Management of Acute Pain in Children: Pharmacologic

Nonsteroidal Anti-inflammatory Drugs

Except in the newborn period, when the half-life after administration is significantly longer, the pharmacodynamics and pharmacokinetics of the NSAIDs in children are not much different than in adults.²⁷ Children appear to have a lower incidence of renal and GI side effects^28,29 than adults even with chronic administration.³⁰

Ibuprofen is frequently chosen for mild to moderate pain, because it is available in a liquid form allowing for easy administration to younger children. Since it became available as an over-the-counter medication for fever reduction as well as pain relief, there is a large amount of clinical experience in infants and children with this drug. A review of short-term ibuprofen use in a large cohort of children revealed no increase in clinically significant renal or GI side effects compared to acetaminophen.²⁹

View Initial Dosage Guidelines for Nonopioid Analgesics in Infants and Children

Ketorolac is the only parenteral NSAID currently available in the U.S. It has been used both as an adjuvant to opioid analgesia, and as a single agent for the treatment of postoperative pain in children and adolescents.^31,32 One study demonstrated that the administration of a single dose of 0.8 mg/kg of ketorolac could reduce the need for self-administered opioid analgesia by approximately 30% in the first 12 hours after surgery.³³ This led to a significant reduction in urinary retention compared to opioid analgesia alone. Dosage recommendations have been reduced in the last few years to 0.25 to 0.5 mg/kg every 6 hours with no requirement for a loading dose. A review of the short-term use (48 hours) of intravenous ketorolac in over 1,700 children demonstrated a low rate of complications.³⁴

Several selective COX-2 inhibitors have been introduced into clinical practice in the past several years. Adult studies have found that, in comparison with traditional NSAIDs, COX-2 inhibitors demonstrate a significantly lower incidence of gastritis or ulcers, and preservation of platelet function.^35,36 Unfortunately, cardiovascular toxicity data in adult patients has led to the removal of rofecoxib and valdecoxib from the market and none of these agents has undergone formal study in pediatric patients. Only the COX-2 inhibitor, celecoxib, is available for oral administration. Intravenous forms of the COX-2 inhibitors are currently under investigation (e.g., parecoxib) and while they may be particularly beneficial for children when oral dosing is not feasible their future availability is uncertain.