How Much Opioid Do Kids Actually Need? A Prospective Study of Analgesic Prescribing and Postdischarge Opioid Use Among Pediatric Patients With Operative Fractures.

Background: Analgesic guidelines are lacking for most operative pediatric fractures, and little is known about postdischarge opioid use or pain control. We hypothesized that opioid/acetaminophen/non-steroidal anti-inflammatory drugs (NSAID) prescribing would vary, pain would be well controlled, and postdischarge opioid use would be low.

Methods: This prospective cohort study included nonpolytraumatized patients aged 17 years and below with operative fractures at a level 1 trauma center from August 1, 2019 to March 31, 2021. Supracondylar humerus fractures were excluded since they have been studied extensively. Information regarding injury/surgery/analgesics were collected. Discharged patients were called on postoperative days (POD) 1/3/5. Parents/guardians were asked about analgesic use and pain over the preceding 2 days. Complications, pain control, and opioid refills were recorded after first follow-up.

Results: All 100 eligible patients were included. Mean age was 10.1 years (range: 1.8 to 17.8 y). Common fracture types were humeral condyle/epicondyle (28%), radius/ulna (15%), and femoral shaft (13%). Opioids were prescribed to 95% of patients with mean 14 doses (range: 2 to 45). Acetaminophen/NSAIDs were prescribed to 74% and 60% of patients, respectively. Eleven patients were excluded from telephone follow-up (7 non-English speaking, 3 prohibitive social situations, 1 inpatient POD1 to 5). Telephone follow-up was completed for 87/89 eligible patients (98%). Mean pain scores declined from 3.7/10 POD1 to 2.4/10 POD5. Opioids were taken by 50% POD1, 20% POD5. Acetaminophen/NSAID was given before opioid 82% of the time. By POD5, mean total doses of opioid taken postdischarge was 2.3; mean proportion of prescribed opioid doses taken was 22%; and 97% of patients took ≤8 opioid doses postdischarge. Two patients were evaluated early due to poor pain control which improved with cast changes. Pain was well controlled or absent at follow-up in 97% of patients.

Conclusions: Pain is consistently well controlled after operative pediatric fractures. Nearly all were prescribed opioids, while acetaminophen/NSAIDs were inconsistently prescribed and used. Opioid prescriptions are written for 4 to 5 times the amount needed. Prescribing ≤8 doses of opioid is adequate for acute pain through POD5 in 97% of patients. Poorly controlled pain should prompt early evaluation for possible complications.

Level Of Evidence: Level II-prospective comparative study.