Medication With Children And Fractures Essay
Medication With Children And Fractures Essay
The research design applied in any study is determined by the variables as well as the direction taken by the research hypothesis. In the proposed research, the researcher seeks to study the effects of different medications in children with pain fractures admitted in the emergency department. The best design possible here is quantitative translational research design. Translational research design involves the use of basic clinical, lab or population-based data and transforming it into clinical applications, tools, processes or models (Burns & Grove, 2010). Medication With Children And Fractures Essay. Essentially, this design methodology focuses on moving from basic research to clinical knowledge with a view to improving patient outcomes by linking basic research to the point of care.
In this proposed research, the researcher will have to rely on clinical data as recorded in a particular emergency department and this is only for the target population which includes only children with pain fractures (Schmidt & Brown, 2014). The issue being investigated in to determine the effects of three medications usually administered in such clinical cases involving pain fractures. These three medications include IV morphine, oral ibuprofen, and oral Tylenol with codeine. Medication With Children And Fractures Essay. In this case, the target population is defined and the outcomes (effects) will be regarded as the dependent variables upon which the study will draw comparisons. Three groups from the target population will each be subjected to one of the medications and monitored closely by the researcher to determine and record the effects and ultimately the outcomes. The variability within the results of each medication will then be weighed scientifically to determine which medication is more suited to the target population in regard to the pain fractures (Burns & Grove, 2010). The purpose of quantitative translational research is to collect, monitor and disseminate research findings comparatively and ultimately apply that which works best.
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References
Burns, N., & Grove, S. K. (2010). Understanding nursing research: Building an evidence-based practice. Elsevier Health Sciences.
Schmidt, N. A., & Brown, J. M. (2014). Evidence-based practice for nurses. Jones & Bartlett Publishers.
mother brings her 6-year-old son to the emergency department (ED) for treatment of forearm pain after a bicycle accident. Clinical examination reveals a swollen and tender wrist. A radiograph confirms a diagnosis of a nondisplaced distal radial fracture. After proper stabilization, the little boy is discharged home, with a visit to his primary care physician scheduled for the following week. If he were your patient, what would you prescribe for outpatient analgesia?
Musculoskeletal trauma is a common pediatric presentation, in both emergency and office settings. In fact, it is estimated that by age 15, one-half to two-thirds of children will have fractured a bone.4 Physicians commonly prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids—especially acetaminophen with codeine—as analgesia for children with fractures,5 but few studies have directly compared these medications in pediatric patients. Medication With Children And Fractures Essay.
No consensus on analgesia for musculoskeletal pain in kids
Pain associated with an acute fracture is substantial, and most children who incur fractures are managed at home, and thus require effective and well-tolerated oral analgesia. However, prescribing practices vary widely, and there is no consensus regarding the first-line medication for kids with fracture.
A Cochrane review of adult postoperative pain concluded that NSAIDs are effective, and they are commonly prescribed to adult patients for various types of pain.6 Fewer studies of pain control in children exist. Before the 2009 study reported on here, there were just 2 RCTs that addressed pediatric musculoskeletal pain in patients presenting to the ED.
In single-dose studies, ibuprofen comes out ahead
The smaller of the 2 trials (N=66) compared ibuprofen alone vs ibuprofen plus oxycodone for suspected orthopedic injury. The researchers found that pain relief was equivalent, but the oxycodone group had more adverse effects.2 The larger trial (N=336) compared ibuprofen, acetaminophen, and codeine for acute pediatric musculoskeletal injuries. An hour after receiving their study drug, children in the ibuprofen group had significantly greater reduction in pain than those in either the acetaminophen group or the codeine group. They were also more likely to report adequate analgesia.3 Neither study followed patients after discharge from the ED.
STUDY SUMMARY: New RCT evaluates pain relief once patients go home
The Drendel study was a randomized, controlled, double-blind trial of outpatient analgesia for pediatric fractures.1 The investigators randomized 336 children ages 4 to 18 years with radiographically confirmed arm fractures to a suspension of either ibuprofen (10 mg/kg) or acetaminophen with codeine (1 mg/kg codeine component per dose), which are recommended dosages. They enrolled a convenience sample of children with nondisplaced fractures that did not require reduction in the ED.
Children were excluded if they weighed more than 60 kg, preferred tablets to liquid medication, sought care more than 12 hours after injury, or had developmental delays or contraindications to any study medication. Also excluded were children—or their parents—who did not speak English and those who were inaccessible by telephone for follow-up.
Study groups had similar baseline demographic and fracture characteristics, and similar pain scores. Patients and their parents were blinded to the assigned drug; all received the same discharge instructions and 2 doses of a rescue medication (the alternate study drug). Medication With Children And Fractures Essay. The primary outcome was use of rescue medication due to failure of the assigned study drug. Secondary outcomes included decrease in pain score, functional outcomes (play, school, eating, sleeping), and satisfaction with the medication.
During the 72 hours after discharge from the ED, patients and parents filled out a standard diary recording pain and medication use. The diaries were returned by mail. Follow-up was good, with about 75% of diaries returned.
Ibuprofen users had fewer problems
Analysis of 244 diaries revealed that less rescue medication was used in the ibuprofen group, although the difference was not statistically significant (20.3% vs 31% [absolute risk reduction, 10.7%], 95% confidence interval, -0.2% to 21.6%). Decrease in mean pain score was the same in both groups. Functional status the day after the injury was better in the ibuprofen group compared with the acetaminophen/codeine group. In addition, 50.9% of patients in the acetaminophen/codeine group reported adverse events, vs 29.5% of those in the ibuprofen group (number needed to harm=4.7).
At the study’s end, children were more satisfied with ibuprofen. Only 10% of patients who took ibuprofen said they would not use it for future fractures; in comparison, 27.5% of patients in the acetaminophen/codeine group said they would not choose to use codeine again. Medication With Children And Fractures Essay.
The authors followed participants for 1 to 4 years through orthopedic clinic records and telephone calls for any long-term adverse orthopedic outcomes. Four cases of refracture at the same site occurred (1.6%), 3 of which were in the acetaminophen/codeine group. There were no cases of nonunion.
WHAT’S NEW: Ibuprofen emerges as first-line agent for kids
Both ibuprofen and acetaminophen with codeine are commonly prescribed for outpatient pediatric analgesia, but this is the first study to compare them head-to-head for outpatient management of postfracture pain. Ibuprofen worked at least as well as acetaminophen with codeine for fracture pain control, and had fewer adverse effects. Children given ibuprofen were better able to eat and play than those given acetaminophen with codeine—an important patient-oriented functional outcome. Patients and their parents were also more satisfied when ED physicians prescribed ibuprofen. This study is consistent with short-term (single-dose) studies and confirms that ibuprofen should be the first-line agent for outpatient analgesia in this group.
CAVEATS: Study did not address NSAIDs’ effect on bone healing
In theory, ibuprofen—like other NSAIDs—can diminish the proinflammatory milieu required for bone turnover and fracture healing. Medication With Children And Fractures Essay. Chart reviews of up to 4 years after the incident fracture found no evidence that ibuprofen delayed healing or increased rates of refracture. However, this study was neither designed nor powered to examine this outcome. Previous studies have found no conclusive evidence that short-term use of NSAIDs impairs fracture healing.7,8
Results apply only to simple fractures. Patients in this study did not require manipulation or reduction of their fracture, limiting the scope of the authors’ recommendation to simple arm fractures. More severe injury may require narcotic analgesia. One can assume, based on this and other supporting literature, that the findings extrapolate to other similarly painful pediatric musculoskeletal injuries.2
Twenty-five percent of subjects were lost to follow-up. Follow-up diaries were available from about 75% of the participants. It is possible that a clearer beneficial outcome would have been found with 1 of the analgesics studied if the response rate had been higher. Because this study is consistent with the previous ED-only studies comparing ibuprofen with acetaminophen plus codeine, however, it is unlikely that a higher response rate would find ibuprofen inferior to acetaminophen plus codeine. Medication With Children And Fractures Essay.
CHALLENGES TO IMPLEMENTATION: Parents—or patients—may expect an Rx
Prescribing an effective, common, inexpensive, and well-tolerated oral medication should have no barriers to implementation. Still, use of an over-the-counter medication, however effective, may face resistance from patients or parents who expect “something more” for fracture pain.
Acknowledgments
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources; the grant is a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health. Medication With Children And Fractures Essay.
Contributor Information
Laura Morris, Department of Family and Community Medicine, University of Missouri, Columbia,
Debra Stulberg, Department of Family Medicine, The University of Chicago,
James J. Stevermer, Department of Family and Community Medicine, University of Missouri, Columbia, . Medication With Children And Fractures Essay.
