Should paracetamol or ibuprofen be the first line analgesic given to non febrile children presenting to A&E with musculoskeletal pain?

Report By: Dr L C Parkinson - ST3 Emergency Medicine
Search checked by Dr T Cheri - ST3 Emergency Medicine
Institution: Hull Royal Infirmary
Date Submitted: 30th March 2008
Last Modified: 5th August 2008
Status: Blue (submitted but not checked)

Three Part Question

In [non febrile children presenting to A&E with musculoskeletal pain not requiring opiates] is [ibuprofen better than paracetamol as the first line analgesic] in [reducing pain score]

Clinical Scenario

A 4yr old presents to the Emergency Department with a limp after sustaining an inversion injury to the ankle. Should you prescribe paracetamol or ibuprofen initially for pain?

Search Strategy

PubMed (inc Medline) from 1949 - present (14/05/08)
Cochrane Database released 16/04/08
References of relevant papers
ibuprofen AND paracetamol AND pain AND ((Humans[Mesh]) AND (Clinical Trial[ptyp] OR Meta-Analysis[ptyp] OR Practice Guideline[ptyp] OR Randomized Controlled Trial[ptyp] OR Review[ptyp]) AND ((infant[MeSH] OR child[MeSH] OR adolescent[MeSH])) )

Search Outcome

Pubmed - 73 papers found, 1 relevant
Cochrane Database - 17 papers found, none relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Clark E, Plint AC, Correll R, Gaboury I, Passi B 2007 Canada	6-17yrs old Presenting to Emergency Dept with musculoskeletal injury to neck, back or extremeties within the preceding 48hrs	PRCT	Pain by VAS 30 mins	No significant difference	Research assisstant able to guess more frequently than expected by chance, which medication administered.
			Pain by VAS 60 mins	Greater improvement in VAS with ibuprofen, versus paracetamol or codeine. More patients with adequate analgesia at 60 mins in ibuprofen group (as measured by VAS <30mm)
			Adverse effects	No significant difference

Comment(s)

The one relevant paper provides good evidence that ibuprofen is superior to paracetamol as a first line analgesic in children with musculoskeletal pain. Ibuprofen provides better pain relief and is more likely to result in adequate analgesia after a single dose than paracetamol.

Clinical Bottom Line

Ibuprofen as a first line analgesic provides better pain relief in children with musculoskeletal pain than paracetamol.

References

Clark E, Plint AC, Correll R, Gaboury I, Passi B A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics 2007 Mar;119(3):460-7