Ibuprofen Provides Analgesia Equivalent to Acetaminophen–Codeine in the Treatment of Acute Pain in Children with Extremity Injuries: A Randomized Clinical Trial

Abstract

Objectives: This study compared the analgesic effectiveness of acetaminophen-codeine with that of ibuprofen for children with acute traumatic extremity pain, with the hypothesis that the two medications would demonstrate equivalent reduction in pain scores in an emergency department (ED) setting.Methods: This was a randomized, double-blinded equivalence trial. Pediatric ED patients 5 to 17 years of age with acute traumatic extremity pain received acetaminophen-codeine (1 mg ⁄ kg as codeine, maximum 60 mg) or ibuprofen (10 mg ⁄ kg, maximum 400 mg). The patients provided Color Analog Scale (CAS) pain scores at baseline and at 20, 40, and 60 minutes after medication administration. The primary outcome measured was the difference in changes in pain score at 40 minutes, compared to a previously described minimal clinically significant change in pain score of 2 cm. The difference was defined as (change in ibuprofen CAS score from baseline) -(change in acetaminophen-codeine CAS score from baseline); negative values thus favor the ibuprofen group. Additional outcomes included need for rescue medication and adverse effects. Results:The 32 acetaminophen-codeine and the 34 ibuprofen recipients in our convenience sample had indistinguishable pain scores at baseline. The intergroup differences in pain score change at 20 minutes ()0.6, 95% confidence interval [CI] = )1.5 to 0.3), 40 minutes ()0.4, 95% CI = )1.4 to 0.6), and 60 minutes (0.2, 95% CI = )0.8 to 1.2) were all less than 2 cm. Adverse effects were minimal: vomiting (one patient after acetaminophen-codeine), nausea (one patient after ibuprofen), and pruritus (one after acetaminophen-codeine). The three patients in each group who received rescue medications all had radiographically demonstrated fractures or dislocations.Conclusions: This study found similar performance of acetaminophen-codeine and ibuprofen in analgesic effectiveness among ED patients aged 5-17 years with acute traumatic extremity pain. Both drugs provided measurable analgesia. Patients tolerated them well, with few treatment failures and minimal adverse effects.ACADEMIC EMERGENCY MEDICINE 2009; 16:711-716 ª

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

“…Therefore, we included 23 studies involving 2,300 patients: 17 randomized controlled trials, 2 nonrandomized controlled trials, 1 case report, 1 cross-sectional survey, 1 chart review, and 1 prospective cohort (Table 1) [13, 19, 27, 57–76]. Studies were published between 1991 and 2014 (median year 2007) and were conducted in the United States ( n = 7), Canada (5), France (3), Italy (3), and Germany (2) and one each in Finland, New Zealand, and the United Kingdom.…”

“…This makes physiologic sense, as opioids have CNS depressant effects which NSAIDS and acetaminophen lack. A child who needs to avoid CNS symptoms (e.g., a school-aged child, during daytime hours) should likely be treated with ibuprofen or acetaminophen for mild-moderate pain, as they have a lower AE profile, as compared to low-mid dose opioids, a comparably potent analgesic agent [19, 27, 66]. Current evidence suggests that ibuprofen likely has superior analgesic potency for many clinical conditions including fractures, sprains, and postoperative pain [13, 19, 76, 81–84].…”

Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians

“…Ibuprofen appears to have emerged as a reasonable first-line medication for mild to moderate pain. 39,40 Oxycodone and oral morphine may be feasible alternatives or adjuncts for moderate to severe pain and are gaining popularity with clinicians. Further research is needed to determine the optimal opioid analgesic for moderate to severe pain in children.…”

<p>Emergency Department Revisits Due to Cast-Related Pain in Children with Forearm Fractures</p>

“…Children who report their pain as 4-6 receive oral dipyrone 15mg/kg, and children who report their pain as 7-10 receive oral morphine 0.2mg/kg, oral oxycodone 0.2mg/kg, or intranasal fentanyl 1.5mcg/kg. 9,10 According to department protocol, pain level in children with fractures is reassessed before discharge to verify that patients are discharged with a pain score of 4 or less. At discharge, caregivers are provided with an information pamphlet by the patient's nurse.…”