Ibuprofen as effective as morphine for fracture pain in children, study showsBMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g6581 (Published 03 November 2014) Cite this as: BMJ 2014;349:g6581
Ibuprofen should be the drug of choice for analgesia in children with uncomplicated extremity fractures, a study published this week in the journal of the Canadian Medical Association, CMAJ, has shown. It was as effective as oral morphine but produced fewer side effects.
The randomised, blinded trial showed that oral ibuprofen and oral morphine reduced pain scores in children by the same degree. Children tolerated ibuprofen well, with fewer reported adverse effects within 72 hours than for morphine.1
Researchers assessed children (5-17 years old) presenting to a single emergency department in London, Ontario, from September 2012 to February 2014. Fractures had to be uncomplicated and to have occurred within 24 hours. Children received either oral morphine (0.5 mg/kg) or ibuprofen (10 mg/kg) in the 24 hours after discharge. Doses could be given every six hours. Paracetamol (15 mg/kg) could be used for breakthrough pain as required. Of the 183 children enrolled, 134 took at least one dose of the study drug (66 morphine, 68 ibuprofen). Age, sex, and median pain on discharge did not differ between those who took the study drug and those who did not.
Children rated their pain using the faces pain scale-revised before they took the drug and 30 minutes after. This scale ranges from 0 to 5 with a corresponding facial depiction of pain for each score. Both drugs reduced pain scores, with no significant difference between groups across all doses—after the first dose, the mean reduction in pain score was 1.5±1.2 for morphine and 1.3±1.0 for ibuprofen.
Children who took morphine reported significantly more adverse events than those who took ibuprofen (56.1% v 30.9%, P<0.01), particularly nausea (27.3% v 5.9%, P<0.01). More children in the morphine group reported drowsiness (34.8% v 20.6%), but this did not reach statistical significance (P=0.07). Incidence of constipation did not differ between groups.
One limitation was that the study was not powered to detect between-group differences in analgesia for breakthrough pain. Another potential drawback is the possible effect of non-steroidal anti-inflammatory drugs on bone healing. Several studies have tried to clarify whether such a link exists,2 but an article published in the Canadian Family Physician said that data from randomised controlled trials, although limited, did not indicate an effect.3
That codeine is no longer advocated in children under 12 has left a gulf in the treatment options for managing moderate pain in children.4 These new data will hopefully make prompt pain management after injury easier by identifying a tolerated drug acceptable to physicians, children, and their families.
Cite this as: BMJ 2014;349:g6581