Optimal pain relief for pediatric MSK injury.

Evidence Single-agent comparisons: • Ibuprofen versus acetaminophen versus codeine: RCT1 of 336 children with MSK injuries (54% fractures). -At 60 minutes on a 100-mm pain scale, ibuprofen led to —greater mean reduction (-24 mm) versus acetaminophen (-12 mm) or codeine (-11 mm). —more patients achieving adequate analgesia (< 30 mm) versus acetaminophen (number needed to treat [NNT] = 7) or codeine (NNT = 9). • Morphine versus ibuprofen: RCT2 of 134 children with uncomplicated extremity fractures given ibuprofen or morphine, followed for 24 hours. -No difference in pain score at any time point. -Less nausea with ibuprofen (NNT = 5). Combination comparisons: 2 RCTs with arm fracture or MSK limb trauma. • Acetaminophen and codeine versus ibuprofen: 336 children followed for 3 days.3 -No difference in mean pain scores. -Ibuprofen resulted in substantially less pain-related functional limitation. -Fewer adverse events with ibuprofen (NNT = 5). • Ibuprofen and codeine versus ibuprofen: 81 children followed for 120 minutes.4 -No difference in pain score at any of 4 time points. Four smaller (underpowered) RCTs5-8 with 60 to 72 patients found no difference in any comparison of ibuprofen, acetaminophen, oxycodone, or acetaminophen-codeine. Limitations include small sample sizes,2,4-8 high dropout rates,2 low pain scores at study entry (making it harder to show a difference),2 and dosing of morphine (every 6 hours).4