist of two complementary, randomized, placebo-controlled trials that will run simultaneously for patients presenting to the ED with an acute limb injury and a self-reported pain score of at least 5/10, measured via a verbal numerical rating scale (vNRS). Caregiver/parent choice will determine whether patients are randomized to the two-arm or three-arm trial. In the two-arm trial, patients will be randomized to receive either ibuprofen alone or ibuprofen in combination with acetaminophen. In the three-arm trial, patients can also be randomized to a third arm where they would receive ibuprofen in combination with hydromorphone. This article details the statistical analysis plan for the No OUCH study and was submitted before the trial outcomes were available for analysis.

Methods/design

The primary endpoint of the No OUCH study is self-reported pain at 60 min, recorded using a vNRS. The principal safety outcome is the presence of any adverse event related to study drug administration. Secondary effectiveness endpoints include pain measurements using the Faces Pain Scale-Revised and the visual analog scale, time to effective analgesia, requirement of a rescue analgesic, missed fractures, and observed pain reduction using different definitions of successful analgesia. Secondary safety outcomes include sedation measured using the Ramsay Sedation Score and serious adverse events. Finally, the No OUCH study investigates the reasons given by the caregiver for selecting the two-arm (Non-Opioid) or three-arm (Opioid) trial, caregiver satisfaction, physician preferences for analgesics, and caregiver comfort with at-home pain management.

Discussion

The No OUCH study will inform the relative effectiveness of acetaminophen and hydromorphone, in combination with ibuprofen, and ibuprofen alone as analgesic agents for patients presenting to the ED with an acute musculoskeletal injury. The data from these trials will be analyzed in accordance with this statistical analysis plan. This will reduce the risk of producing data-driven results and bias in our reported outcomes.

Trial registration

ClinicalTrials.gov NCT03767933. Registered on December 7, 2018.

Study protocol for two complementary trials of non-steroidal or opioid analgesia use for children aged 6 to 17 years with musculoskeletal injuries (the No OUCH study)

INTRODUCTION

Musculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children's pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference.

METHODS AND ANALYSIS

Using a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant.

TRIAL REGISTRATION NUMBER

NCT03767933, first registered on 07 December 2018.

Emergency Department Revisits Due to Cast-Related Pain in Children with Forearm Fractures

Background

Cast immobilization is the primary treatment for children with forearm fractures. After emergency department (ED) discharge, some patients develop cast-related pain (CstRP) around the distal part of the upper extremity. We examined variables associated with ED revisits due to CstRP in children with forearm fractures.

Methods

A retrospective cohort study of all children who were treated with cast immobilization for forearm fracture over a 7-year period was conducted. Patient demographics, fracture location, casting method (below elbow/above elbow), first visit pain scores, treatment with fracture reduction, and revisit data were collected. Multivariate regression was used to identify predictors of revisits due to CstRP within 72 hrs post-discharge.

Results

A total of 2307 children were treated with cast immobilization; 95 (4.2%) revisited the ED due to CstRP (median pain score 7, interquartile range 5–9). No patient had neurovascular compromise or required surgery or re-reduction. Fifty-eight (61.1%) patients were treated with cast splitting, 10 (10.5%) with trimming, and 27 (28.4%) with cast replacement. Variables on first visit that were associated with increased odds for ED revisit included treatment with fracture reduction (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.58–3.36) and a median pain score of 6 or more upon ED presentation (OR 1.57; 95% CI 1.32–2.13).

Discussion

A small number of children with forearm fractures revisited the ED due to CstRP. Study findings suggest that being treated with closed reduction and having a pain score ≥ 6 on the first visit were associated with ED revisit due to CstRP.

The use of opioids in low acuity pediatric trauma patients

OBJECTIVE

To describe temporal trends and factors associated with opioid administration among children discharged from the emergency department (ED) after a trauma visit.

METHODS

This was a cross-sectional study of ED visits for children <19 years old who received a trauma-related diagnosis and were discharged from the ED. Data were obtained from the National Hospital Ambulatory Medical Care Survey 2006-2015.

OUTCOME MEASURES

Administration of an opioid medication either during the ED visit or as a discharge prescription. Survey-adjusted regression analyses were used to determine the probability of a patient receiving an opioid medication.

RESULTS

During the study period, there were 19,241 pediatric trauma visits discharged from the ED, of which 14% were associated with an opioid. Opioid administration decreased by nearly 30% during the study period (p<0.001 for trend). In multivariable analysis, patient factors associated with opioid administration were adolescent age, evening visit, region of the country, and severe pain score. The diagnosis associated with the most opioids was ankle sprain and the diagnosis with the highest rate of opioid administration was radius fracture. The most common opioid administered to children under 12 years of age was acetaminophen-codeine.

CONCLUSIONS

Opioid administration appears to be decreasing among pediatric patients presenting to the ED with trauma, but a high number of children continue to be exposed to opioids every year. Further education on opioid sparing pain management strategies may be warranted to decrease opioid exposure, including the inappropriate use of codeine, in this low risk trauma population.

Current Evidence for Acute Pain Management of Musculoskeletal Injuries and Postoperative Pain in Pediatric and Adolescent Athletes

OBJECTIVE

Sports-related injuries in young athletes are increasingly prevalent with an estimated 2.6 million children and adolescents sustaining a sports-related injury annually. Acute sports-related injuries and surgical correction of sports-related injuries cause physical pain and psychological burdens on pediatric athletes and their families. This article aims to evaluate current acute pain management options in pediatric athletes and acute pain management strategies for postoperative pain after sports-related injuries. This article will also elucidate which areas of pain management for pediatric athletes are lacking evidence and help direct future clinical trials.

DATA SOURCES

We conducted a literature search through PubMed and the Cochrane Central Register of Controlled Trials to provide an extensive review of initial and postoperative pain management strategies for pediatric sports-related musculoskeletal injuries.

MAIN RESULTS

The current knowledge of acute pain management for initial sports-related injuries, postoperative pain management for orthopedic surgeries, as well as complementary and alternative medical therapies in pediatric sports-related injuries is presented. Studies evaluating conservative management, enteral and nonenteral medications, regional anesthesia, and complementary medical therapies are included.

CONCLUSIONS

Adequate pain management is important for sports injuries in children and adolescents for emotional as well as physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. More studies are needed to evaluate the efficacy of nonopioid analgesic medications and complementary therapies in pediatric patients with acute sports-related injuries.

Guidelines of the French Society of Otorhinolaryngology (SFORL): Nonsteroidal anti-inflammatory drugs (NSAIDs) and pediatric ENT infections. Short version

OBJECTIVES

To present the guidelines of the French Society of Otolaryngology-Head and Neck Surgery concerning the use of non-steroidal anti-inflammatory drugs (NSAIDs) in pediatric ENT infections.

METHODS

Based on a critical analysis of the medical literature up to November 2016, a multidisciplinary workgroup of 11 practitioners wrote clinical practice guidelines. Levels of evidence were classified according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system: GRADE A, B, C or "expert opinion". The first version of the text was reworked by the workgroup following comments by the 22 members of the reading group.

RESULTS

The main recommendations are: NSAIDs are indicated at analgesic doses (e.g. 20-30 mg/kg/day for ibuprofen) in combination with paracetamol (acetaminophen) in uncomplicated pediatric ENT infections (acute otitis media, tonsillitis, upper respiratory infections, and maxillary sinusitis) if: o pain is of medium intensity (visual analogue scale (VAS) score 3-5 or "Evaluation Enfant Douleur" (EVENDOL) child pain score 4-7) and insufficiently relieved by first-line paracetamol (residual VAS≥3 or EVENDOL≥4); o pain is moderate to intense (VAS 5-7 or EVENDOL 7-10). When combined, paracetamol and ibuprofen are ideally taken simultaneously every 6h. It is recommended: (1) o not to prescribe NSAIDs in severe or complicated pediatric ENT infections; (2) o to suspend NSAIDs treatment in case of unusual clinical presentation of the infection (duration or symptoms); (3) o not to prescribe NSAIDs for more than 72h.

Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial

IMPORTANCE

Timely analgesia is critical for children with injuries presenting to the emergency department, yet pain control efforts are often inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Opioids are historically used for significant pain from traumatic injuries but have concerning adverse effects. Intranasal ketamine may provide an effective alternative.

OBJECTIVE

To determine whether intranasal ketamine is noninferior to intranasal fentanyl for pain reduction in children presenting with acute extremity injuries.

DESIGN, SETTING, AND PARTICIPANTS

The Pain Reduction With Intranasal Medications for Extremity Injuries (PRIME) trial was a double-blind, randomized, active-control, noninferiority trial in a pediatric, tertiary, level 1 trauma center. Participants were children aged 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries between March 2016 and February 2017. Analyses were intention to treat and began in May 2017.

INTERVENTIONS

Intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 µg/kg).

MAIN OUTCOMES AND MEASURES

The primary outcome was reduction in visual analog scale pain score 30 minutes after intervention. The noninferiority margin for this outcome was 10.

RESULTS

Of 90 children enrolled, 45 (50%) were allocated to ketamine (mean [SD] age, 11.8 [2.6] years; 26 boys [59%]) and 45 (50%) to fentanyl (mean [SD] age, 12.2 [2.3] years; 31 boys [74%]). Thirty minutes after medication, the mean visual analog scale reduction was 30.6 mm (95% CI, 25.4-35.8) for ketamine and 31.9 mm (95% CI, 26.6-37.2) for fentanyl. Ketamine was noninferior to fentanyl for pain reduction based on a 1-sided test of group difference less than the noninferiority margin, as the CIs crossed 0 but did not cross the prespecified noninferiority margin (difference in mean pain reduction between groups, 1.3; 90% CI, -6.2 to 8.7). The risk of adverse events was higher in the ketamine group (relative risk, 2.5; 95% CI, 1.5-4.0), but all events were minor and transient. Rescue analgesia was similar between groups (relative risk, 0.89; 95% CI, 0.5-1.6).

CONCLUSIONS AND RELEVANCE

Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02778880.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship

BACKGROUND

Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture.

METHODS

Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics.

RESULTS

Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex.

CONCLUSIONS

Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Böttiger B, Bouillon B, Fischer M, Gaier G, Gliwitzky B, Helm M, Hilbert-Carius P, Hossfeld B, Meisner C, Schempf B, Wafaisade A, Bernhard M. Analgesia in Patients with Trauma in Emergency Medicine

BACKGROUND

Suitable analgesic drugs and techniques are needed for the acute care of the approximately 18 200-18 400 seriously injured patients in Germany each year.

METHODS

This systematic review and meta-analysis of analgesia in trauma patients was carried out on the basis of randomized, controlled trials and observational studies. A systematic search of the literature over the 10-year period ending in February 2016 was carried out in the PubMed, Google Scholar, and Springer Link Library databases. Some of the considered trials and studies were included in a meta-analysis. Mean differences (MD) of pain reduction or pain outcome as measured on the Numeric Rating Scale were taken as a summarizing measure of treatment efficacy.

RESULTS

Out of 685 studies, 41 studies were considered and 10 studies were included in the meta-analysis. Among the drugs and drug combinations studied, none was clearly superior to another with respect to pain relief. Neither fentanyl versus morphine (MD -0.10 with a 95% confidence interval of [-0.58; 0.39], p = 0.70) nor ketamine versus morphine (MD -1.27 [-3.71; 1.16], p = 0.31), or the combination of ketamine and morphine versus morphine alone (MD -1.23 [-2.29; -0.18], p = 0.02) showed clear superiority regarding analgesia.

CONCLUSION

Ketamine, fentanyl, and morphine are suitable for analgesia in spontaneously breathing trauma patients. Fentanyl and ketamine have a rapid onset of action and a strong analgesic effect. Our quantitative meta-analysis revealed no evidence for the superiority of any of the three substances over the others. Suitable monitoring equipment, and expertise in emergency procedures are prerequisites for safe and effective analgesia by healthcare professionals..

Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT

BACKGROUND

Musculoskeletal injuries (MSK-Is) are a common and painful condition among children that remains poorly treated in the emergency department (ED). We aimed to test the efficacy of a combination of an anti-inflammatory drug with an opioid for pain management of MSK-I in children presenting to the ED.

METHODS

In this randomized, double-blinded, placebo-controlled trial, we enrolled children between 6 and 17 years presenting to the ED with an MSK-I and a pain score >29 mm on the visual analog scale (VAS). Participants were randomly assigned to oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo of morphine. Primary outcome was children with VAS pain score <30 mm at 60 minutes postmedication administration.

RESULTS

A total of 501 participants were enrolled and 456 were included in primary analyses (morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9% (morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine + ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to -14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P < .001) and in the morphine group (P < .001) experienced more side effects than those in the ibuprofen group. No serious adverse event was reported.

CONCLUSIONS

Combination of morphine with ibuprofen did not provide adequate pain relief for children with MSK-I in the ED. None of the study medication provided an optimal pain management because most of children did not reach a mild pain score (NCT02064894).

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review

Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0-18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.

Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians

OBJECTIVES

To describe pediatric emergency medicine (PEM) physicians' reported pain management practices across Canada and explore factors that facilitate or hinder pain management.

METHODS

This study was a prospective survey of Canadian pediatric emergency physicians. The Pediatric Emergency Research Canada physician database was used to identify participants, and a modified Dillman's Total Design Survey Method was used for recruitment.

RESULTS

The survey response rate was 68% (139 of 206). Most physicians were 31 to 50 years old (82%) with PEM training (56%) and had been in practice for less than 10 years (55%). Almost all pain screening in emergency departments (EDs) occurred at triage (97%). Twenty-four percent of physicians noted institutionally mandated pain score documentation. Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain (88% and 83%, respectively). Over half of urinary catheterizations (60%) and intravenous (53%) starts were performed without any analgesia. The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively. Training background and gender of physicians affected the likelihood of using nonpharmacologic interventions. Physicians noted time restraints to be the greatest barrier to optimal pain management (55%) and desired improved access to pain medications (32%), better policies and procedures (30%), and further education (25%).

CONCLUSIONS

When analgesia was reported as provided, ibuprofen and acetaminophen were most commonly used. Both procedural and presenting pain remained suboptimally managed. There is a substantial evidence practice gap in children's ED pain management, highlighting the need for further knowledge translation strategies and policies to support optimal treatment.

Analgesia for fracture pain in children: methodological issues surrounding clinical trials and effectiveness of therapy

Fractures in childhood are common painful conditions. Suboptimal analgesia has been reported in the emergency department and following discharge. Recently, concern about the safety of narcotics such as codeine has sparked a renewed interest in opioids such as morphine for pediatric fracture pain. Consequently, opioids are being increasingly used in the clinical setting. Despite this, there is ample evidence that clinicians are more willing to offer opioids to adults than children. The existence of limited evidence supporting their use in children is likely a major contributing factor. A closer look at the limitations of designing high-quality analgesic trials in children with fractures is needed to enable investigators to anticipate problems and clinicians to make evidence-based choices.

Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial

BACKGROUND

Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain.

METHODS

We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale - Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose.

RESULTS

We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre-post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) -0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI -0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ -0.1 [95% CI -0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI -0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01).

INTERPRETATION

We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01690780.

Ibuprofen with Acetaminophen for Postoperative Pain Control following Tonsillectomy Does Not Increase Emergency Department Utilization

Objective

To compare the performance of ibuprofen vs codeine for postoperative pain management after tonsillectomy as measured by need for emergency department (ED) treatment for pain and/or dehydration.

Study Design

Retrospective case series with chart review.

Setting

Tertiary children’s hospital.

Subjects and Methods

Consecutive series of patients who underwent tonsillectomy with or without adenoidectomy at a tertiary children’s hospital. Patients were categorized based on the type of postoperative pain management (acetaminophen with codeine vs acetaminophen and ibuprofen). The main outcome measure was the proportion of patients requiring ED visits or inpatient admissions for inadequate pain control or dehydration. Secondary measures included antibiotic use, postoperative hemorrhage, need for return to the operating room, vomiting, and oral diet tolerance.

Results

Patients in the ibuprofen/acetaminophen group were younger than those in the codeine/acetaminophen group (6.2 vs 8.1 years, P < .05). Patients in the codeine/acetaminophen group were more likely to use antibiotics in the postoperative period (50.3% vs 5.9%, P < .05). The proportion of patients requiring ED visits or inpatient admission for dehydration was not significantly different between the groups (5.1% for codeine, 2.7% for ibuprofen, P = .12). Multivariable analysis controlling for age and antibiotic use showed no difference in ED visits or admission for dehydration ( P = .09). There was no difference between the groups for any of the secondary measures.

Conclusions

Ibuprofen with acetaminophen represents a safe and acceptable analgesic alternative to codeine and acetaminophen in patients undergoing pediatric tonsillectomy.

National patterns of codeine prescriptions for children in the emergency department

BACKGROUND AND OBJECTIVES

National guidelines have recommended against codeine use in children, but little is known about prescribing patterns in the United States. Our objectives were to assess changes over time in pediatric codeine prescription rates in emergency departments nationally and to determine factors associated with codeine prescription.

METHODS

We performed a serial cross-sectional analysis (2001-2010) of emergency department visits for patients ages 3 to 17 years in the nationally representative National Hospital Ambulatory Medical Care Survey. We determined survey-weighted annual rates of codeine prescriptions and tested for linear trends over time. We used multivariate logistic regression to identify characteristics associated with codeine prescription and interrupted time-series analysis to assess changes in prescriptions for upper respiratory infection (URI) or cough associated with two 2006 national guidelines recommending against its use for these indications.

RESULTS

The proportion of visits (N = 189 million) with codeine prescription decreased from 3.7% to 2.9% during the study period (P = .008). Odds of codeine prescription were higher for children ages 8 to 12 years (odds ratio [OR], 1.42; 95% confidence interval [1.21-1.67]) and among providers outside the northeast. Odds were lower for children who were non-Hispanic black (OR, 0.67 [0.56-0.8]) or with Medicaid (OR, 0.84 [0.71-0.98]). The 2006 guidelines were not associated with a decline in codeine prescriptions for cough or URI visits.

CONCLUSIONS

Although there was a small decline in codeine prescription over 10 years, use for cough or URI did not decline after national guidelines recommending against its use. More effective interventions are needed to prevent codeine prescription to children.

Postoperative pain control after supracondylar humerus fracture fixation

BACKGROUND

Postoperative pain control in pediatric patients has become a priority for all institutions. There is a paucity of literature on pain control after orthopedic procedures in the pediatric population. The purpose of this study is to compare the efficacy of acetaminophen with narcotic analgesics, specifically, acetaminophen/codeine and morphine, for pain management after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children.

METHODS

We retrospectively evaluated 217 patients who received closed reduction and percutaneous pinning of type II or III supracondylar humerus fractures at our institution from 2003 to 2009. Hospital charts were reviewed to obtain demographic data. Patients were divided into narcotic and non-narcotic groups. The Oucher and FLACC scales were used to quantify the effectiveness of the pain control that was delivered.

RESULTS

A total of 174 patients were treated with non-narcotic pain medications and 43 patients received narcotics. The average age of these patients was 5.45 years. The mean postoperative pain score for the non-narcotic group was 1.9, whereas the mean postoperative pain score for the narcotic group was 2.2. This difference was not statistically significant. To account for the difference of age in patients and severity of fracture type, we created an age-matched cohort of patients with only type III supracondylar fractures. The average age of this group was 6.22 years. The mean pain score for the acetaminophen subgroup was 2.1 compared with a mean pain score of 2.4 for the narcotic subgroup. This difference was not statistically significant. Severe nausea or vomiting attributed to either class of medication was not observed. In addition, no patients developed a compartment syndrome.

CONCLUSIONS

Acetaminophen is as effective as narcotic analgesics for providing pain control after supracondylar fracture surgery in children and is historically associated with fewer side effects. It is our recommendation to use acetaminophen alone for postoperative pain control in these patients.

LEVEL OF EVIDENCE

III.

Comparison of a morphine and midazolam combination with morphine alone for paediatric displaced fractures: a randomized study

AIM

To compare the efficacy of sublingual midazolam with oral morphine versus that of oral morphine with placebo in a paediatric population attending an emergency department (ED) with acute long-bone fractures.

METHODS

A sample of children aged 5-16 years with clinically deformed closed long-bone fractures was randomized to groups receiving either oral morphine (0.5 mg/kg)/sublingual placebo or oral morphine (0.5 mg/kg)/sublingual midazolam (0.2 mg/kg). The main exclusion criteria were narcotic or benzodiazepine use, significant head injury, multiple organ failure, femoral fracture and allergy. Pain scores were rated on a 100-mm visual analogue scale (VAS) at 0, 15, 30, 60, 90 and 120 min.

RESULTS

Fifty-eight children were enrolled (mean age: 10.5 years, SD 2.7). Fractures concerned the radius or ulna in 43 cases (74.1%), the humerus (22.4%) and the tibia or fibula (3.5%). No significant difference in VAS scores was observed between the two treatment arms (p = 0.72). Drowsiness was significantly more frequent in the midazolam group (p = 0.007) during the first 2 h after administration. No serious adverse event was observed.

CONCLUSION

The analgesic performances of morphine and the combination of morphine with midazolam assessed by VAS were similar in children presenting at the ED with a long-bone fracture.

Premarketing surveillance of ibuprofen suppositories in febrile children

In many countries, ibuprofen is available only in oral formulations. The authors aimed to investigate parental satisfaction and possible adverse reactions among children receiving newly marketed ibuprofen suppositories, prior to their arrival at the pharmaceutical points of distribution. Children needing antipyretic medication were recruited from 11 pediatric wards and clinics in Israel. Each patient received ibuprofen suppositories (5-10 mg/kg/dose) after completing a data collection form. After 3 to 7 days of treatment, information regarding parent satisfaction, possible adverse reactions, and concomitant use of drugs was obtained. Overall, 490 children completed the study. Parents' satisfaction was high (4.5 ± 0.47 on a scale of 1-5), and 92.2% reported that they would use the medication in the future. Adverse reactions were reported in 8 patients (1.63%, 95% confidence interval = 1.77-3.25), the most common being diarrhea. Rectal administration of ibuprofen suppositories is well tolerated and overall satisfaction and the repeated expected use were high.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.

Pain management of musculoskeletal injuries in children: current state and future directions

BACKGROUND

Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated.

OBJECTIVES

Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy.

RESULTS

Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain.

CONCLUSIONS

There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.