Major Problems in Treating Pediatric Pain

MARCH 12, 2016
The treatment of acute pain exists in a state of extremes. Adequate pain relief is often not achieved, and yet overprescribing of opioid analgesics is causing an epidemic in the United States.
In the pediatric population, this problem is amplified by the limited amount of data to support any treatment. To further complicate the matter, codeine has been deemed unsafe for use in those younger than 18 years, so available options for treating pain in pediatric patients are few and far between.1,2
The risks of undertreating pain in the pediatric population are significant. Both short-term effects (delayed healing) and long-term effects (fears of health care and needles) can be observed sequela.
Fortunately, results from a study involving children suggests that oral ibuprofen is just as effective as oral morphine in treating post-orthopedic fracture pain.3

The researchers designed a parallel, randomized, blinded study comparing oral morphine (0.5 mg/kg) with ibuprofen (10 mg/kg) for 24 hours after discharge from the emergency department with uncomplicated extremity fracture. In both treatment groups, change in pain score based on the Faces Pain Scale—Revised was recorded immediately before and 30 minutes after receiving each dose.
The children enrolled in the study ranged in age from 5 to 17 years and had nonoperative, radiographically evident extremity fracture but did not have a history of hypersensitivity to either study drug, chronic use of either study drug (or another drug in the respective medication classes), associated injuries requiring analgesia, known renal disease, bleeding disorders, poor fluency in English, sleep apnea, and pregnancy. If breakthrough pain occurred, acetaminophen was permitted.

Of the 134 patients analyzed, 66 were in the morphine group and 68 were in the ibuprofen group. Although there was no significant difference in the change in pain scores between morphine and ibuprofen at any time observed in this study (p=0.6), there were significantly more adverse events among those receiving morphine (p<0.01). The most common adverse events were nausea and vomiting, and no reports of respiratory depression or hypersensitivity occurred.

The authors concluded that ibuprofen demonstrated similar analgesic efficacy to morphine in children with fractures for the first 24 hours after their discharge from the emergency department, and given that morphine was associated with more adverse events, ibuprofen is a safe and effective therapy for outpatient management of fracture pain. Because this study only followed patients for 24 hours, the short-term follow up and long-term effects of this treatment is unknown. Therefore, the choice of analgesic therapy should remain patient-specific.

  1. Ciszkowski C, Madadi P, Phillips MS, et al. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009;361: 827–828.
  2. Voronov P, Przybylo HJ, Jagannathan N. Apnea in a child after oral codeine: a genetic variant — an ultra-rapid metabolizer. Paediatr Anaesth. 2007;17: 684–687.
  3. Poonai N, et al. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ. 2014 Dec 9;186(18): 1358–1363.

Craig Cocchio, PharmD
Craig Cocchio, PharmD
Craig Cocchio, PharmD, BCPS, is an Emergency Medicine Clinical Pharmacist at Trinity Mother Frances Hospital in Tyler, Texas. Follow on Twitter @iEMPharmD and on his blog at