Fracture pain relief for kids? Ibuprofen does it better
This OTC analgesic is as effective as acetaminophen with codeine and better tolerated, a new study of children with arm fractures shows.
Ibuprofen users had fewer problems
Analysis of 244 diaries revealed that less rescue medication was used in the ibuprofen group, although the difference was not statistically significant (20.3% vs 31% [absolute risk reduction, 10.7%], 95% confidence interval, -0.2% to 21.6%). Decrease in mean pain score was the same in both groups. Functional status the day after the injury was better in the ibuprofen group compared with the acetaminophen/codeine group. In addition, 50.9% of patients in the acetaminophen/codeine group reported adverse events, vs 29.5% of those in the ibuprofen group (number needed to harm=4.7).
At the study’s end, children were more satisfied with ibuprofen. Only 10% of patients who took ibuprofen said they would not use it for future fractures; in comparison, 27.5% of patients in the acetaminophen/codeine group said they would not choose to use codeine again.
The authors followed participants for 1 to 4 years through orthopedic clinic records and telephone calls for any long-term adverse orthopedic outcomes. Four cases of refracture at the same site occurred (1.6%), 3 of which were in the acetaminophen/codeine group. There were no cases of nonunion.
WHAT'S NEW: Ibuprofen emerges as first-line agent for kids
Both ibuprofen and acetaminophen with codeine are commonly prescribed for outpatient pediatric analgesia, but this is the first study to compare them head-to-head for outpatient management of postfracture pain. Ibuprofen worked at least as well as acetaminophen with codeine for fracture pain control, and had fewer adverse effects. Children given ibuprofen were better able to eat and play than those given acetaminophen with codeine—an important patient-oriented functional outcome. Patients and their parents were also more satisfied when ED physicians prescribed ibuprofen. This study is consistent with short-term (single-dose) studies and confirms that ibuprofen should be the first-line agent for outpatient analgesia in this group.
CAVEATS: Study did not address NSAIDs’ effect on bone healing
In theory, ibuprofen—like other NSAIDs—can diminish the proinflammatory milieu required for bone turnover and fracture healing. Chart reviews of up to 4 years after the incident fracture found no evidence that ibuprofen delayed healing or increased rates of refracture. However, this study was neither designed nor powered to examine this outcome. Previous studies have found no conclusive evidence that short-term use of NSAIDs impairs fracture healing.7,8
Results apply only to simple fractures. Patients in this study did not require manipulation or reduction of their fracture, limiting the scope of the authors’ recommendation to simple arm fractures. More severe injury may require narcotic analgesia. One can assume, based on this and other supporting literature, that the findings extrapolate to other similarly painful pediatric musculoskeletal injuries.2
Twenty-five percent of subjects were lost to follow-up. Follow-up diaries were available from about 75% of the participants. It is possible that a clearer beneficial outcome would have been found with 1 of the analgesics studied if the response rate had been higher. Because this study is consistent with the previous ED-only studies comparing ibuprofen with acetaminophen plus codeine, however, it is unlikely that a higher response rate would find ibuprofen inferior to acetaminophen plus codeine.
CHALLENGES TO IMPLEMENTATION: Parents—or patients—may expect an Rx
Prescribing an effective, common, inexpensive, and well-tolerated oral medication should have no barriers to implementation. Still, use of an over-the-counter medication, however effective, may face resistance from patients or parents who expect “something more” for fracture pain.
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources; the grant is a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
