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To compare the effectiveness and safety of prescribing ibuprofen and oxycodone for at-home management of children's fracture pain. A prospective observational cohort was conducted at the Stollery Children's Hospital pediatric emergency department (June 2010-July 2014). Children aged 4-16 years with an isolated fracture discharged home with advice to use either ibuprofen or oxycodone were recruited. A cohort of 329 children (n = 217 ibuprofen, n = 112 oxycodone) were included. Mean age was 11.1 years (SD 3.5); 68% (223/329) were male. Fracture distribution included 80.5% (264/329) upper limb with 34.3% (113/329) requiring fracture reduction. The mean reduction in Faces Pain Score-Revised score (maximum pain-post-treatment pain) for Day 1 was 3.6 (SD 1.9) (ibuprofen) and 3.8 (SD 2.1) (oxycodone) (p = 0.50); Day 2 was 3.6 (SD 1.8) (ibuprofen) and 3.7 (SD 1.6) (oxycodone) (p = 0.56); Day 3 was 3.7 (SD 1.7) (ibuprofen) and 3.3 (SD 1.7) (oxycodone) (p = 0.24). Children prescribed ibuprofen (51.2%, 109/213) experienced less adverse events compared to those prescribed oxycodone (70.5% 79/112) on Day 1 (p = 0.001). Children prescribed ibuprofen (71.8%, 150/209) had their function (eat, play, school, sleep) affected less than those prescribed oxycodone (83.0%, 93/112) (p = 0.03) on Day 1. Children prescribed ibuprofen or oxycodone experienced similar analgesic effectiveness for at-home fracture pain. Oxycodone prescribing was associated with more adverse events and negatively impacted function. Oxycodone use does not appear to confer any benefit over ibuprofen for pain relief and has a negative adverse effect profile. Ibuprofen appears to be a safe option for fracture-related pain.

Cannabis ingestions in young children frequently lead to emergency department (ED) visits requiring substantial diagnostic evaluation, including advanced neuroimaging. We assessed the relationship between presenting chief complaint, timing of cannabis test results, and the use of advanced neuroimaging in these visits. In this retrospective study using Epic's Cosmos database (January 2016 – June 2024), we included ED visits for children <6 years with a cannabis poisoning diagnosis and cannabis laboratory test. We described clinical characteristics and illustrated timing of drug testing results during these ED visits. We compared use of neuroimaging by chief complaint, using chi-squared tests and logistic regression. There were 3653 encounters included. Median age was 29 (IQR 16–45) months and the cohort was 51 % female, 41 % White, 35 % Black, and 15 % Hispanic. The most common category of chief complaint was altered mental status (39 %), followed by ingestion/exposure (35 %), with seizures/abnormal movements present in 5 %. The median times from ED arrival to cannabis test collection and result were 93 (IQR 40–208) and 152 (IQR 90–277) minutes respectively. Neuroimaging was performed in 35 % of encounters, with significantly lower use in those with ingestion vs. neurologic chief complaints (8.8 % vs. 56 %; OR 0.08, 95 % CI: 0.06–0.10). For children with cannabis poisoning, drug screen results were frequently unavailable until late in ED visits, and presenting chief complaint strongly influenced the use of neuroimaging. These findings underscore the need for strategies to facilitate early caregiver disclosure of ingestion and expedite drug screening to optimize care.

In adolescents and young adults, suicide is the second leading cause of death [1]. Suicide is a growing public health concern which requires ongoing effort to identify patients with suicidal ideation early to provide necessary resources and interventions to prevent negative outcomes.Financial support This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.Author contributions Michelle L Pickett: Conceptualization, methodology, formal analysis, writing-original draft, visualization; Callie Krentz: Data curation, formal analysis, writing-original draft; Mark Nimmer: Data curation, formal analysis, writing-review and editing; Ashley Servi: conceptualization, writing-review and editing; Anna Schmitz: Methodology, writing-review and editing; Amy L Drendel: Conceptualization, writing-review and editing, supervision.Presentation This was presented as a poster presentation at the Pediatric Academic Societies annual meeting in Baltimore, Maryland in April 2019.Declaration of Competing Interest None. Screened (N = 1577) Not screened (N = 484) p-Value Gender, female 851 (54.0) 255 (52.7) 0.622 Age 0.279 11–14 years old 862 (54.7) 251 (51.9) 15–18 years old 715 (45.3) 233 (48.1) Chief complaint 0.023 Non-psychiatric 1494 (94.7) 445 (91.9) Psychiatrica 83 (5.3) 39 (8.1) Triage level <0.001 1 4 (0.25) 14 (2.9) 2 193 (12.2) 121 (25.0) 3 781 (49.5) 208 (43.0) 4 516 (32.7) 108 (22.3) 5 83 (5.3) 21 (4.3) Unknown 0 (0.0) 12 (2.5) Disposition <0.001 Discharged 1373 (87.1) 332 (68.6) Admitted 178 (11.3) 114 (23.6) AMA/Eloped/LWBSb 5 (0.32) 15 (3.1) Transferred (psychiatric) 17 (1.1) 18 (3.7) Transferred (non-psychiatric) 4 (0.26) 3 (0.61) Unknown 0 (0.0) 2 (0.40) Table 2 Comparison of screened and not screened patient encounters during the post-implementation period, N (%).

The emergency department (ED) is a stressful environment for children. Few studies assess pediatric anxiety in the ED. “Gold standard” for measuring state-anxiety, Spielberger's State-Trait Anxiety Inventory for Children (STAI-C state), is lengthy and of limited use in this setting. The objective was to evaluate agreement between STAI-C, Likert, and modified Yale Preoperative Anxiety Scale (m-YPAS) and determine if shorter measures may be adequate replacements for STAI-C in the ED. This is a secondary analysis of data from a previous observational cohort study of a convenience sample of children 5–17 years old presenting to the ED. Anxiety was measured using STAI-C, Likert, and m-YPAS. Spearman correlations were used to evaluate agreement between STAI-C and the brief scales. A sub-analysis evaluated agreement between scales for children ≥9 years old to assess the impact of age. Eighty children were included. Median (IQR) STAI-C state score was 32.5 (30.0, 37.8). This represents moderate state anxiety with 30% of children exhibiting elevated state anxiety. Median (IQR) Likert score was 2.0 (1.0, 2.0). Correlation between the Likert and STAI-C was moderate (rs = 0.51; p < 0.0001). Median (IQR) m-YPAS was 28.3 (24.2, 33.3). The m-YPAS and STAI-C were unrelated (rs = 0.12; p > 0.05). For children ≥9 years old, correlation between Likert and STAI-C remained moderate (rs = 0.52; p < 0.0001); STAI-C and m-YPAS were unrelated (rs = 0.10; p > 0.05). Children in the ED experienced moderate-elevated state anxiety. Likert scale may be an acceptable substitute for STAI-C state. Further studies of this scale will aid in identifying patients with anxiety to facilitate timely management.

Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

Introduction: After discharge from the emergency department (ED), pain management challenges parents, who have been shown to undertreat their children’s pain. Our goal was to evaluate the effectiveness of a five-minute instructional video for parents on pain treatment in the home setting to address common misconceptions about home pediatric pain management. Methods: We conducted a randomized, single-blinded clinical trial of parents of children ages 1-18 years who presented with a painful condition, were evaluated, and were discharged home from a large, tertiary care pediatric ED. Parents were randomized to a pain management intervention video or an injury prevention control video. The primary outcome was the proportion of parents that gave their child pain medication at home after discharge. These data were recorded in a home pain diary and analyzed using the chi square test to determine significant difference. Parents’ knowledge about components of at-home pain treatment were tested before, immediately following, and two days after intervention. We used McNemar’s test statistic to compare incorrect pretest/correct post-test answers between intervention and control groups. Results: A total of 100 parents were enrolled: 59 parents watched the pain education video, and 41 the control video. Overall, 75% of parents completed follow-up, providing information about home medication use. Significantly more parents provided pain medication to their children after watching the educational video: 96% vs 80% (difference 16%; 95% CI 7.8-31.3%). Significantly more parents had correct pain treatment knowledge immediately following the educational video about pain scores (P = 0.04); the positive effects of analgesics (P <0.01); and pain medication misconceptions (P = 0.02). Most differences in knowledge remained two days after the video intervention. Conclusion: The five-minute educational video about home pain treatment viewed by parents in the ED prior to discharge significantly increased the proportion of children receiving pain medication at home as well as parents’ knowledge about at-home pain management.

IntroductionMusculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children’s pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference.Methods and analysisUsing a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019.Ethics and disseminationThis study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant.Trial registration numberNCT03767933, first registered on 07 December 2018.

Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0–18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.

ObjectiveTo quantify the frequency and intensity of adverse events (AEs), commonly known as side effects, experienced by children receiving either ibuprofen or oxycodone for pain management following an acute fracture. Secondary objectives were to quantify functional outcome impairment and describe demographic and clinical characteristics associated with AEs.DesignObservational cohort study.SettingPaediatric emergency department.PatientsPatients (n=240) aged 4–16 years diagnosed with an acute fracture.InterventionPrescribed either ibuprofen (n=179) or oxycodone (n=61) for pain.Main outcome measuresFamilies were called for the first 3 days after discharge to report the presence and intensity of AEs and their child’s functional outcomes (ability to eat, sleep, play or attend school).ResultsOn day 1, children using oxycodone were more likely to report any AE (χ21=13.5, p<0.001), nausea (χ21=17.0, p<0.001), vomiting (χ21=11.2, p<0.001), drowsiness (χ21=13.7,p<0.001), constipation (χ21=8.9, p=0.003) and dizziness (χ21=19.1, p<0.001), compared with those using ibuprofen. Children receiving oxycodone reported greater severity of abdominal pain (oxycodone: mean 5.4 SD 3.1; ibuprofen mean 2.5 SD 1.4, F113=6.5, p=0.02) on day 1 and worse intensity of constipation (oxycodone: mean 4.9 SD 2.1; ibuprofen mean 3.2 SD 2.2, F133=4.5, p=0.04) over all 3 days. Use of oxycodone was associated with an increased odds of experiencing an AE on day 1 (OR=1.31 (95% CI 1.13 to 1.52)). Higher pain scores (OR=1.50 (95% CI 1.12 to 2.01)), lower extremity fracture (OR=1.25 (95% CI 1.07 to 1.47)) and undergoing ED sedation (OR=1.16 (95% CI 1.01 to 1.34)) were associated with missing school. Higher pain scores (OR=1.50 (95% CI 1.14 to 1.97)) and lower extremity fractures (OR=1.23 (95% CI 1.07 to 1.43)) were also associated with less play.ConclusionsOxycodone is associated with more frequent AEs overall, higher intensity gastrointestinal AEs and greater functional limitations compared with ibuprofen. Lower extremity fractures cause more functional limitations than upper extremity fractures. Clinicians should consider these differences when providing fracture pain care for children.