What pain relief medications should I prescribe for regular and PRN use for a 3-year-old female with a left ulnar fracture?

Pain Management for a 3-Year-Old Female with Left Ulnar Fracture

For a 3-year-old female with a left ulnar fracture, regular acetaminophen (paracetamol) at 15 mg/kg every 4-6 hours should be prescribed as first-line regular pain relief, with ibuprofen 10 mg/kg every 6-8 hours as PRN for breakthrough pain. 1

Primary Pain Management Strategy

Regular Medication

• Acetaminophen (Paracetamol)
  • Dosage: 15 mg/kg per dose
  • Frequency: Every 4-6 hours
  • Maximum daily dose: 60 mg/kg/day
  • Administration: Oral liquid formulation

PRN (As-Needed) Medication

• Ibuprofen
  • Dosage: 10 mg/kg per dose
  • Frequency: Every 6-8 hours (not to exceed 40 mg/kg/day)
  • Administration: Oral liquid formulation

Evidence-Based Rationale

This recommendation follows the European Society for Paediatric Anaesthesiology (ESPA) pain management guidelines 1, which provide specific dosing for pediatric patients with acute pain. For a 3-year-old child in the 1-5 years age group, acetaminophen is considered first-line therapy due to its safety profile and effectiveness.

The combination of acetaminophen and ibuprofen provides superior analgesia through different mechanisms of action:

• Acetaminophen works centrally to reduce pain perception
• Ibuprofen provides both analgesic and anti-inflammatory effects, which is particularly beneficial for fracture pain

Research has shown that ibuprofen provides equivalent or better analgesia than paracetamol for pediatric limb fractures 2, 3, making it an excellent choice for breakthrough pain.

Implementation Considerations

Practical Administration Tips

• Ensure accurate weight-based dosing
• Use calibrated measuring devices (not household spoons)
• Administer with food to minimize GI effects (particularly for ibuprofen)
• Maintain a pain diary to track effectiveness

Non-Pharmacological Approaches

• Proper immobilization of the fracture
• Application of ice packs (with appropriate protection to prevent cold injury)
• Elevation of the affected limb
• Age-appropriate distraction techniques

Monitoring and Follow-Up

• Assess pain regularly using age-appropriate pain scales
• Monitor for potential side effects:
  • Acetaminophen: Hepatotoxicity (with overdose)
  • Ibuprofen: GI upset, potential renal effects with prolonged use

Common Pitfalls to Avoid

1. Underdosing: Weight-based dosing is essential for efficacy
2. Irregular administration: Regular dosing provides better pain control than as-needed dosing
3. Overreliance on opioids: The WSES guidelines specifically recommend acetaminophen as first-line treatment for trauma pain in a multimodal approach 1
4. Inadequate immobilization: Proper splinting/casting is crucial for pain management

Special Considerations

If pain control is inadequate with acetaminophen and ibuprofen:

• Consider adding tramadol 1-1.5 mg/kg every 4-6 hours as a second-line PRN medication 1
• Avoid codeine due to variable metabolism and potential respiratory depression in children
• For severe breakthrough pain requiring additional intervention, consult with pediatric pain specialists

This approach prioritizes effective pain management while minimizing risks, particularly avoiding unnecessary opioid exposure in young children.