Which is the best analgesic to treat acute pain in children?

Nonsteroidal anti-inflammatory drugs (NSAIDs), ketamine, opioids . . . which of these commonly used pharmacological treatments for acute pain in children is the most effective and least risky? In a recent systematic review and meta-analysis published in JAMA Pediatrics1, researchers from the London Health Sciences Centre in Ontario sought to comprehensively compare the safety and efficacy of available analgesics to inform clinical recommendations and practices.Dr. Laura Olejnik's team examined 41 randomized clinical trials involving 4,935 children with pain for less than four weeks. Of these 41 trials, 25 involved participants with musculoskeletal pain, six with otolaryngological pain, five with abdominal pain, and five combined different pain conditions.Additionally, 35 trials were conducted in emergency departments. In 29 of these, the drug was administered by healthcare professionals, and in 34 trials, outcomes were measured in the hospital.NSAIDs, as effective but saferThe first finding was that opioids, ketamine, and NSAIDs were more effective than placebo in reducing pain, with at least moderate certainty:NSAID: weighted mean difference [WMD], −1.29; 95% CI, −1.89 to −0.70; modeled risk difference [RD] for achieving WMD, 16%Ketamine: WMD, −1.12; 95% CI, −2.09 to −0.14; Modeled RD to achieve WMD, 14%Medium- to high-potency opioids: WMD, −1.19; 95% CI, −1.83 to −0.55; modeled RD to achieve WMD, 15%But one class of medications stood out as being less risky for children. Only NSAIDs reduced the use of rescue medications, with a relative risk of 0.31 (95% CI, 0.14 to 0.68; modeled RD, 16% fewer patients). Furthermore, NSAIDs did not increase the risk of short-term gastrointestinal adverse events (RR 0.69; 95% CI, 0.31-1.55), unlike other analgesics apart from paracetamol (RR 0.63; 95% CI, 0.21-1.87)."NSAIDs offer the greatest benefits and the fewest risks, suggesting they should be the first-line treatment for acute painful conditions in children," the authors conclude.However, they note several limitations to their research, such as a lack of data and studies on short-term and long-term harmful effects (opioid overuse) or serious adverse effects (gastrointestinal bleeding).Results consistent with the new guidelinesNevertheless, their results are generally consistent with the first clinical practice guidelines2 published in October 2024 by the American Academy of Pediatrics for prescribing opioids to children and adolescents with acute pain in the outpatient setting.These guidelines specifically state that "opioids should not be prescribed as monotherapy for children or adolescents with acute pain." When this is the case, “clinicians should prescribe immediate-release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial supply of five days or less.”A technical report3 accompanying the guidelines, based on 11 randomized controlled trials, further emphasizes that "no evidence was found that opioid pain control is superior to non-opioid alternatives."Studies comparing opioids to no opioids "support the use of NSAIDs as first-line treatment for postoperative pain based on similar pain control and fewer side effects."This article has been translated from its original French and first appeared on our sister site Profession Santé. References: Olejnik L, Lima JP, Sadeghirad B, et al. Pharmacologic Management of Acute Pain in Children: A Systematic Review and Network Meta-Analysis. JAMA Pediatr. Published online February 03, 2025. doi:10.1001/jamapediatrics.2024.5920Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, et coll. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics (2024) 154 (5): e2024068752. https://doi.org/10.1542/peds.2024-068752Raman SR, Smith MJ, Evidence for the Use of Opioid Medication for Pediatric Acute Pain in the Outpatient Setting: Technical Report. Pediatrics (2024) 154 (5): e2024068753. https://doi.org/10.1542/peds.2024-068753

Which is the best analgesic to treat acute pain in children?

Register for free access or login.

Related Topics

Business Topic