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

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

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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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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  • 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: Accessed March 24, 2015.

Authors do not have any conflicts of interest to declare.

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