15 June 2023

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Management of acute pain in childhood

Lara Figini

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The management of intense pain in childhood is often difficult and causes concern both for the parents of the young patient and clinician.

At the pharmacological level, there are two types of drugs commonly administered: non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. NSAIDs possess anti-inflammatory, analgesic, antipyretic and antiplatelet properties. The main categories of NSAIDs are salicylic acids (aspirin), propionic acids (ibuprofen, naproxen) and selective inhibitors of cyclo-oxygenase-2 (celecoxib).

Adverse events associated with NSAID absorption include an increased incidence of cardiovascular events, increased platelet function, decreased renal blood flow and gastritis with pain and bleeding.

Acetaminophen is a pain reliever often prescribed for mild to moderate pain and is primarily an antipyretic. To date, there are no clinical practice guidelines that provide recommendations to assist patients and dentists in determining the most appropriate pharmacological strategies for the management of acute dental pain.

Materials and methods

In a systematic review published in the Journal of the American Dental Association in May 2023, the authors evaluated the clinical efficacy of analgesics for the management of acute pain after tooth extractions and pain associated with irreversible pulpitis in children.

Researchers conducted a literature search through Medline, Embase, the Cochrane Central Register of Controlled Trials, and the U.S. Clinical Trials Registry through November 2020. They included randomized controlled trials comparing all pharmacological interventions with a placebo in pediatric participants undergoing tooth extractions or with intense pain due to irreversible pulpitis.

After screening and data extraction, the authors conducted a random effects meta-analysis. They assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool and the certainty of the evidence using the Grading of Recommendations Assessment, Development and Development Evaluation approach.

Results

The authors included six randomized controlled trials reporting eight comparisons. The review data showed that ibuprofen may reduce pain intensity more than acetaminophen (mean difference [MD], 0.27 points; 95% CI, 0.13 to 0.68; low certainty) and a placebo (MD, 0.19 points; 95% CI, 0.58 to 0.21; low certainty).

Acetaminophen may reduce pain intensity compared with placebo (MD, 0.13 points; 95% CI, 0.52 to 0.26; low certainty). Acetaminophen and ibuprofen combined reduce pain intensity compared with acetaminophen alone (MD, 0.75 points; 95% CI, 1.22 to 0.27; moderate certainty) and ibuprofen alone (MD, 0.01 point; 95% CI, 0.53 to 0.51; moderate certainty).

There has been little research regarding the adverse effects of these drugs.

Conclusions

From the data of this study, it can be concluded that there are no studies addressing the effects of analgesics for pain management in irreversible pulpitis in children.

Regarding the effects of analgesics for the treatment of pain after tooth extractions, ibuprofen can reduce pain intensity compared to a placebo and paracetamol.

The combination of paracetamol and ibuprofen reduces pain intensity compared to paracetamol alone and ibuprofen alone.

For more information: "Analgesics for the management of acute dental pain in the pediatric population. A systematic review and meta-analysis."