1. No significant difference was seen in visual analog scale (VAS) pain ratings morphine + ibuprofen, morphine + placebo, and ibuprofen + placebo among children with musculoskeletal injuries (MSK-I) at 60 minutes from baseline.
2. About one third of patients from each group reported a mild pain rating from baseline to 60 minutes.
Evidence Level: 1 (Excellent)
Study Rundown: Musculoskeletal injury (MSK-I) pain is one of the top complaints among pediatric patients presenting to the emergency department (ED). The literature shows that management of pediatric MSK-I pain is highly variable, often leading to under-treatment of pain. This trial evaluated the efficacy of combination morphine plus ibuprofen compared to either of the 2 medications alone for achieving optimal pain control among children with MSK-I pain. Results showed that there was no significant difference in visual analog scale (VAS) pain ratings between the 3 groups from baseline to 60 minutes (T-60). Slightly less than one third of participants from each group reported a VAS of mild pain at 60 minutes. The only significant difference seen in pain score improvement was in the ibuprofen + placebo group compared with the morphine + placebo group at T-120. These results are limited by a high loss to follow-up rate at 120 minutes, however the primary outcome (pain at T-60) had an attrition rate of <8%. These findings suggest that adequate pain control for MSK-I in children can be achieved with ibuprofen alone, which has implications for reducing use of opioid medications among children.
In-depth [randomized controlled trial]: In this double-blind, randomized controlled trial, 501 children aged 6 to 17 years (mean age 11.9 years, 55.3% male) with musculoskeletal injuries (60% soft tissue, 38% fractures) were randomized to receive either morphine + ibuprofen, morphine + placebo, or ibuprofen + placebo. VAS scores were measured at baseline (mean 60.9mm) and compared with pain scores at T-30, T-60, T-90, and T-120. The primary outcome was the proportion of patients in each group who achieved a pain score of <30mm (mild) at T-60. Results showed no significant difference between study groups in proportion of children who reported mild pain at T-60 (30% morphine + ibuprofen, 29% morphine + placebo, 33% ibuprofen + placebo, p=.81). Similarly, no difference was seen between treatment groups at T-60 when comparisons were made between baseline VAS stratified by severity (30-69mm p=.56, ≥70 p=.41). From all the time points measured, only the ibuprofen + placebo group showed a significantly greater reduction in VAS compared to baseline and compared to the morphine + placebo group at T-120 (-27.1 95%CI -33.1 to -21.1 and -16.5 95%CI -21.1 to -12.0 respectively).
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