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Early analgesia for children with acute abdominal pain did not affect management or outcome

BMJ 2005; 331 doi: (Published 17 November 2005) Cite this as: BMJ 2005;331:0-e

Research question Does pain relief mask the symptoms and signs of appendicitis in children with abdominal pain?

Answer In a small randomised trial, intravenous morphine had no measurable effect on the management of such children or their outcomes

Why did the authors do the study? Children who present to emergency departments with abdominal pain are rarely given pain relief because doctors worry that it could mask the symptoms and signs of appendicitis. Trials have already suggested that this doesn't happen in adults, and practice is changing. These authors wanted to find out if it's safe to give analgesia to children.

What did they do? One hundred and eight children were enrolled in a randomised double blind placebo controlled trial. They all presented to one emergency department with acute abdominal pain that had lasted less than two days. Fifty two of the children were given intravenous morphine (up to two doses of 0.05 mg/kg), and 56 were given intravenous normal saline. They were formally assessed by the attending doctor before and 15 minutes after each treatment. The children recorded their pain on a 10 cm visual analogue scale before and 15 minutes after each treatment. A surgeon assessed each child less than an hour after the child's first treatment, made a diagnosis, and recorded his or her confidence in it—from 0 to 100%. Further management was at the surgeon's discretion.

What did they find? The two groups of children had statistically indistinguishable management and outcomes. About half the children in each group had an immediate laparotomy (25/52 given morphine v 24/56 given saline), and most of these children had appendicitis (24/25 v 22/24). Nineteen children given morphine and 22 given placebo were admitted for observation. Of these, a similar number in each group later turned out to have appendicitis (7/19 children given morphine v 4/22 in the placebo group, P = 0.29). Overall, 15/52 children given morphine and 12/56 given saline had a perforated appendix. Four of the five children who had a negative laparotomy (normal appendix) were in the placebo group. Appendicitis was missed in one child in the placebo group, and in none in the group given morphine. The morphine had no demonstrable impact on the surgeon's confidence in his or her initial diagnosis (74% for both groups of children), but it did relieve the children's pain better than normal saline (2.2 cm decrease v 1.2 cm, P = 0.015).

What does it mean? In this trial, giving morphine to children with abdominal pain seemed to make little difference to their management or eventual outcome. The trial was small, however, and not powerful enough to resolve an important safety issue—whether giving early analgesia to children increases the risk of missing an inflamed appendix. The authors did a power calculation, but not until their study was complete. They estimate that, to answer this question with any certainty, a trial would have to recruit at least 2000 children.

Green et al. Early analgesia for children with acute abdominal pain. Pediatrics 2005;116:978-83.

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