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Early Analgesia For Children With Acute Abdominal Pain: Objectives
Early Analgesia For Children With Acute Abdominal Pain: Objectives
Early Analgesia For Children With Acute Abdominal Pain: Objectives
Robert Green, MD*; Blake Bulloch, MD‡; Amin Kabani, MD§; Betty Jean Hancock, MD㛳; and
Milton Tenenbein, MD§
P
ABSTRACT. Objectives. The objectives of this study ain is a common symptom among children
were to determine whether the administration of mor- presenting for care at emergency departments
phine to children with acute abdominal pain would im- (EDs). Traditionally, the physician’s focus has
pede the diagnosis of appendicitis and to determine the been on the diagnosis of the condition producing the
efficacy of morphine in relieving the pain. pain, rather than on the relief of the pain. However,
Methods. This was a double-blind, randomized, pla-
cebo-controlled trial involving 5- to 16-year-old children
emergency physicians are now concerning them-
who presented to the emergency department of a chil- selves with the latter, and several authorities have
dren’s hospital with a chief complaint of acute abdomi- produced position statements on the management of
nal pain that was thought by the pediatric emergency pain in EDs.1–3
attending physician to require a surgical consultation. Fifteen percent of school-aged children are
Subjects were randomized to receive intravenously ad- brought to a physician because of abdominal pain,
ministered morphine or normal saline solution. Clinical making this symptom a common presenting com-
data and the emergency physician’s confidence in his or plaint in the pediatric ED.4 The most common seri-
her clinical diagnosis (0 –100%) were recorded systemat- ous, pediatric, abdominal emergency is appendici-
ically with a standardized form. This was repeated 15 tis.5 As with adult patients, it has been thought that
minutes after administration of the study medication.
The surgeon assessed the child within 1 hour and com-
analgesic use among pediatric patients with surgical
pleted a similar data collection sheet. Pain was assessed, abdominal findings may impede the diagnosis. The-
with a color analog scale, before and after study medica- oretically, analgesia may mask pain and subse-
tion administration. Each subject was monitored for 2 quently diminish the physical signs associated typi-
weeks after enrollment. cally with a surgical condition. Current practice in
Results. One hundred eight children were enrolled; pediatric emergency medicine and pediatric surgery
52 received morphine and 56 received a placebo saline dictates that children should not receive analgesics
solution. There were no differences between groups in when presenting with acute abdominal pain.6,7 This
demographic variables or the degree of pain. There were practice among children is a result of traditional
no differences between groups in the diagnoses of ap- teaching and only recently has been challenged in a
pendicitis or perforated appendicitis or the number of
children who were observed and then underwent lapa-
manner similar to that for adults.8
rotomy. The reduction in the mean pain score was sig- There is a need to determine whether the practice
nificantly greater in the morphine group (2.2 vs 1.2 cm). of analgesic administration to pediatric patients with
The emergency physicians’ and surgeons’ confidence in acute abdominal pain impedes the diagnosis of the
their diagnoses was not affected by the administration of condition causing the pain. The objectives of this
morphine. study were to assess whether morphine would in-
Conclusions. Our data show that morphine effec- crease the rate of missed appendicitis, to determine
tively reduces the intensity of pain among children with its efficacy in treating acute pediatric abdominal
acute abdominal pain and morphine does not seem to pain, and to examine its effect on physician confi-
impede the diagnosis of appendicitis. Pediatrics 2005;116: dence in the diagnosis of the condition causing the
978–983; abdominal pain, analgesia, appendicitis, diagnosis,
surgery.
pain.
METHODS
ABBREVIATIONS. CAS, color analog scale; ED, emergency de- This study was conducted in the ED of a tertiary care, aca-
partment; CI, confidence interval; WBC, white blood cell. demic, pediatric ED with an annual census of 39 000. This facility
is staffed by pediatric emergency medicine attending physicians.
The study was a double-blind, randomized, placebo-controlled,
clinical trial, with the primary outcome measure being the rate of
From the *Department of Emergency Medicine, Dalhousie University, Hali- missed appendicitis among children who received intravenous
fax, Canada; ‡Department of Pediatrics, University of Arizona, Tucson, morphine treatment. The secondary outcomes were rates of per-
Arizona; and Departments of §Pediatrics and Child Health and 㛳Surgery, forated appendicitis, delays in diagnosis, pain relief, and confi-
University of Manitoba, Manitoba, Canada. dence of pediatric emergency physicians and pediatric surgeons in
Accepted for publication Jun 1, 2005. the diagnoses. Ethics approval for this study was obtained from
doi:10.1542/peds.2005-0273 our university’s institutional review board.
No conflict of interest declared. Male and female patients between the ages of 5 and 16 years
Reprint requests to (M.T.) Department of Pediatrics and Child Health, (inclusive) who presented with nontraumatic abdominal pain of
Children’s Hospital, 840 Sherbrook St, Winnipeg, Manitoba, Canada R3A ⬍48-hour duration were eligible for the study if, after assessment
1S1. E-mail: mtenenbein@hsc.mb.ca by the attending pediatric emergency physician, it was thought
PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- that a surgical consultation was warranted for a possible surgical
emy of Pediatrics. condition. Exclusion criteria included allergy to opiates, previous
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TABLE 1. Initial Assessment Before Study Drug Administration
Morphine Placebo P Value
Mean initial pain score (95% CI) 6.65 (6.27–7.03) 6.66 (6.29–7.02) .98
Right lower quadrant tenderness, % 100 100 1.00
Positive Rosving sign, % 49.0 55.4 .51
Positive psoas sign, % 69.2 67.9 .88
Positive obturator sign, % 49.1 51.8 .77
Involuntary guarding, % 55.8 50.0 .55
Voluntary guarding, % 65.4 69.6 .64
Time from study drug to surgical 38.5 (33.4–43.6) 44.4 (38.1–50.8) .15
assessment, min
TABLE 2. Outcomes
No. of Patients
Morphine Normal Saline Solution
(N ⫽ 52) (N ⫽ 56)
Laparotomy immediately after ED assessment 25 24
Appendicitis (perforated) 24 (12) 22 (11)
Normal appendix 1 2
Admitted for observation after ED assessment 19 22
Laparotomy 7 6
Appendicitis (perforated) 7 (3) 4 (1)
Normal appendix 0 2
No laparotomy 12 16
Urinary tract infection 0 1
Ovarian cyst 0 1
Self-resolving pain 12 14
Discharged home after ED assessment 8 10
Self-resolving pain 5 9
Subsequent laparotomy for appendicitis 1 (4 mo later) 1 (5 d later)
Pneumonia 1 0
Urinary tract infection 1 0
had final diagnoses of appendicitis. Perforated ap- group, compared with 1.2 cm in the placebo group (P
pendicitis occurred for 27 patients, with no differ- ⫽ .015).
ence between groups (P ⫽ .51). Laparotomies were The emergency physicians thought that the pain
performed for 4 patients with normal appendices in had diminished for 46 (88.5%) children who received
the placebo group and 1 in the morphine group. The morphine, compared with 33 (63.5%) children in the
incidences of other diagnoses and self-resolving ab- placebo group (P ⫽ .0005). No emergency physician
dominal pain were not different between the groups thought that the pain grew worse in either group, but
(P ⫽ .70). physicians thought that the pain was unchanged for
Of the 41 children admitted for observation, 13 6 (11.5%) children in the morphine group and 23
underwent a laparotomy subsequently, ie, 7 in the (44.2%) children in the placebo group (P ⫽ .0002).
morphine group and 6 in the placebo group. All 7 Physician confidence in diagnoses was not altered
children in the morphine group had appendicitis (3 for children who received morphine. Emergency
perforated), as did 4 in the placebo group (1 perfo- physicians recorded no change in their confidence in
rated). There was no difference in the proportions of diagnoses after patients received either morphine or
patients admitted for observation and subsequently placebo. The emergency physician confidence in di-
found to have appendicitis (7 of 19 patients in the agnoses was 68.9% in the morphine group before
morphine group and 4 of 22 patients in the placebo study medication administration, compared with
group; P ⫽ .29). 65.5% in the placebo group. After morphine admin-
Both groups experienced reductions in recorded istration, physician confidence increased to 69.5%
CAS scores, as assessed by self-report. The mean (effect size: 1.2%; 95% CI: ⫺2.9% to 5.3%), compared
pain scores and 95% confidence intervals (CIs) before with 70.9% in the placebo group (effect size: 5.3%;
and after morphine or placebo administration are 95% CI: 2.7–7.9%). Similarly, there was no demon-
shown in Table 3. Figure 2 shows that the reduction strable effect of morphine on the surgeons’ confi-
in the mean pain score was 2.2 cm in the morphine dence in diagnoses. The surgeons were 73.8% confi-
dent of their diagnoses for the morphine group,
TABLE 3. Pain Scores compared with 73.6% for the placebo group (effect
Pain Scores (95% CI) size: 0.01%; 95% CI: ⫺0.39 – 0.40%).
Two children in our study were discharged from
Before After
Administration Administration
the hospital after receiving the study medication and
subsequently returned with acute appendicitis. One
Morphine 6.65 (6.27–7.03) 4.50 (4.11–4.88) child was in the morphine group and returned 4
Normal saline solution 6.66 (6.29–7.02) 5.55 (5.17–5.93)
months later with a perforated appendix. This child
was asymptomatic in the interval between study en- dix was found in the high pelvic region on the sacral
rollment and return to the hospital, making it un- promontory, with the sigmoid colon wrapped
likely that morphine had any effect in delaying the around the left side of it. Infected exudate was found
diagnosis. The other child was in the placebo group on the sigmoid mesentery. The patient fared well
and returned 5 days later with acute appendicitis. after her operation and was discharged from the
All children were monitored specifically for apnea, hospital 5 days later.
hypoxemia, hypotension, or changes in the level of Patient 2 (randomized to the normal saline solu-
consciousness. These adverse events were not ob- tion group) was 11 years of age when he visited the
served in either group. ED because of generalized abdominal pain that had
Four of the 13 children who underwent a laparot- been present for the past 15 hours. This had been
omy after being admitted to the hospital for obser- preceded by a 7-day history of flu-like symptoms
vation were found to have a perforated appendix (sore throat, malaise, and fever). Amoxicillin treat-
and intraabdominal infection. Their operations were ment had been started 1 day before presentation. The
performed 20 to 48 hours after presentation to the patient had a poor appetite and no vomiting or di-
ED. Their case histories are as follows. arrhea. His vital signs were as follows: heart rate: 112
Patient 1 (randomized to the morphine group) was beats per minute; respiratory rate: 20 breaths per
12 years of age when she visited the ED because of minute; temperature: 37.3°C; blood pressure: 122/77
abdominal pain that had begun 4 days previously, in mm Hg. The patient had generalized tenderness over
the periumbilical region. During the previous 3 days, his abdomen, slightly increased in the right lower
her pain had been in the suprapubic region and she quadrant, and no rebound tenderness. Admission to
had been vomiting. Diarrhea began 1 day before the surgical inpatient unit was arranged. The follow-
presentation, and the patient had dysuria. She had ing investigation results were obtained: WBC count:
experienced a normal menstrual period 2 weeks pre- 12 900 cells per mm3 (11 400 neutrophils per mm3);
viously. She walked with a hunched-over gait, and urinalysis: normal findings. The findings of an ab-
her vital signs were as follows: heart rate: 96 beats dominal radiograph were consistent with gastroen-
per minute; respiratory rate: 28 breaths per minute; teritis. During the first 24 hours in the hospital, the
temperature: 38.0°C; blood pressure: 122/76 mm Hg. patient experienced 6 episodes of diarrhea, with no
There were decreased bowel sounds, with suprapu- vomiting, and his pain diminished. During his sec-
bic tenderness. The patient had a positive psoas sign ond night in the hospital, his temperature increased
and rebound tenderness. Admission to the surgical to 39.5°C and the patient was found to have marked
inpatient unit was arranged. The following investi- tenderness in the right lower quadrant. Laparotomy
gation results were obtained: white blood cell (WBC) was performed 48 hours after presentation to the ED.
count: 17 800 cells per mm3 (14 600 neutrophils per A periappendiceal abscess was found in the middle
mm3); urinalysis: normal findings. A sonogram of lower abdomen, extending toward the right. The
the patient’s abdomen found no abnormality; the patient fared well after surgery and was discharged
report stated, “The appendix is well visualized and from the hospital 6 days later.
appears normal pre and post compression. A normal Patient 3 (randomized to the morphine group) was
appearing appendix.” The patient experienced pain 10 years of age when he visited the ED because of 3
requiring 3 doses of morphine through the night. In days of lower abdominal pain in both quadrants.
the morning, the surgeon noted tenderness and re- There had been no nausea, vomiting, diarrhea, dys-
bound tenderness in both lower quadrants but uria, or anorexia. The patient’s vital signs were as
greater on the left side. Laparotomy was performed follows: heart rate: 84 beats per minute; respiratory
20 hours after presentation to the ED. Free pus was rate: 24 breaths per minute; temperature: 36.7°C;
found in the peritoneal cavity. The perforated appen- blood pressure: 116/67 mm Hg. The patient had
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normal bowel sounds and left lower quadrant ten- These 4 children demonstrate the well-known het-
derness, with rebound tenderness. Admission to the erogeneity of the presentation and clinical course of
surgical inpatient unit was arranged. The following appendicitis and the challenge of making this diag-
investigation results were obtained: WBC count: nosis for some children. Common to all 4 of these
11 500 cells per mm3 (9500 neutrophils per mm3); children was the fact that their inflamed appendix
urinalysis: normal findings. The results of an abdom- was not in the right lower quadrant, which is the
inal radiograph were normal. The patient’s abdomi- likely explanation for their atypical presentations
nal pain persisted during the first 24 hours in the and clinical courses. Their clinical courses demon-
hospital. The patient was allowed fluids and had no strate that the delays in diagnosis and the develop-
emesis. At 13 hours, he was found to have mild left ment of perforation were not consequences of anal-
lower quadrant tenderness, with no guarding or re- gesic administration.
bound tenderness. His temperature increased to
39.1°C on the evening of his first hospital day, 24 DISCUSSION
hours after admission. However, his abdominal find- Pain is one of the most common presenting symp-
ings were unchanged. The patient slept well through toms in primary care practice. Some estimate that 5%
the night and was afebrile in the morning. He had of patients seek medical attention for a variety of
some abdominal tenderness. The results of an ab- painful conditions.10 These patients expect pain re-
dominal sonogram were normal. Later that day, lief. However, the practice of analgesic use in the ED
however, the patient experienced marked right is a relatively recent topic in the literature. Wilson
lower quadrant pain and tenderness. Laparotomy and Pendleton11 retrospectively reviewed 198 charts
was performed 43 hours after presentation to the ED. of patients with “painful medical and surgical con-
A small amount of pus was encountered after entry ditions,” such as chest pain, abdominal pain, and
into the peritoneal cavity. The cecum had turned up renal colic, and found that 56% of these patients
on itself in a cranial manner, with the appendix being received no analgesia. Although 44% did receive
adherent behind the ileum toward the middle of the some analgesia, 69% of them waited ⬎1 hour. The
abdomen, in a wall of omentum. Free pockets of pus authors concluded that “oligoanalgesia” is prevalent
were found. The patient fared well after surgery and in the ED setting. Other studies have also demon-
was discharged from the hospital 6 days later. strated inadequate analgesia use in the ED.12,13
Patient 4 (randomized to the morphine group) was This has also been studied among children. Fried-
5.5 years of age when she visited the ED because of land et al14 retrospectively reviewed the charts of
abdominal pain that had begun 1 day previously. pediatric patients who presented to the ED with 3
The pain was generalized and progressive in sever- painful conditions. They found that children with
ity. The patient had vomited once and passed 1 sickle cell crisis received analgesia 100% of the time
normal stool. She had a 2-day history of sore throat, but those with long-bone fractures and burns re-
cough, and rhinorrhea. Fever began 8 hours before ceived analgesia in only 31% and 26% of cases, re-
arrival. The patient preferred to lie still, and her vital spectively. The authors concluded that there was
signs were as follows: heart rate: 199 beats per suboptimal use of analgesia for children.
minute; respiratory rate: 20 breaths per minute; tem- The realization that frequently physicians do not
perature: 38.3°C; blood pressure: 119/74 mm Hg. provide their patients with optimal analgesia has led
The patient had normal bowel sounds, with tender- to widespread concern, with many organizations
ness in both lower quadrants and a distended blad- publishing policies that integrate the need for pain
der. After voiding, she seemed more comfortable management with an ethical obligation.1–3,14,15 Ab-
and her abdomen seemed softer. Admission to the dominal pain is often a diagnostic challenge. Surgical
surgical inpatient unit was arranged. The following practice has dictated that no analgesic should be
investigation results were obtained: WBC count: given to these patients, for fear of obscuring the
8500 cells per mm3 (6800 neutrophils per mm3); uri- diagnosis. An editorial in the British Medical Journal
nalysis: 2 to 6 pus cells per high-power field. No addressed this issue in 1979,16 but studies were con-
imaging studies were performed. The patient was ducted only more recently. Zoltie and Cust17 were
allowed clear fluids, and there was no emesis. In the the first to address this issue and others fol-
morning, the patient’s temperature was 38.1°C and lowed,18–20 by comparing opiate use with placebo
her condition was judged to be improved. The pa- use among adults with acute abdominal pain. All
tient seemed to be more comfortable, and her pain found analgesic use to be safe and effective in reduc-
seemed diminished. Her abdomen was soft, and she ing pain without increasing morbidity.17–20 These
had periumbilical and right lower quadrant abdom- studies changed practice in adult emergency medi-
inal pain. The notation in the record at that time cine and adult general surgery. It is now the accepted
stated, “I do not think this is appendicitis.” Several standard of care to provide pain relief to adults with
hours later, the patient’s abdomen was distended acute abdominal pain, before definitive diagnosis
and she had decreased bowel sounds and increased and before surgical assessment.
tenderness. Laparotomy was performed 23 hours af- Typically, children with acute abdominal pain re-
ter presentation to the ED. The appendix was found quiring surgical referral are not provided with anal-
behind the bladder. There was purulent exudate con- gesia. This stems from a combination of traditional
fined to the periumbilical region. The patient fared surgical teaching, limited confidence in the assess-
well after surgery and was discharged from the hos- ment of pediatric acute abdominal conditions by re-
pital 3 days later. ferring physicians, and healthy skepticism in the
ARTICLES 983
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Early Analgesia for Children With Acute Abdominal Pain
Robert Green, Blake Bulloch, Amin Kabani, Betty Jean Hancock and Milton
Tenenbein
Pediatrics 2005;116;978
DOI: 10.1542/peds.2005-0273
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2005 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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located on the World Wide Web at:
http://pediatrics.aappublications.org/content/116/4/978
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2005 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.