A Randomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain

Abstract

Abstract. Objective: To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. Methods: A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of Յ5 days' duration, pain score Ն5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later. Results: Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group. Conclusions: Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions. Key words: analgesia; acute abdominal pain; children; pediatrics. ACADEMIC EMERGENCY MEDICINE 2002; 9: 281-287 F OR decades, analgesia was withheld from patients with acute abdominal pain in the fear of masking symptoms, changing physical findings, and ultimately delaying diagnosis and definitive surgical intervention.1,2 This non-evidence-based teaching/practice was challenged recently by several studies that demonstrated effectiveness of opioids in providing pain relief to adult patients with acute abdominal pain without adverse effects or delay in diagnosis.3-7 These findings have led to the recommendation for judicious use of analgesia 8,9 Furthermore, the Agency for Healthcare Research and Quality (AHRQ) concluded that appropriate use of analgesics in patients with acute abdominal pain effectively decreases pain and does not interfere with diagnosis or treatment.10 However, application of this recommendation in children with acute abdominal pain has not been studied to date. Our study objective was to examine the effect of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. METHODSStudy Design. A randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the effects of intravenous morphine on pain reduction, ...

Oxycodone vs Placebo in Children With Undifferentiated Abdominal Pain

“…Some authors suggest that early pain relief would actually facilitate a definitive diagnosis, 1,2 and others conclude that opioid analgesia is not associated with harmful effects on diagnostic accuracy. 3,7 Our study showed relationships between the use of oxycodone and an altered diagnosis or treatment. In 5 children, the provisional diagnosis of NSAP changed to the correct diagnosis of appendicitis after the administration of oxycodone; postdose guarding developed in 3 children, but peritoneal tenderness was present already in 2 children with the initial diagnosis of NSAP.…”

“…[1][2][3][4][5][6] Until recently, only 1 study has addressed the is-sue of analgesia for undifferentiated abdominal pain in children. 7 In this study, the authors demonstrated effective pain relief with intravenous morphine in children with acute abdominal pain without causing adverse affects or a delay in diagnosis.…”

Question 2

“…Diagnostic accuracy was defined in two studies as true surgical and true non-surgical diagnoses as a proportion of all results. One study detected no difference,3 while the other1 noted a difference when children were examined by one subgroup of doctors, although the confidence intervals are borderline, and the authors’ other measure of diagnostic accuracy (reduction in mean number of areas of abdominal tenderness) was unaffected by the administration of analgesia. One study2 used the doctors’ estimation of confidence in diagnosis as their measure of diagnostic accuracy.…”

Morphine analgesia in patients with acute appendicitis: a randomised double-blind clinical trial

“…Kim et al 19 reported a significant reduction in the median pain difference in the group receiving morphine. Morphine significantly reduced pain severity in patients diagnosed with acute appendicitis, which supports the findings of others.…”