The authors of the above study have investigated whether acetaminophen, ibuprofen, or codeine provides the most effective pain relief—as determined by rapidity of onset and by amount of relief—in children age six to 17 with acute musculoskeletal pain. They recruited 336 children with soft-tissue injury or closed fracture and randomly assigned them to receive one of the above three agents at the maximal recommended dose of each agent. The analgesics were formulated as a purple, grape-flavored liquid given by a nurse not involved in the study to maintain blinding, as the volumes were not identical among the drugs. Pain scores using a 100 mm visual analog scale (VAS) were recorded at 0, 30, 60, and 120 minutes after drug administration. (The use of the VAS in children older than six has been validated.) A 15-mm change in pain score was considered to be clinically significant and pain rated at <30 mm was considered adequate pain control. Both of these endpoints fall within acceptable ranges in several studies of pain measure in children.
The baseline pain scores in each group were not significantly different, ranging between 51 and 57 mm VAS. However, only the group receiving ibuprofen had a clinically significant diminution of pain after 60 minutes (-27 mm, p<0.001). In addition, 52% of patients receiving ibuprofen achieved adequate pain relief as measured by a VAS of <30 mm. Patients receiving acetaminophen did not have clinically significant pain relief until 60 min (-17 mm) and those receiving codeine reported pain relief at 120 min (-17 mm). Only 36% and 40% of the acetaminophen and codeine groups respectively achieved adequate pain control. In patients with a high degree of pain at baseline (VAS >30 mm), ibuprofen provided the most rapid relief, achieving significance by 30 minutes; codeine was equally effective at 120 minutes. Of interest, patients with fractures received the most benefit from ibuprofen. Diminution of pain in patients with soft-tissue injuries did not achieve significance in any group. Side effects were equivalent.
One of the more common myths of adulthood is that children do not suffer from pain without serious illness. Yet cross-sectional studies of the prevalence of pain in children have demonstrated between 20% and 40% of children have pain at any one time. Looking retrospectively, 80% of school-age children will report having had pain at some time in a three-month period. Hence, knowing how to treat pain in children is clearly important. Upon encountering this study, I assumed it would help me overcome my reluctance to use narcotic analgesics in treating pain. However, I was startled to see ibuprofen outperforming codeine. On second look, I was sorely disappointed that, as the authors state, at best 50% of children achieved adequate analgesia with the highest recommended dose of ibuprofen.