Practice Changer
Use ibuprofen instead of acetaminophen with codeine for pediatric arm fractures. It controls the pain at least as well and is better tolerated.1-3
Strength of Recommendation
A: Based on 1 longer-term and 2 short-term randomized controlled trials (RCTs).
1. Drendel AL, Gorelick MH, Weisman SJ, et al. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Ann Emerg Med. 2009;54:553-560.
2. Koller DM, Myers AB, Lorenz D, et al. Effectiveness of oxycodone, ibuprofen, or the combination in the initial management of orthopedic injury-related pain in children. Pediatr Emerg Care. 2007;23:627-633.
3. Clark E, Plint AC, Correll R, et al. A randomized controlled clinical trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics. 2007;119:460-467.
Illustrative case
A mother brings her 6-year-old son to the emergency department (ED) for treatment of forearm pain after a bicycle accident. clinical examination reveals a swollen and tender wrist. A radiograph confirms a diagnosis of a nondisplaced distal radial fracture. After proper stabilization, the little boy is discharged home, with a visit to his primary care physician scheduled for the following week. if he were your patient, what would you prescribe for outpatient analgesia?
Musculoskeletal trauma is a common pediatric presentation, in both emergency and office settings. In fact, it is estimated that by age 15, one-half to two-thirds of children will have fractured a bone.4 Physicians commonly prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids—especially acetaminophen with codeine—as analgesia for children with fractures,5 but few studies have directly compared these medications in pediatric patients.
No consensus on analgesia for musculoskeletal pain in kids
Pain associated with an acute fracture is substantial, and most children who incur fractures are managed at home, and thus require effective and well-tolerated oral analgesia. However, prescribing practices vary widely, and there is no consensus regarding the first-line medication for kids with fracture.
A Cochrane review of adult postoperative pain concluded that NSAIDs are effective, and they are commonly prescribed to adult patients for various types of pain.6 Fewer studies of pain control in children exist. Before the 2009 study reported on here, there were just 2 RCTs that addressed pediatric musculoskeletal pain in patients presenting to the ED.
In single-dose studies, ibuprofen comes out ahead
The smaller of the 2 trials (N=66) compared ibuprofen alone vs ibuprofen plus oxycodone for suspected orthopedic injury. The researchers found that pain relief was equivalent, but the oxycodone group had more adverse effects.2 The larger trial (N=336) compared ibuprofen, acetaminophen, and codeine for acute pediatric musculoskeletal injuries. An hour after receiving their study drug, children in the ibuprofen group had significantly greater reduction in pain than those in either the acetaminophen group or the codeine group. They were also more likely to report adequate analgesia.3 Neither study followed patients after discharge from the ED.
STUDY SUMMARY: New RCT evaluates pain relief once patients go home
The Drendel study was a randomized, controlled, double-blind trial of outpatient analgesia for pediatric fractures.1 The investigators randomized 336 children ages 4 to 18 years with radiographically confirmed arm fractures to a suspension of either ibuprofen (10 mg/kg) or acetaminophen with codeine (1 mg/kg codeine component per dose), which are recommended dosages. They enrolled a convenience sample of children with nondisplaced fractures that did not require reduction in the ED.
Children were excluded if they weighed more than 60 kg, preferred tablets to liquid medication, sought care more than 12 hours after injury, or had developmental delays or contraindications to any study medication. Also excluded were children—or their parents—who did not speak English and those who were inaccessible by telephone for follow-up.
Study groups had similar baseline demographic and fracture characteristics, and similar pain scores. Patients and their parents were blinded to the assigned drug; all received the same discharge instructions and 2 doses of a rescue medication (the alternate study drug). The primary outcome was use of rescue medication due to failure of the assigned study drug. Secondary outcomes included decrease in pain score, functional outcomes (play, school, eating, sleeping), and satisfaction with the medication.
During the 72 hours after discharge from the ED, patients and parents filled out a standard diary recording pain and medication use. The diaries were returned by mail. Follow-up was good, with about 75% of diaries returned.