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#14 Optimal Pain Relief for Acute Pediatric Musculoskeletal Injuries – NSAIDs or Opioids?


CLINICAL QUESTION
QUESTION CLINIQUE
 In children with acute musculoskeletal (MSK) injuries, what is the optimal approach to pain management?

BOTTOM LINE
RÉSULTAT FINAL
 Current evidence suggests that ibuprofen provides better single-agent relief than acetaminophen or codeine, and is at least equivalent to both acetaminophen with codeine and morphine for acute injury related pediatric pain, with fewer adverse events.


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EVIDENCE
DONNÉES PROBANTES
 Single-agent comparisons:
  • Ibuprofen versus acetaminophen versus codeine: Randomized Controlled Trial (RCT)1 of 336 children with MSK injuries (54% fractures)
    • At 60 minutes on 100mm pain scale, ibuprofen led to:
      • Greater mean reduction (-24mm) versus acetaminophen (-12mm) or codeine (-11mm).
      • More patients achieving adequate analgesia (<30 mm) versus acetaminophen [Numbers Needed to Treat (NNT)=7] or codeine (NNT=9)
  • Morphine versus ibuprofen: RCT2 of 134 children with uncomplicated extremity fractures given ibuprofen or morphine, followed 24 hours:
    • No difference in pain score at any time point.
    • Less nausea with ibuprofen (NNT=5).
Combinations: Two RCTs with arm fracture or MSK limb trauma:
  • Acetaminophen + codeine versus ibuprofen3 (336 children), followed three days:
    • No difference in mean pain scores.
    • Ibuprofen resulted in significantly less pain-related functional limitation.
    • Less adverse events with ibuprofen (NNT=5).
  • Ibuprofen + codeine versus ibuprofen4 (81 children), followed 120 minutes.
    • No difference pain score at any of four time points.
Four smaller (underpowered) RCTs5-8 with 60-72 patients found no difference in any comparison of ibuprofen, acetaminophen, oxycodone, or acetaminophen-codeine. Limitations of evidence: Small size,2,4,5-8 high drop-out rates,2 low pain scores at study entry (making it harder to show a difference),2 and dosing of morphine (every six hours).4   Context:
  • In one systematic review9 of ibuprofen versus acetaminophen for any pediatric pain, ibuprofen was statistically significantly better in 6/18 trials (others showed no difference).
  • Study doses1-4 were ibuprofen 10 mg/kg (max 400-600 mg), acetaminophen 15 mg/kg (max 650 mg), codeine 1 mg/kg (max 60 mg) and morphine 0.5 mg/kg (max 10 mg).
  • NSAIDS do not appear to impact fracture healing.10
  • Health Canada warning 2013: Codeine can be (rarely) associated with serious side effects and thus should not be used in children <12 years.11

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Author(s)
Auteur(s)
  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP

1. Clark E, Plint AC, Correll R, et al. Pediatrics. 2007; 119:460-7.

2. Poonai N, Bhullar G, Lin K, et al. CMAJ. 2014 Dec 9; 186(18):1358-63.

3. Drendel AL, Gorelick MH, Weisman SJ, et al. Ann Emerg Med. 2009; 54:553-60.

4. Le May S, Gouin S, Fortin C, et al. J Emerg Med. 2013; 44:536-42.

5. Koller DM, Myers AB, Lorenz D, et al. Pediatr Emerg Care. 2007; 23:627-33.

6. Shepherd M, Aickin R. Emerg Med Australas. 2009; 21:484-90.

7. Friday JH, Kanegaye JT, McCaslin I, et al. Acad Emerg Med. 2009; 16:711-6.

8. Bondarsky EE, Domingo AT, Matuza NM, et al. Am J Emerg Med. 2013; 31:1357-60.

9. Pierce CA, Voss B. Ann Pharmacother. 2010; 44:489-506.

10. Taylor IC, Lindblad AJ, Kolber MR. Fracture healing and NSAIDs. Can Fam Physician. 2014; 60:817, e439-40.

11. Health Canada. Health Canada’s review recommends codeine only be used in patients aged 12 and over. Ottawa: Health Canada; 2013. Available from: http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2013/33915aeng.php?_ga=1.225644442.1625660531.1411482248. Accessed March 24, 2015.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.