Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain.

We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale — Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose.

We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre–post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) −0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI −0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ −0.1 [95% CI −0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI −0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01).

We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures.

There is ample evidence that analgesia is underused,1 underprescribed,2 delayed in its administration2 and suboptimally dosed 3 in clinical settings. Children are particularly susceptible to suboptimal pain management4 and are less likely to receive opioid analgesia.5 Untreated pain in childhood has been reported to lead to short-term problems such as slower healing6 and to long-term issues such as anxiety, needle phobia,7 hyperesthesia8 and fear of medical care.9 The American Academy of Pediatrics has reaffirmed its advocacy for the appropriate use of analgesia for children with acute pain.10

Fractures constitute between 10% and 25% of all injuries.11 The most severe pain after an injury occurs within the first 48 hours, with more than 80% of children showing compromise in at least 1 functional area.12 Low rates of analgesia have been reported after discharge from hospital.13 A recently improved understanding of the pharmacogenomics of codeine has raised significant concerns about its safety,14,15 and has led to a Food and Drug Administration boxed warning16 and a Health Canada advisory17 against its use. Although ibuprofen has been cited as the most common agent used by caregivers to treat musculoskeletal pain,12,13 there are concerns that its use as monotherapy may lead to inadequate pain management.6,18 Evidence suggests that orally administered morphine13 and other opioids are increasingly being prescribed.19 However, evidence for the oral administration of morphine in acute pain management is limited.20,21 Thus, additional studies are needed to address this gap in knowledge and provide a scientific basis for outpatient analgesic choices in children. Our objective was to assess if orally administered morphine is superior to ibuprofen in relieving pain in children with nonoperative fractures.