Ibuprofen Better Than Morphine After Minor Surgery in Kids

Veronica Hackethal, MD

October 10, 2017

Ibuprofen has fewer adverse effects and may be better than oral morphine for pain relief in children after minor orthopaedic outpatient surgery, according to a study published online today in the Canadian Medical Association Journal.

"In this trial of at-home pain management in children who underwent minor orthopedic surgery, both oral morphine and ibuprofen reduced pain with no apparent difference in analgesic efficacy," write Naveen Poonai, MD, from Western University in London, Ontario, Canada, and colleagues. "Oral morphine was associated with significantly more adverse effects, which suggests that ibuprofen is a safer first-line analgesic."

Unlike oral morphine, ibuprofen is readily available over the counter, relatively inexpensive, has less addictive potential, and has less severe consequences in the case of overdose or accidental ingestion.

Yet oral morphine has become increasingly popular for treating pain after minor pediatric surgery, despite the fact that its efficacy for home use in this setting has yet to be supported by research.

Therefore, Dr Poonai and colleagues conducted a randomized controlled trial that included 154 children who had undergone minor orthopaedic outpatient surgery at Children's Hospital, London Health Sciences Centre, Ontario, Canada, between June 2013 and September 2016. Participants were aged 5 to 17 years; 46% were female.

The investigators randomly assigned patients to receive home care with oral morphine (0.5 mg/kg) or oral ibuprofen (10 mg/kg). Participants could take one dose every 6 hours, up to a maximum of eight doses 48 hours after discharge.

Children self-reported their pain just before and 30 minutes after taking a dose, using the Faces Pain Scale. This scale is recommended for assessing pediatric pain and was revised for postoperative use in children aged 4 to 12 years, but has not been validated for home use.

Results showed that more than 80% of children needed pain relief within the first 24 hours of surgery.

Ibuprofen and oral morphine showed no difference in efficacy. For both medications, pain scores before and after the first dose decreased by one, which is the minimal change needed to be considered clinically important (P = .2).

For the remainder of the doses, morphine and ibuprofen both decreased pain scores, with no significant differences between the two groups (P = .4).

However, the morphine group reported significantly more adverse effects than the ibuprofen group (69% vs 39%, respectively; P < .001). The most common adverse effects with morphine were drowsiness (48%) and nausea (46%).

The authors mentioned several limitations, including the possibility that results may not generalize to children with more than moderate levels of pain.

They also highlighted results showing that neither drug provided adequate pain relief.

"This result suggests that adequate pain management should be an important goal of care, even after minor outpatient surgery, and that more effective pharmacologic and nonpharmacologic strategies should be explored," they conclude.

The authors have disclosed no relevant financial relationships.

CMAJ. 2017;189:E1252-E1258. Full text

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