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Sansone L, Gentile C, Grasso EA, Di Ludovico A, La Bella S, Chiarelli F, Breda L. Pain Evaluation and Treatment in Children: A Practical Approach. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1212. [PMID: 37508709 PMCID: PMC10378137 DOI: 10.3390/children10071212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Pain is the most common complaint reported by children who access the emergency departments, but despite its frequency and the availability of many international guidelines, it often remains underreported and undertreated. Recently, the American Academy of Pediatrics and the American Pain Society have reiterated the importance of a multidisciplinary approach in order to eliminate pain in children. In all pediatric settings, an adequate assessment is the initial stage in a proper clinical approach to pain, especially in the emergency departments; therefore, an increasing number of age-related tools have been validated. A wide range of analgesic agents are currently available for pain management, and they should be tailored according to the patient's age, the drug's pharmacokinetics and the intensity of pain. In order to facilitate the choice of the appropriate drug, a treatment algorithm based on a ladder approach can be used. Moreover, non-pharmacological techniques should be considered to alleviate anxiety and distress in pediatric age. This review aims to offer a simple but intuitive description of the best strategies for pain relief in children, starting with the prompt recognition and quantification of pain through adequate assessment scales, and following with the identification of the most appropriate therapeutic choice among the ones available for pediatric age.
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Affiliation(s)
- Lorenzo Sansone
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Cristina Gentile
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Eleonora Agata Grasso
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Armando Di Ludovico
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Saverio La Bella
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Luciana Breda
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
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Pharmacokinetics of Morphine Sulfate Orodispersible Tablets and Bioequivalence with Immediate-Release Oral Morphine Sulfate Formulations in Healthy Adult Subjects Under Fasting Conditions: Single-Dose Comparative Bioavailability Studies. Clin Drug Investig 2022; 42:1101-1112. [DOI: 10.1007/s40261-022-01214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
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Comparison of the psychometric properties of 3 pain scales used in the pediatric emergency department: Visual Analogue Scale, Faces Pain Scale-Revised, and Colour Analogue Scale. Pain 2019; 159:1508-1517. [PMID: 29608509 DOI: 10.1097/j.pain.0000000000001236] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Appropriate pain measurement relies on the use of valid, reliable tools. The aim of this study was to determine and compare the psychometric properties of 3 self-reported pain scales commonly used in the pediatric emergency department (ED). The inclusion criteria were children aged 6 to 17 years presenting to the ED with a musculoskeletal injury and self-reported pain scores ≥30 mm on the mechanical Visual Analogue Scale (VAS). Self-reported pain intensity was assessed using the mechanical VAS, Faces Pain Scale-Revised (FPS-R), and Colour Analogue Scale (CAS). Convergent validity was assessed by Pearson correlations and the Bland-Altman method; responsiveness to change was assessed using paired sample t tests and standardized mean responses; and reliability was estimated using relative and absolute indices. A total of 456 participants were included, with a mean age of 11.9 years ± 2.7 and a majority were boys (252/456, 55.3%). Correlations between each pair of scales were 0.78 (VAS/FPS-R), 0.92 (VAS/CAS), and 0.79 (CAS/FPS-R). Limits of agreement (95% confidence interval) were -3.77 to 2.33 (VAS/FPS-R), -1.74 to 1.75 (VAS/CAS), and -2.21 to 3.62 (CAS/FPS-R). Responsiveness to change was demonstrated by significant differences in mean pain scores among the scales (P < 0.0001). Intraclass correlation coefficient and coefficient of repeatability estimates suggested acceptable reliability for the 3 scales at, respectively, 0.79 and ±2.29 (VAS), 0.82 and ±2.07 (CAS), and 0.76 and ±2.82 (FPS-R). The scales demonstrated good psychometric properties for children with acute pain in the ED. The VAS and CAS showed a strong convergent validity, whereas FPS-R was not in agreement with the other scales.
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Montaud Q, Lanoux T, Watremez M, Fontaine X. Évaluation et prise en charge de la douleur d’origine traumatique chez l’enfant de moins de quinze ans aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0784-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Le May S, Ali S, Plint AC, Mâsse B, Neto G, Auclair MC, Drendel AL, Ballard A, Khadra C, Villeneuve E, Parent S, McGrath PJ, Leclair G, Gouin S. Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT. Pediatrics 2017; 140:peds.2017-0186. [PMID: 29021235 DOI: 10.1542/peds.2017-0186] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Musculoskeletal injuries (MSK-Is) are a common and painful condition among children that remains poorly treated in the emergency department (ED). We aimed to test the efficacy of a combination of an anti-inflammatory drug with an opioid for pain management of MSK-I in children presenting to the ED. METHODS In this randomized, double-blinded, placebo-controlled trial, we enrolled children between 6 and 17 years presenting to the ED with an MSK-I and a pain score >29 mm on the visual analog scale (VAS). Participants were randomly assigned to oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo of morphine. Primary outcome was children with VAS pain score <30 mm at 60 minutes postmedication administration. RESULTS A total of 501 participants were enrolled and 456 were included in primary analyses (morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9% (morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine + ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to -14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P < .001) and in the morphine group (P < .001) experienced more side effects than those in the ibuprofen group. No serious adverse event was reported. CONCLUSIONS Combination of morphine with ibuprofen did not provide adequate pain relief for children with MSK-I in the ED. None of the study medication provided an optimal pain management because most of children did not reach a mild pain score (NCT02064894).
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Affiliation(s)
- Sylvie Le May
- Faculties of Nursing and .,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Samina Ali
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Departments of Pediatrics and.,Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Benoit Mâsse
- CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Gina Neto
- Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Amy L Drendel
- Departments of Pediatrics and.,Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ariane Ballard
- Faculties of Nursing and.,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
| | - Christelle Khadra
- Faculties of Nursing and.,CHU Sainte-Justine Research Center, Montreal, Quebec, Canada.,Women and Children's Health Research Institute, Edmonton, Alberta, Canada
| | | | | | - Patrick J McGrath
- IWK Health Centre, Nova Scotia Health Authority and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Serge Gouin
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada; and
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Poonai N, Datoo N, Ali S, Cashin M, Drendel AL, Zhu R, Lepore N, Greff M, Rieder M, Bartley D. Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial. CMAJ 2017; 189:E1252-E1258. [PMID: 29018084 DOI: 10.1503/cmaj.170017] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Oral morphine for postoperative pain after minor pediatric surgery, while increasingly popular, is not supported by evidence. We evaluated whether oral morphine was superior to ibuprofen for at-home management of children's postoperative pain. METHODS We conducted a randomized superiority trial comparing oral morphine (0.5 mg/kg) with ibuprofen (10 mg/kg) in children 5 to 17 years of age who had undergone minor outpatient orthopedic surgery (June 2013 to September 2016). Participants took up to 8 doses of the intervention drug every 6 hours as needed for pain at home. The primary outcome was pain, according to the Faces Pain Scale - Revised, for the first dose. Secondary outcomes included additional analgesic requirements, adverse effects, unplanned health care visits and pain scores for doses 2 to 8. RESULTS We analyzed data for 77 participants in each of the morphine and ibuprofen groups. Both interventions decreased pain scores with no difference in efficacy. The median difference in pain score before and after the first dose of medication was 1 (interquartile range 0-1) for both morphine and ibuprofen (p = 0.2). For doses 2 to 8, the median differences in pain score before and after the dose were not significantly different between groups. Significantly more participants taking morphine reported adverse effects (45/65 [69%] v. 26/67 [39%], p < 0.001), most commonly drowsiness (31/65 [48%] v. 15/67 [22%] in the morphine and ibuprofen groups, respectively; p = 0.003). INTERPRETATION Morphine was not superior to ibuprofen, and both drugs decreased pain with no apparent difference in efficacy. Morphine was associated with significantly more adverse effects, which suggests that ibuprofen is a better first-line option after minor surgery. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01686802.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis.
| | - Natasha Datoo
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Megan Cashin
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Amy L Drendel
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Rongbo Zhu
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Natasha Lepore
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Michael Greff
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Michael Rieder
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Debra Bartley
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
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How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Pain Res Manag 2016; 2016:5346819. [PMID: 28077923 PMCID: PMC5203901 DOI: 10.1155/2016/5346819] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 10/18/2016] [Accepted: 10/27/2016] [Indexed: 11/18/2022]
Abstract
Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.
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Abstract
Far more attention is now given to pain management in children in the emergency department (ED). When a child arrives, pain must be recognized and evaluated using a pain scale that is appropriate to the child's development and regularly assessed to determine whether the pain intervention was effective. At triage, both analgesics and non-pharmacological strategies, such as distraction, immobilization, and dressing should be started. For mild pain, oral ibuprofen can be administered if the child has not received it at home, whereas ibuprofen and paracetamol are suitable for moderate pain. For patients who still require pain relief, oral opioids could be considered; however, many EDs have now replaced this with intranasal fentanyl, which allows faster onset of pain relief and can be administered on arrival pending either intravenous access or definitive care. Intravenous opioids are often required for severe pain, and paracetamol or ibuprofen can still be considered for their likely opioid-sparing effects. Specific treatment should be used for patients with migraine. In children requiring intravenous access or venipuncture, non-pharmacological and pharmacological strategies to decrease pain and anxiety associated with needle punctures are mandatory. These strategies can also be used for laceration repairs and other painful procedures. Despite the gaps in knowledge, pain should be treated with the most up-to-date evidence in children seen in EDs.
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Affiliation(s)
- Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1C5, Canada.
| | - Evelyne D Trottier
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
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Le May S, Ali S, Khadra C, Drendel AL, Trottier ED, Gouin S, Poonai N. Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review. Pain Res Manag 2016; 2016:4809394. [PMID: 27445614 PMCID: PMC4904632 DOI: 10.1155/2016/4809394] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/03/2015] [Indexed: 12/21/2022]
Abstract
Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0-18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.
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Affiliation(s)
- Sylvie Le May
- Faculty of Nursing, University of Montreal, Montreal, QC, Canada H3T 1A8
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
| | - Samina Ali
- Women and Children's Health Research Institute, Edmonton, AB, Canada T6G 1C9
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada T6G 1C9
| | - Christelle Khadra
- Faculty of Nursing, University of Montreal, Montreal, QC, Canada H3T 1A8
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- McGill University Health Centre, Montreal, QC, Canada H4A 3J1
| | - Amy L. Drendel
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Evelyne D. Trottier
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- Division of Emergency Medicine, Department of Pediatrics, Sainte-Justine Hospital (CHU Sainte-Justine), Montreal, QC, Canada H3T 1C5
| | - Serge Gouin
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- Division of Emergency Medicine, Department of Pediatrics, Sainte-Justine Hospital (CHU Sainte-Justine), Montreal, QC, Canada H3T 1C5
| | - Naveen Poonai
- Children's Hospital, London Health Sciences Centre, London, ON, Canada N6A 5W9
- Schulich School of Medicine and Dentistry, London, ON, Canada N6A 5C1
- Child Health Research Institute, London, ON, Canada N6C 2V5
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Poonai N, Kilgar J, Mehrotra S. Analgesia for fracture pain in children: methodological issues surrounding clinical trials and effectiveness of therapy. Pain Manag 2015; 5:435-45. [DOI: 10.2217/pmt.15.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fractures in childhood are common painful conditions. Suboptimal analgesia has been reported in the emergency department and following discharge. Recently, concern about the safety of narcotics such as codeine has sparked a renewed interest in opioids such as morphine for pediatric fracture pain. Consequently, opioids are being increasingly used in the clinical setting. Despite this, there is ample evidence that clinicians are more willing to offer opioids to adults than children. The existence of limited evidence supporting their use in children is likely a major contributing factor. A closer look at the limitations of designing high-quality analgesic trials in children with fractures is needed to enable investigators to anticipate problems and clinicians to make evidence-based choices.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Paediatric Emergency Department, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jennifer Kilgar
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Shruti Mehrotra
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
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Poonai N, Bhullar G, Lin K, Papini A, Mainprize D, Howard J, Teefy J, Bale M, Langford C, Lim R, Stitt L, Rieder MJ, Ali S. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ 2014; 186:1358-63. [PMID: 25349008 DOI: 10.1503/cmaj.140907] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain. METHODS We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale - Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose. RESULTS We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre-post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) -0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI -0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ -0.1 [95% CI -0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI -0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01). INTERPRETATION We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01690780.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta.
| | - Gina Bhullar
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Kangrui Lin
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Adam Papini
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - David Mainprize
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Jocelyn Howard
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - John Teefy
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Michelle Bale
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Cindy Langford
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Rodrick Lim
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Larry Stitt
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Michael J Rieder
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
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Wille-Ledon C, Chappuy H, Giraud C, Tréluyer JM, Chéron G. Comparison of a morphine and midazolam combination with morphine alone for paediatric displaced fractures: a randomized study. Acta Paediatr 2011; 100:e203-7. [PMID: 21480984 DOI: 10.1111/j.1651-2227.2011.02311.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To compare the efficacy of sublingual midazolam with oral morphine versus that of oral morphine with placebo in a paediatric population attending an emergency department (ED) with acute long-bone fractures. METHODS A sample of children aged 5-16 years with clinically deformed closed long-bone fractures was randomized to groups receiving either oral morphine (0.5 mg/kg)/sublingual placebo or oral morphine (0.5 mg/kg)/sublingual midazolam (0.2 mg/kg). The main exclusion criteria were narcotic or benzodiazepine use, significant head injury, multiple organ failure, femoral fracture and allergy. Pain scores were rated on a 100-mm visual analogue scale (VAS) at 0, 15, 30, 60, 90 and 120 min. RESULTS Fifty-eight children were enrolled (mean age: 10.5 years, SD 2.7). Fractures concerned the radius or ulna in 43 cases (74.1%), the humerus (22.4%) and the tibia or fibula (3.5%). No significant difference in VAS scores was observed between the two treatment arms (p = 0.72). Drowsiness was significantly more frequent in the midazolam group (p = 0.007) during the first 2 h after administration. No serious adverse event was observed. CONCLUSION The analgesic performances of morphine and the combination of morphine with midazolam assessed by VAS were similar in children presenting at the ED with a long-bone fracture.
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Affiliation(s)
- Chrystèle Wille-Ledon
- Service d'Urgences pédiatriques, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, France
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Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics 2010; 126:e1168-98. [PMID: 20921070 DOI: 10.1542/peds.2010-1609] [Citation(s) in RCA: 338] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference. OBJECTIVES To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility. METHODS Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori. RESULTS From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS. CONCLUSIONS For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.
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Affiliation(s)
- Deborah Tomlinson
- Child Health Evaluative Services, Hospital for Sick Children, Toronto, Ontario, Canada.
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Oxycodone versus codeine for triage pain in children with suspected forearm fracture: a randomized controlled trial. Pediatr Emerg Care 2008; 24:595-600. [PMID: 18772726 DOI: 10.1097/pec.0b013e3181850ca3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the efficacy of pain reduction of triage oxycodone (O) versus codeine (C) to children with suspected forearm fractures. DESIGN/METHODS Children, aged 4 to 17 years, were randomized to receive O (0.2 mg/kg; maximum, 15 mg) or C (2 mg/kg; maximum, 120 mg) if isolated forearm fracture was suspected by the emergency department (ED) triage nurse. All other ED staff were blinded to the assignment. The primary outcome measure was a 5-point facial scale (0 = no pain, 4 = severe) completed by subjects to assess pain at baseline then at 30-minute intervals until ED discharge or procedural sedation for fractures requiring reduction. Ten adverse effects were assessed at baseline and the succeeding intervals. Identification of the most painful part of the visit was assessed at discharge. Efficacy and adverse effects of O versus C were compared using generalized estimate equation modeling. RESULTS One hundred seven subjects (mean age, 10.4 years; African American, 55%; males, 56%) were randomized to O (n = 51) or C (n= 56). Subjects taking O reported a pain score significantly lower than subjects taking C (0.4 faces, P = 0.01). Minor adverse effects occurred in both groups, but itching occurred less in O subjects (odds ratio, 0.37; 95% confidence interval, 0.14-0.99). The most painful part of the visit was radiography (O = 41%, C = 38%) followed by extremity examination (O = 16%, C = 13%) then casting (O = 8%, C = 13%). CONCLUSIONS Triage-administered O tended toward greater pain reduction compared with C in children with suspected forearm fractures. Although minor adverse effects occurred in both groups, itching occurred more in C. Identification of radiography as the most painful part of fracture evaluation underscores the need for early triage administration of analgesia for suspected fractures.
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15
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Rogovik AL, Goldman RD. Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries. Am J Emerg Med 2007; 25:400-5. [PMID: 17499657 DOI: 10.1016/j.ajem.2006.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 11/23/2006] [Accepted: 11/27/2006] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of the study was to document prehospital analgesia (PA) for children with extremity injuries at home or en route to the hospital, as assessed by research personnel at the pediatric emergency department. METHODS Two parallel groups of patients with fractures or soft-tissue injuries (STIs) were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. Parents or children were interviewed, pain assessed, and data from the emergency department charts collected. RESULTS A total of 310 patients were recruited; their mean age was 10.2 years, and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and STI. Of the patients, 78% had PA, 73% received first aid (icing, immobilization), and 37% had medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures. CONCLUSION Most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.
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Affiliation(s)
- Alex L Rogovik
- Pediatric Research in Emergency Therapeutics (PRETx) Program, Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada M5G 1X8
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Rogovik AL, Rostami M, Hussain S, Goldman RD. Physician pain reminder as an intervention to enhance analgesia for extremity and clavicle injuries in pediatric emergency. THE JOURNAL OF PAIN 2007; 8:26-32. [PMID: 17207741 DOI: 10.1016/j.jpain.2006.05.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2005] [Revised: 05/16/2006] [Accepted: 05/22/2006] [Indexed: 11/30/2022]
Abstract
UNLABELLED The purpose of this study was to document analgesic use for limb and clavicle injuries in the pediatric emergency department (ED) and to determine whether a physician-oriented pain scale form on the patient's chart would enhance the administration of analgesia. Patients 3 to 18 years old were recruited prospectively in our tertiary pediatric ED in Toronto. The study included 4 crossover periods, 2 with the pain scale form on the patient's chart and 2 without. A total of 310 patients were recruited, mean age was 10 years, 64% were boys, and 62% had sustained fractures. The mean pain score was 4.4. Only 90 (29%) patients received an analgesic in the ED, and 65 (72%) of them were ordered by a physician. Only 24 (20%) in the study group and 22 (14%) in the control group received sufficient analgesia (P = .13). The median time to physician-initiated analgesia after arrival was 2.0 hours (1.0 to 3.3 hours), without a significant difference between groups. Pain control was 4-fold more appropriate in children receiving opioids versus nonopioids. Physician pain reminders did not enhance, and other measures should be taken to increase the dispensing of analgesia. PERSPECTIVE This is the first study to evaluate whether the addition of a physician-oriented pain-scale form on the chart of patients with injuries improves administration of analgesia in the ED. We found that physicians do not give sufficient analgesia even with this reminder form.
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Affiliation(s)
- Alex L Rogovik
- Pediatric Research in Emergency Therapeutics Program, Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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