NSAIDs Most Effective and Safest for Acute Pediatric Pain: JAMA

According to a systematic review and meta-analysis of 41 randomized clinical trials, involving nearly 5,000 children, NSAIDs, ketamine, and mid- to high-potency opioids all reduced acute pediatric pain, though the effects were modest. Among these options, NSAIDs provided the greatest benefit with the least harm, making them a preferred choice for managing acute pain in children. The study, led by Laura Olejnik, MD, of London Health Sciences in Ontario, Canada, confirmed that all three drug categories were more effective than a placebo with at least moderate certainty. The findings of the study have appeared in JAMA Pediatrics.

Several pharmacologic options exist for the management of acute pediatric pain; however, their comparative effectiveness remains uncertain. A study was done to assess the relative benefits and harms of pharmacotherapy for acute pediatric pain through a network meta-analysis of randomized clinical trials. Trials that enrolled children (aged <18 years) with acute pain and randomized them to receive a pharmacologic analgesic vs an alternate analgesic or placebo were included.

Pairs of reviewers independently reviewed abstracts, extracted data, and assessed the risk of bias in eligible trials. A frequentist random-effects model was used for all meta-analyses, and the certainty of evidence was assessed for treatment effects using the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcomes were pain severity (range, 0-10 cm using a visual analogue scale; minimally important difference [MID], 1 cm), need for rescue medication, symptom relief, and adverse drug events.

Results A total of 41 trials involving 4935 children were included. High- to moderate-certainty evidence found that compared with placebo, nonsteroidal anti-inflammatory drugs (NSAIDs) (weighted mean difference [WMD], −1.29; 95% CI, −1.89 to −0.70; modelled risk difference [RD] for achieving the MID, 16%), ketamine (WMD, −1.12; 95% CI, −2.09 to −0.14; modelled RD for achieving the MID, 14%), and mid-high potency opioids (WMD, −1.19; 95% CI, −1.83 to −0.55; modelled RD for achieving the MID, 15%) reduced pain. Only NSAIDs reduced the need for rescue medication (relative risk [RR], 0.31; 95% CI, 0.14 to 0.68; modelled RD, 16% fewer patients).

Neither NSAIDs (RR, 0.69; 95% CI, 0.31 to 1.55) nor acetaminophen (RR, 0.63; 95% CI, 0.21 to 1.87) increased the risk of short-term gastrointestinal adverse events. All other comparisons showed moderate-certainty evidence of little to no difference from placebo or were supported by low/very low–certainty evidence. Compared with placebo, NSAIDs, ketamine, and mid-to high-potency opioids are effective in reducing acute pediatric pain. NSAIDs provide the greatest benefits and least harm, suggesting that they should be the first-line therapy for acute painful conditions in children.