A recent article in the academy of emergency medicine has suggested that ibuprofen provides similar analgesia equivalent to acetominophen-codeine combinations in the treatement of acute pain.
See below for more information:
Friday JH, Kanegaye JT, McCaslin I, Zheng A, Harley JR. Ibuprofen provides analgesia equivalent to acetaminophen-codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial. Acad Emerg Med. 2009;16:711-716.
Pain Management in Children
Pain control is a key element of fracture management, but many children receive inadequate analgesia in the acute patient care setting. A study of 1210 children found that few to none of them received analgesia for routine procedures, such as venipuncture or nasogastric tube placement. Only 29% of young children undergoing lumbar puncture had a documented pain management plan.
But the practice of pain management for children in the acute setting is changing. Pain should be assessed as the "fifth vital sign" during triage, and multiple simple, validated scales may help assess a child's degree of pain. Topical analgesia, such as eutectic mixture of topical anesthetics (EMLA®) may be applied in triage in the anticipation of procedures such as venipuncture or lumbar puncture. For infants, pacifiers and oral sucrose have been demonstrated to reduce patient response to painful stimuli.
Oral and intravenous medications are important in the management of a child's pain, but children are particularly prone to adverse events associated with analgesics. In a review of cases from 12 pediatric hospitals, the overall rate of adverse drug events was 11.1 for every 100 admissions, and analgesics were by far the leading cause of such events. Nearly half of the adverse events associated with the use of analgesics were considered preventable.
Results
The mean baseline pain scores of 6.1 and 6.9 in the acetaminophen-codeine and ibuprofen groups, respectively, did not significantly differ. At 40 minutes, the mean pain scores had fallen to 4.4 and 4.8 for acetaminophen-codeine and ibuprofen groups, and these values were also statistically similar, as were the mean pain scores for the groups at 20 minutes (5.3 and 5.5) and 60 minutes (3.8 and 4.8). The difference in mean pain score between the 2 groups at 60 minutes on the Color Analog Scale was 0.2 cm, a nonsignificant difference that favored acetaminophen-codeine.
Only 3 children experienced adverse events related to study therapy. Acetaminophen with codeine was associated with cases of vomiting and pruritus without rash, whereas ibuprofen was associated with a single case of nausea.
The current study was limited by the low number of participants, because many children had received analgesic therapy at home. Researchers recruited children into the study in a nonconsecutive fashion, which could have introduced some bias with regard to the children that were included in the trial. Finally, the study medications were not identical in appearance, although the patient, parent, investigator, and treating physician were all blind to study treatment.
Commentary
This study confirms previous research that suggested that opiates are not superior to nonopiate analgesics for children with acute injuries. A study of 66 children with acute orthopaedic injuries demonstrated similar efficacy of ibuprofen and codeine in controlling pain for 120 minutes. Moreover, the combination of ibuprofen and oxycodone was not more effective than either medication alone, although combination therapy was associated with a higher rate of adverse events.
Although initial analgesia is important, it is a small part of the pain management required for fractures, and a previous study suggests that gaps in pain management persist when the child returns home. In this study, rates of withholding postfracture analgesia were 30% on day 1 and 20% on day 2, and children who received additional analgesia on these days were commonly given only a single dose of analgesic per day.[Whereas most children in pain were likely to be quiet and withdrawn, louder behaviors such as crying were significantly correlated with receiving more analgesic medication. The investigators concluded that more time should be invested in educating parents about how to proactively manage pain in their child who has an extremity fracture.
The results of previous research and the current trial provide physicians with some clear mandates with regard to analgesia for children. The precise type of analgesia is not nearly as critical as assessing the pain appropriately and prescribing appropriate analgesics when children are initially seen in the emergency department. Physicians also need to impress upon parents the need for close monitoring of pain and the correct use of analgesics at home. Following these simple steps should help to reduce children's burden of pain.
How do you manage pain in your pediatric patient population?
