What are the recommended pain management medications for a child with a fracture?

Pain Management for Children with Fractures

Acetaminophen and ibuprofen should be used as first-line medications for pain management in children with fractures, with weight-based dosing and regular administration rather than as-needed. 1

First-Line Medications

Acetaminophen

• Dosage: 15 mg/kg per dose every 4-6 hours
• Maximum daily dose: 60 mg/kg/day
• Administration: Oral liquid formulation preferred for children 1, 2

Ibuprofen

• Dosage: 10 mg/kg per dose every 6-8 hours
• Maximum daily dose: 40 mg/kg/day
• Administration: Oral liquid formulation preferred for children 1, 3

Pain Management Algorithm Based on Pain Severity

Mild Pain

• Acetaminophen OR ibuprofen alone 4
• Regular administration rather than as-needed

Moderate Pain

• Combination of acetaminophen AND ibuprofen 4
• Research shows this combination provides superior pain relief compared to either medication alone

Severe Pain

• Ibuprofen AND morphine (0.5 mg/kg orally) 4, 5
• Note: Ibuprofen has been shown to be as effective as morphine for fracture pain but with significantly fewer adverse effects (30.9% vs 56.1%) 5

Non-Pharmacological Interventions

• Proper immobilization of the fracture
• Application of ice packs (20 minutes on, 20 minutes off)
• Elevation of the affected limb
• Age-appropriate distraction techniques 1

Special Considerations

Regional Anesthesia

For severe pain or complex fractures, consider regional anesthesia techniques:

• Femoral nerve block for femur fractures
• Fascia iliaca compartment block
• Landmark-based or ultrasound-guided blocks with long-acting local anesthetics 6

Important Evidence Highlights

• Multiple studies have shown ibuprofen to be at least as effective as acetaminophen with codeine for fracture pain, with fewer side effects 7, 8
• A randomized clinical trial demonstrated that ibuprofen provides better functional outcomes (play, sleep, eating, school) compared to acetaminophen with codeine 8
• Another study showed no significant difference in pain relief between ibuprofen and paracetamol (acetaminophen) for pediatric limb fractures 9

Monitoring and Follow-up

• Assess pain regularly using age-appropriate pain scales
• Monitor for potential side effects:
  • Acetaminophen: Hepatotoxicity with overdose
  • NSAIDs: GI upset, potential renal effects with prolonged use
  • Opioids: Respiratory depression, constipation, nausea 1

Common Pitfalls to Avoid

1. Underdosing pain medications or using "as needed" instead of scheduled dosing
2. Relying solely on opioids when non-opioid options may be equally effective with fewer side effects
3. Failing to reassess pain after treatment (studies show this happens in up to 57% of cases) 4
4. Not providing clear instructions to parents/caregivers about proper medication administration

By following this evidence-based approach to pain management for pediatric fractures, clinicians can effectively control pain while minimizing adverse effects and improving functional outcomes.