Ibuprofen, Champion of the (Pediatric) World

Accept no additions!

There’s a whole mass of literature for the inpatient and post-operative world regarding multi-modal and opiate-sparing analgesia.

This is not that.

This is one-shot, acute musculoskeletal pain in children in the (Canadian) emergency department – and you can have one of these oral analgesic combinations:

• Ibuprofen plus placebo.

• Ibuprofen plus acetaminophen.

• Ibuprofen plus hydromorphone.

Here’s your pain waterfalls for the primary outcome:

The shapes are similar, and so are the median (and IQR) of their respective VAS – and all the secondary pain outcomes were basically the same. No children required rescue analgesia. However, there was an excess of drowsiness and gastrointestinal upset in the patients receiving hydromorphone.

You can see these are fairly middling pain scores to start with – the trial did not enroll children with obvious skeletal deformities, or those who necessitated immediate intravenous or intranasal analgesia. So, these observations don’t generalize to every instance of musculoskeletal pain. However, this is fairly consistent with other literature saying pain is usually adequately managed by non-opiate monotherapy – and opiates are not a valued addition to the team.