Use of nonsteroidal anti-inflammatory drugs in children

Naproxen versus Acetaminophen for Therapy of Soft Tissue Injuries to the Ankle in Children

Background:

Musculoskeletal (MSK) ankle injuries cause significant morbidity in ambulatory pediatric populations. No optimal pharmacotherapy is available.

Objective:

To conduct a randomized, double-blind trial to compare 2 drug therapies for soft tissue injury of the ankle.

Methods:

Patients (N = 77, aged 8–14 y, 61% male) with ankle injuries presenting to a regional pediatric emergency department were assigned to receive either acetaminophen (15 mg/kg 4 times a day) or naproxen (5 mg/kg 4 times a day) in a double-blind fashion on a routine basis for a 5 day period. On days 0 and 7, patients rated their degree of disability and pain on weight bearing using a 10 cm visual analog scale developed for this study. In addition, they were examined by a physician who rated pain, tenderness on palpation, and swelling using a 4 point scale. There were 3 follow-up telephone calls on days 3, 14, and 21. Adherence was evaluated by self-report and pill count.

Results:

Both the acetaminophen and naproxen groups had significant improvement in degree of disability and pain from day 0 to day 7. There was no statistically significant difference in outcome between the 2 groups by patient self-evaluation or physician assessment. There also was no significant difference in adverse event rates between the 2 groups, and the majority of patients in both groups felt that the medication was helpful.

Conclusions:

No significant difference in efficacy of pain control or improvement of disability between the naproxen and acetaminophen groups suggests no preferential advantage for naproxen over acetaminophen for MSK injuries when given on a regular basis, with concurrent supportive treatment. Possible differential benefit from intermittent therapy needs to be evaluated among children with ankle injury.

Nonsteroidal antiinflammatory drugs. Renal toxicity. Review of pediatric issues

Nonsteroidal antiinflammatory drugs (NSAIDs) are an important part of therapy for childhood rheumatic disease and for the symptomatic management of clinical problems such as fever, musculoskeletal pain, and dysmenorrhea. Overall, there is a low incidence of significant complications resulting from NSAID therapy in children, but serious adverse effects on renal function have occurred. The physician should be aware of the potential renal toxicity of these drugs and monitor patients accordingly.

Pharmacologic management of pain in children and adolescents

In the management of chronic pain conditions, the combination of pharmacologic measures with physical and psychologic modalities becomes even more important. A pain clinic and pain consultation service are one model that facilitates this combined approach. Initial management of mild to moderate pain begins with nonopioid analgesics such as acetaminophen and NSAIDs. Persistent severe pain of a neuropathic character merits careful trials of antidepressants or anticonvulsants. Traditionally, use of opioids for chronic pain not due to cancer has been discouraged for adults as well as children. Recently, this view was challenged by reports by Portenoy and Foley and by Taub, who followed a group of adults with chronic pain due to a variety of conditions. They found that the majority of these patients, if managed with opioids on a regular schedule as part of an overall treatment program, could be made comfortable and were able to increase their level of functioning for several years. In general, dosage escalation and compulsive drug-seeking behaviors were not seen. Since this report was retrospective and did not involve children, caution must be applied in extrapolating these findings to children. For example, remarkably little is known about the effects of chronic opioid administration in childhood on growth and development. Certainly, this issue deserves further study before general recommendations can be made. It seems prudent to emphasize the importance of maximizing nonpharmacologic and nonopioid approaches in the management of chronic pain in children prior to embarking on long-term use of opioids.