Olejnik Laura, Lima João Pedro, Sadeghirad Behnam, Busse Jason W, Florez Ivan D, Ali Samina, Bunker James, Jomaa Danny, Bleik Adam, Eltorki Mohamed
Department of Emergency Medicine, London Health Sciences, London, Ontario, Canada.
Department of Pain and Anesthesia, Western University, London, Ontario, Canada.
JAMA Pediatr. 2025 Apr 1;179(4):407-417. doi: 10.1001/jamapediatrics.2024.5920.
Several pharmacologic options exist for the management of acute pediatric pain; however, their comparative effectiveness remains uncertain.
To assess the relative benefits and harms of pharmacotherapy for acute pediatric pain through a network meta-analysis of randomized clinical trials.
Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL, Web of Science, and Scopus to October 2023.
Trials that enrolled children (aged <18 years) with acute pain and randomized them to receive a pharmacologic analgesic vs an alternate analgesic or placebo were included.
Pairs of reviewers independently reviewed abstracts, extracted data, and assessed risk of bias of eligible trials. A frequentist random-effects model was used for all meta-analyses, and the certainty of evidence was assessed for treatment effects using the Grading of Recommendations Assessment, Development, and Evaluation approach.
The primary outcomes were pain severity (range, 0-10 cm using a visual analog scale; minimally important difference [MID], 1 cm), need for rescue medication, symptom relief, and adverse drug events.
A total of 41 trials involving 4935 children were included. High- to moderate-certainty evidence found that compared with placebo, nonsteroidal anti-inflammatory drugs (NSAIDs) (weighted mean difference [WMD], -1.29; 95% CI, -1.89 to -0.70; modeled risk difference [RD] for achieving the MID, 16%), ketamine (WMD, -1.12; 95% CI, -2.09 to -0.14; modeled RD for achieving the MID, 14%), and mid-high potency opioids (WMD, -1.19; 95% CI, -1.83 to -0.55; modeled RD for achieving the MID, 15%) reduced pain. Only NSAIDs reduced the need for rescue medication (relative risk [RR], 0.31; 95% CI, 0.14 to 0.68; modeled RD, 16% fewer patients). Neither NSAIDs (RR, 0.69; 95% CI, 0.31 to 1.55) nor acetaminophen (RR, 0.63; 95% CI, 0.21 to 1.87) increased the risk of short-term gastrointestinal adverse events. All other comparisons showed moderate-certainty evidence of little to no difference from placebo or were supported by low/very low-certainty evidence.
Compared with placebo, NSAIDs, ketamine, and mid- to high-potency opioids are effective in reducing acute pediatric pain. NSAIDs provide the greatest benefits and least harm, suggesting that they should be the first-line therapy for acute painful conditions in children.
治疗儿童急性疼痛有多种药物选择；然而，它们的相对疗效仍不确定。
通过对随机临床试验的网状荟萃分析，评估药物治疗儿童急性疼痛的相对益处和危害。
截至2023年10月的考克兰系统评价数据库、Medline、Embase、护理学与健康领域数据库（CINAHL）、科学引文索引（Web of Science）和Scopus。
纳入了招募急性疼痛儿童（年龄<18岁）并将其随机分组接受药物镇痛剂与替代镇痛剂或安慰剂的试验。
由两名评审员独立审查摘要、提取数据并评估符合条件试验的偏倚风险。所有荟萃分析均使用频率学派随机效应模型，并采用推荐分级的评估、制定和评价方法评估治疗效果的证据确定性。
主要结局包括疼痛严重程度（范围为0至10厘米，采用视觉模拟量表；最小重要差异[MID]为1厘米）、急救药物需求、症状缓解及药物不良事件。
共纳入41项试验，涉及4935名儿童。中高确定性证据表明，与安慰剂相比，非甾体抗炎药（NSAIDs）（加权平均差[WMD]，-1.29；95%置信区间，-1.89至-0.70；达到MID的模拟风险差[RD]为16%）、氯胺酮（WMD，-1.12；95%置信区间，-2.09至-0.14；达到MID的模拟RD为14%）和中高效力阿片类药物（WMD，-1.19；95%置信区间，-1.83至-0.55；达到MID的模拟RD为15%）可减轻疼痛。只有NSAIDs可减少急救药物需求（相对风险[RR]，0.31；95%置信区间，0.14至0.68；模拟RD，患者减少16%）。NSAIDs（RR，0.69；95%置信区间，0.31至1.55）和对乙酰氨基酚（RR，0.63；95%置信区间，0.21至1.87）均未增加短期胃肠道不良事件的风险。所有其他比较均显示中确定性证据表明与安慰剂差异不大或得到低/极低确定性证据的支持。
与安慰剂相比，NSAIDs、氯胺酮和中高效力阿片类药物在减轻儿童急性疼痛方面有效。NSAIDs益处最大且危害最小，表明它们应作为儿童急性疼痛状况的一线治疗药物。
