Doctor, I have a child with acute pain. What medication can I give them for pain relief?

Nonsteroidal anti-inflammatory drugs (NSAIDs) were the best at relieving pain and had the fewest side effects, making them the preferred first choice of treatment of pain that was present for less than 4 weeks. Only NSAIDs reduced the need for extra pain medication. Other treatments were either no better than placebo (inactive treatment) or had a higher risk of side effects.

What is the evidence?

SUMMARY OF FINDINGS

Comparison of Medications for Management of Acute Pain* in Children and Adolescents

Outcome	Medication	Change in VAS* Score (cm)	Certainty of Evidence
Pain relief	NSAIDs (e.g., ibuprofen, naproxen, ketorolac)	-1.29	High
Pain relief	Mid-high potency opioids (e.g., morphine, oxycodone, fentanyl)	-1.19	Moderate
Pain relief	Ketamine	-1.12	Moderate
Need for more pain medication	NSAIDs	Children who took NSAIDs were 16% less likely to need additional pain medication compared to those who took other types of pain medications.	High

VAS: Visual Analog Scale, a 10-point scale where 0 means no pain and 10 means the worst pain possible (noticeable reduction in pain = 1 cm change); *pain that was present for less than 4 weeks

Outcomes did not differ for children who received acetaminophen, codeine, tramadol, or combination treatments compared with those who received placebo.
NSAIDs provided effective pain relief and were the only treatment that reduced the need for extra medication. They were also no more likely than placebo to cause short-term side effects, making them the preferred first choice for pain relief.
Opioids reduced pain but did not decrease the need for extra pain medication. They were more likely than NSAIDs to cause system side effects, making them a second choice.

What kind of study was this?

This was a systematic review and network meta-analysis. A systematic review summarizes all available studies on a treatment to provide high-quality evidence. A network meta-analysis compares multiple treatments even if they have not been directly compared in the same study.

Who? This review included 41 randomized controlled trials with 4,935 children under 18 years old (average age, 9 years) who had acute pain (pain that was present for less than 4 weeks) from arm or leg injuries, abdominal pain, or ear, nose, and throat conditions. The study did not include children with chronic pain, migraines, or sickle cell crises.

What? The review compared different pain medications, including NSAIDs, acetaminophen, opioids, ketamine, tramadol, and combination treatments, with placebo.

Medications	vs	Placebo or Other Medications
1. NSAIDs (e.g., ibuprofen, naproxen, ketorolac): pain relievers that do not contain narcotics known as opioids. They are available over the counter in many countries. 2. Mid-high potency opioids (e.g., morphine, oxycodone, fentanyl): pain relievers that act on the nervous system. They are only available with a prescription. 3. Ketamine: medication used for pain relief and sedation. This drug can only be given by doctors or nurses.		1. Placebo (an inactive substance that has no effect on the outcome, sometimes referred to as a "sugar pill"), opioids, acetaminophen 2. Any of the other pain-relieving medications.

Medications

Placebo or Other Medications

1. NSAIDs (e.g., ibuprofen, naproxen, ketorolac): pain relievers that do not contain narcotics known as opioids. They are available over the counter in many countries.

2. Mid-high potency opioids (e.g., morphine, oxycodone, fentanyl): pain relievers that act on the nervous system. They are only available with a prescription.

3. Ketamine: medication used for pain relief and sedation. This drug can only be given by doctors or nurses.

1. Placebo (an inactive substance that has no effect on the outcome, sometimes referred to as a "sugar pill"), opioids, acetaminophen

2. Any of the other pain-relieving medications.

Why was this research done?

Pain is one of the most common reasons children visit emergency rooms, affecting nearly 60% of pediatric emergency visits. While several medications are available, which one might be the best for children and adolescents is unclear. This review compared several drugs to find out which ones work the best and have the fewest side effects. The findings show that NSAIDs, mid- to high-potency opioids, and ketamine reduce pain. NSAIDs seem to provide the greatest benefit and have the fewest side effects, which makes them a good first choice for acute pain in children (not including migraines). Most of the studies included in the review were done in emergency departments, so the findings may not apply to all settings where children receive pain treatment. Since the studies focused on short-term pain relief in children or adolescents with acute pain, we do not know how well they work over a longer period of time or with pain that has been present for longer than 4 weeks.

This Evidence Summary is based on the following article:

Olejnik L, Lima JP, Sadeghirad B, et al. Pharmacologic Management of Acute Pain in Children: A Systematic Review and Network Meta-Analysis. JAMA Pediatr. 2025 Feb 3. doi: 10.1001/jamapediatrics.2024.5920. PubMed

Published: Thursday, March 13, 2025

Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.

This Evidence Summary was printed from the PAIN+ CPN website on 2025/04/01.

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