Paracetamol (acetaminophen) or non‐steroidal anti‐inflammatory drugs, alone or combined, for pain relief in acute otitis media in children
Background Acute otitis media (AOM) is one of the most common childhood infectious diseases. Pain is the key symptom of AOM and central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (aceta...
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| Veröffentlicht in: | Cochrane database of systematic reviews 2023-08, Vol.2023 (8), p.CD011534 |
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| creator | Damoiseaux, Roger AMJ Sévaux, Joline L.H. Damoiseaux, Roger AMJ de Pol, Alma C Lutje, Vittoria Hay, Alastair D Little, Paul Schilder, Anne GM Venekamp, Roderick P |
| description | Background
Acute otitis media (AOM) is one of the most common childhood infectious diseases. Pain is the key symptom of AOM and central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non‐steroidal anti‐inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management. This is an update of a review first published in 2016.
Objectives
Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs as compared with paracetamol in children with AOM.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 5, April 2023; MEDLINE (Ovid, from 1946 to May 2023), Embase (from 1947 to May 2023), CINAHL (from 1981 to May 2023), LILACS (from 1982 to May 2023), and Web of Science Core Collection (from 1955 to May 2023). We searched the WHO ICTRP and ClinicalTrials.gov for completed and ongoing trials (23 May 2023).
Selection criteria
We included randomised controlled trials comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in non‐hospitalised children aged six months to 16 years with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. We extracted and summarised data for the following comparisons: paracetamol versus placebo, NSAIDs versus placebo, NSAIDs versus paracetamol, and NSAIDs plus paracetamol versus paracetamol alone.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. We rated the overall certainty of evidence for each outcome of interest using the GRADE approach.
Main results
We included four trials (411 children) which were assessed at low to high risk of bias.
Paracetamol versus placebo
Data from one trial (148 children) informed this comparison. Paracetamol may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 10% versus 25%, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.17 to 0.85; number needed to treat for an additional beneficial outco |
| doi_str_mv | 10.1002/14651858.CD011534.pub3 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_10436353</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2853944549</sourcerecordid><originalsourceid>FETCH-LOGICAL-c4743-14708c0adc3bd04b4ed54fd6f1ef4586e2f2ef53afdfda71bdd4a6ebb583bc943</originalsourceid><addsrcrecordid>eNqFUctuFDEQHCEQCYFfiHwMUnaxx_Y8TgiWpxQJDnC2eux21shjL_YMaG98AeIb-RI82mwUuHByubu6qtVVVeeMrhml9TMmGsk62a03ryhjkov1bh74vep0aayWzv07-KR6lPMXSnnT1-3D6oS3she0pqfVz4-QQOMEY_Tk4oBciLsthqckJhJi-P3jV54wRWfAEwiTKwUXrIdxhCmmPTFpvs6XBHwMuMzoOA4uoLkktvx24AJJ6B1aUhDoeSqsyU0ukxGNg6Wqt86bhOFx9cCCz_jk5j2rPr95_WnzbnX14e37zYurlRat4CsmWtppCkbzwVAxCDRSWNNYhlbIrsHa1mglB2usgZYNxghocBhkxwfdC35WPT_olquVJTSGKYFXu-RGSHsVwam_O8Ft1XX8phgVvOGSF4WLG4UUv86YJzW6rNF7CBjnrOpO8l4IKfpCbQ5UnWLOCe2tD6NqSVMd01THNBf3xeP87pa3Y8f4CuHlgfDdedwrHfU2Ff__6P7j8gfcX7ae</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2853944549</pqid></control><display><type>article</type><title>Paracetamol (acetaminophen) or non‐steroidal anti‐inflammatory drugs, alone or combined, for pain relief in acute otitis media in children</title><source>MEDLINE</source><source>Cochrane Library</source><source>EZB-FREE-00999 freely available EZB journals</source><source>Alma/SFX Local Collection</source><creator>Damoiseaux, Roger AMJ ; Sévaux, Joline L.H. ; Damoiseaux, Roger AMJ ; de Pol, Alma C ; Lutje, Vittoria ; Hay, Alastair D ; Little, Paul ; Schilder, Anne GM ; Venekamp, Roderick P</creator><creatorcontrib>Damoiseaux, Roger AMJ ; Sévaux, Joline L.H. ; Damoiseaux, Roger AMJ ; de Pol, Alma C ; Lutje, Vittoria ; Hay, Alastair D ; Little, Paul ; Schilder, Anne GM ; Venekamp, Roderick P</creatorcontrib><description>Background
Acute otitis media (AOM) is one of the most common childhood infectious diseases. Pain is the key symptom of AOM and central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non‐steroidal anti‐inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management. This is an update of a review first published in 2016.
Objectives
Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs as compared with paracetamol in children with AOM.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 5, April 2023; MEDLINE (Ovid, from 1946 to May 2023), Embase (from 1947 to May 2023), CINAHL (from 1981 to May 2023), LILACS (from 1982 to May 2023), and Web of Science Core Collection (from 1955 to May 2023). We searched the WHO ICTRP and ClinicalTrials.gov for completed and ongoing trials (23 May 2023).
Selection criteria
We included randomised controlled trials comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in non‐hospitalised children aged six months to 16 years with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. We extracted and summarised data for the following comparisons: paracetamol versus placebo, NSAIDs versus placebo, NSAIDs versus paracetamol, and NSAIDs plus paracetamol versus paracetamol alone.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. We rated the overall certainty of evidence for each outcome of interest using the GRADE approach.
Main results
We included four trials (411 children) which were assessed at low to high risk of bias.
Paracetamol versus placebo
Data from one trial (148 children) informed this comparison. Paracetamol may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 10% versus 25%, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.17 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 7; low‐certainty evidence). The evidence is very uncertain about the effects of paracetamol on fever at 48 hours (RR 1.03, 95% CI 0.07 to 16.12; very low‐certainty evidence) and adverse events (RR 1.03, 95% CI 0.21 to 4.93; very low‐certainty evidence). No data were available for our other outcomes of interest.
NSAIDs versus placebo
Data from one trial (146 children) informed this comparison. Ibuprofen may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 7% versus 25%, RR 0.28, 95% CI 0.11 to 0.70; NNTB 6; low‐certainty evidence). The evidence is very uncertain about the effect of ibuprofen on fever at 48 hours (RR 1.06, 95% CI 0.07 to 16.57; very low‐certainty evidence) and adverse events (RR 1.76, 95% CI 0.44 to 7.10; very low‐certainty evidence). No data were available for our other outcomes of interest.
NSAIDs versus paracetamol
Data from four trials (411 children) informed this comparison. The evidence is very uncertain about the effect of ibuprofen versus paracetamol in relieving ear pain at 24 hours (RR 0.83, 95% CI 0.59 to 1.18; 2 RCTs, 39 children; very low‐certainty evidence); 48 to 72 hours (RR 0.91, 95% CI 0.54 to 1.54; 3 RCTs, 183 children; low‐certainty evidence); and four to seven days (RR 0.74, 95% CI 0.17 to 3.23; 2 RCTs, 38 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol on mean pain score at 24 hours (0.29 lower, 95% CI 0.79 lower to 0.20 higher; 3 RCTs, 111 children; very low‐certainty evidence); 48 to 72 hours (0.25 lower, 95% CI 0.66 lower to 0.16 higher; 3 RCTs, 108 children; very low‐certainty evidence); and four to seven days (0.30 higher, 95% CI 1.78 lower to 2.38 higher; 2 RCTs, 31 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol in resolving fever at 24 hours (RR 0.69, 95% CI 0.24 to 2.00; 2 RCTs, 39 children; very low‐certainty evidence); 48 to 72 hours (RR 1.18, 95% CI 0.31 to 4.44; 3 RCTs, 182 children; low‐certainty evidence); and four to seven days (RR 2.75, 95% CI 0.12 to 60.70; 2 RCTs, 39 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol on adverse events (RR 1.71, 95% CI 0.43 to 6.90; 3 RCTs, 281 children; very low‐certainty evidence); reconsultations (RR 1.13, 95% CI 0.92 to 1.40; 1 RCT, 53 children; very low‐certainty evidence); and delayed antibiotic prescriptions (RR 1.32, 95% CI 0.74 to 2.35; 1 RCT, 53 children; very low‐certainty evidence).
No data were available on time to resolution of pain.
NSAIDs plus paracetamol versus paracetamol alone
Data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone came from two trials that provided crude subgroup data for 71 children with AOM. The small sample provided imprecise effect estimates, therefore we were unable to draw any firm conclusions (very low‐certainty evidence).
Authors' conclusions
Despite explicit guideline recommendations on the use of analgesics in children with AOM, the current evidence on the effectiveness of paracetamol or NSAIDs, alone or combined, in children with AOM is limited. Paracetamol and ibuprofen as monotherapies may be more effective than placebo in relieving short‐term ear pain in children with AOM. The evidence is very uncertain for the effect of ibuprofen versus paracetamol on relieving short‐term ear pain in children with AOM, as well as for the effectiveness of ibuprofen plus paracetamol versus paracetamol alone, thereby preventing any firm conclusions. Further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol, and other analgesics such as anaesthetic eardrops, for children with AOM.</description><identifier>ISSN: 1465-1858</identifier><identifier>ISSN: 1469-493X</identifier><identifier>EISSN: 1465-1858</identifier><identifier>EISSN: 1469-493X</identifier><identifier>DOI: 10.1002/14651858.CD011534.pub3</identifier><identifier>PMID: 37594020</identifier><language>eng</language><publisher>Chichester, UK: John Wiley & Sons, Ltd</publisher><subject>Acetaminophen ; Acetaminophen - therapeutic use ; Acute otitis media ; Anti-Bacterial Agents ; Anti-Inflammatory Agents, Non-Steroidal ; Anti-Inflammatory Agents, Non-Steroidal - therapeutic use ; Child ; Child health ; Ear ; Ear infections ; Ear, nose & throat ; Fever ; Fever - drug therapy ; Humans ; Ibuprofen ; Ibuprofen - therapeutic use ; Infectious disease ; Medicine General & Introductory Medical Sciences ; Middle ear infection (acute otitis media) ; Other therapies ; Otitis Media ; Otitis Media - complications ; Otitis Media - drug therapy ; Pain ; Treatment</subject><ispartof>Cochrane database of systematic reviews, 2023-08, Vol.2023 (8), p.CD011534</ispartof><rights>Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4743-14708c0adc3bd04b4ed54fd6f1ef4586e2f2ef53afdfda71bdd4a6ebb583bc943</citedby><cites>FETCH-LOGICAL-c4743-14708c0adc3bd04b4ed54fd6f1ef4586e2f2ef53afdfda71bdd4a6ebb583bc943</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,777,781,882,27905,27906</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/37594020$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Damoiseaux, Roger AMJ</creatorcontrib><creatorcontrib>Sévaux, Joline L.H.</creatorcontrib><creatorcontrib>Damoiseaux, Roger AMJ</creatorcontrib><creatorcontrib>de Pol, Alma C</creatorcontrib><creatorcontrib>Lutje, Vittoria</creatorcontrib><creatorcontrib>Hay, Alastair D</creatorcontrib><creatorcontrib>Little, Paul</creatorcontrib><creatorcontrib>Schilder, Anne GM</creatorcontrib><creatorcontrib>Venekamp, Roderick P</creatorcontrib><title>Paracetamol (acetaminophen) or non‐steroidal anti‐inflammatory drugs, alone or combined, for pain relief in acute otitis media in children</title><title>Cochrane database of systematic reviews</title><addtitle>Cochrane Database Syst Rev</addtitle><description>Background
Acute otitis media (AOM) is one of the most common childhood infectious diseases. Pain is the key symptom of AOM and central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non‐steroidal anti‐inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management. This is an update of a review first published in 2016.
Objectives
Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs as compared with paracetamol in children with AOM.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 5, April 2023; MEDLINE (Ovid, from 1946 to May 2023), Embase (from 1947 to May 2023), CINAHL (from 1981 to May 2023), LILACS (from 1982 to May 2023), and Web of Science Core Collection (from 1955 to May 2023). We searched the WHO ICTRP and ClinicalTrials.gov for completed and ongoing trials (23 May 2023).
Selection criteria
We included randomised controlled trials comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in non‐hospitalised children aged six months to 16 years with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. We extracted and summarised data for the following comparisons: paracetamol versus placebo, NSAIDs versus placebo, NSAIDs versus paracetamol, and NSAIDs plus paracetamol versus paracetamol alone.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. We rated the overall certainty of evidence for each outcome of interest using the GRADE approach.
Main results
We included four trials (411 children) which were assessed at low to high risk of bias.
Paracetamol versus placebo
Data from one trial (148 children) informed this comparison. Paracetamol may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 10% versus 25%, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.17 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 7; low‐certainty evidence). The evidence is very uncertain about the effects of paracetamol on fever at 48 hours (RR 1.03, 95% CI 0.07 to 16.12; very low‐certainty evidence) and adverse events (RR 1.03, 95% CI 0.21 to 4.93; very low‐certainty evidence). No data were available for our other outcomes of interest.
NSAIDs versus placebo
Data from one trial (146 children) informed this comparison. Ibuprofen may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 7% versus 25%, RR 0.28, 95% CI 0.11 to 0.70; NNTB 6; low‐certainty evidence). The evidence is very uncertain about the effect of ibuprofen on fever at 48 hours (RR 1.06, 95% CI 0.07 to 16.57; very low‐certainty evidence) and adverse events (RR 1.76, 95% CI 0.44 to 7.10; very low‐certainty evidence). No data were available for our other outcomes of interest.
NSAIDs versus paracetamol
Data from four trials (411 children) informed this comparison. The evidence is very uncertain about the effect of ibuprofen versus paracetamol in relieving ear pain at 24 hours (RR 0.83, 95% CI 0.59 to 1.18; 2 RCTs, 39 children; very low‐certainty evidence); 48 to 72 hours (RR 0.91, 95% CI 0.54 to 1.54; 3 RCTs, 183 children; low‐certainty evidence); and four to seven days (RR 0.74, 95% CI 0.17 to 3.23; 2 RCTs, 38 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol on mean pain score at 24 hours (0.29 lower, 95% CI 0.79 lower to 0.20 higher; 3 RCTs, 111 children; very low‐certainty evidence); 48 to 72 hours (0.25 lower, 95% CI 0.66 lower to 0.16 higher; 3 RCTs, 108 children; very low‐certainty evidence); and four to seven days (0.30 higher, 95% CI 1.78 lower to 2.38 higher; 2 RCTs, 31 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol in resolving fever at 24 hours (RR 0.69, 95% CI 0.24 to 2.00; 2 RCTs, 39 children; very low‐certainty evidence); 48 to 72 hours (RR 1.18, 95% CI 0.31 to 4.44; 3 RCTs, 182 children; low‐certainty evidence); and four to seven days (RR 2.75, 95% CI 0.12 to 60.70; 2 RCTs, 39 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol on adverse events (RR 1.71, 95% CI 0.43 to 6.90; 3 RCTs, 281 children; very low‐certainty evidence); reconsultations (RR 1.13, 95% CI 0.92 to 1.40; 1 RCT, 53 children; very low‐certainty evidence); and delayed antibiotic prescriptions (RR 1.32, 95% CI 0.74 to 2.35; 1 RCT, 53 children; very low‐certainty evidence).
No data were available on time to resolution of pain.
NSAIDs plus paracetamol versus paracetamol alone
Data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone came from two trials that provided crude subgroup data for 71 children with AOM. The small sample provided imprecise effect estimates, therefore we were unable to draw any firm conclusions (very low‐certainty evidence).
Authors' conclusions
Despite explicit guideline recommendations on the use of analgesics in children with AOM, the current evidence on the effectiveness of paracetamol or NSAIDs, alone or combined, in children with AOM is limited. Paracetamol and ibuprofen as monotherapies may be more effective than placebo in relieving short‐term ear pain in children with AOM. The evidence is very uncertain for the effect of ibuprofen versus paracetamol on relieving short‐term ear pain in children with AOM, as well as for the effectiveness of ibuprofen plus paracetamol versus paracetamol alone, thereby preventing any firm conclusions. Further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol, and other analgesics such as anaesthetic eardrops, for children with AOM.</description><subject>Acetaminophen</subject><subject>Acetaminophen - therapeutic use</subject><subject>Acute otitis media</subject><subject>Anti-Bacterial Agents</subject><subject>Anti-Inflammatory Agents, Non-Steroidal</subject><subject>Anti-Inflammatory Agents, Non-Steroidal - therapeutic use</subject><subject>Child</subject><subject>Child health</subject><subject>Ear</subject><subject>Ear infections</subject><subject>Ear, nose & throat</subject><subject>Fever</subject><subject>Fever - drug therapy</subject><subject>Humans</subject><subject>Ibuprofen</subject><subject>Ibuprofen - therapeutic use</subject><subject>Infectious disease</subject><subject>Medicine General & Introductory Medical Sciences</subject><subject>Middle ear infection (acute otitis media)</subject><subject>Other therapies</subject><subject>Otitis Media</subject><subject>Otitis Media - complications</subject><subject>Otitis Media - drug therapy</subject><subject>Pain</subject><subject>Treatment</subject><issn>1465-1858</issn><issn>1469-493X</issn><issn>1465-1858</issn><issn>1469-493X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><sourceid>RWY</sourceid><sourceid>EIF</sourceid><recordid>eNqFUctuFDEQHCEQCYFfiHwMUnaxx_Y8TgiWpxQJDnC2eux21shjL_YMaG98AeIb-RI82mwUuHByubu6qtVVVeeMrhml9TMmGsk62a03ryhjkov1bh74vep0aayWzv07-KR6lPMXSnnT1-3D6oS3she0pqfVz4-QQOMEY_Tk4oBciLsthqckJhJi-P3jV54wRWfAEwiTKwUXrIdxhCmmPTFpvs6XBHwMuMzoOA4uoLkktvx24AJJ6B1aUhDoeSqsyU0ukxGNg6Wqt86bhOFx9cCCz_jk5j2rPr95_WnzbnX14e37zYurlRat4CsmWtppCkbzwVAxCDRSWNNYhlbIrsHa1mglB2usgZYNxghocBhkxwfdC35WPT_olquVJTSGKYFXu-RGSHsVwam_O8Ft1XX8phgVvOGSF4WLG4UUv86YJzW6rNF7CBjnrOpO8l4IKfpCbQ5UnWLOCe2tD6NqSVMd01THNBf3xeP87pa3Y8f4CuHlgfDdedwrHfU2Ff__6P7j8gfcX7ae</recordid><startdate>20230818</startdate><enddate>20230818</enddate><creator>Damoiseaux, Roger AMJ</creator><creator>Sévaux, Joline L.H.</creator><creator>Damoiseaux, Roger AMJ</creator><creator>de Pol, Alma C</creator><creator>Lutje, Vittoria</creator><creator>Hay, Alastair D</creator><creator>Little, Paul</creator><creator>Schilder, Anne GM</creator><creator>Venekamp, Roderick P</creator><general>John Wiley & Sons, Ltd</general><scope>7PX</scope><scope>RWY</scope><scope>ZYTZH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20230818</creationdate><title>Paracetamol (acetaminophen) or non‐steroidal anti‐inflammatory drugs, alone or combined, for pain relief in acute otitis media in children</title><author>Damoiseaux, Roger AMJ ; Sévaux, Joline L.H. ; Damoiseaux, Roger AMJ ; de Pol, Alma C ; Lutje, Vittoria ; Hay, Alastair D ; Little, Paul ; Schilder, Anne GM ; Venekamp, Roderick P</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4743-14708c0adc3bd04b4ed54fd6f1ef4586e2f2ef53afdfda71bdd4a6ebb583bc943</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Acetaminophen</topic><topic>Acetaminophen - therapeutic use</topic><topic>Acute otitis media</topic><topic>Anti-Bacterial Agents</topic><topic>Anti-Inflammatory Agents, Non-Steroidal</topic><topic>Anti-Inflammatory Agents, Non-Steroidal - therapeutic use</topic><topic>Child</topic><topic>Child health</topic><topic>Ear</topic><topic>Ear infections</topic><topic>Ear, nose & throat</topic><topic>Fever</topic><topic>Fever - drug therapy</topic><topic>Humans</topic><topic>Ibuprofen</topic><topic>Ibuprofen - therapeutic use</topic><topic>Infectious disease</topic><topic>Medicine General & Introductory Medical Sciences</topic><topic>Middle ear infection (acute otitis media)</topic><topic>Other therapies</topic><topic>Otitis Media</topic><topic>Otitis Media - complications</topic><topic>Otitis Media - drug therapy</topic><topic>Pain</topic><topic>Treatment</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Damoiseaux, Roger AMJ</creatorcontrib><creatorcontrib>Sévaux, Joline L.H.</creatorcontrib><creatorcontrib>Damoiseaux, Roger AMJ</creatorcontrib><creatorcontrib>de Pol, Alma C</creatorcontrib><creatorcontrib>Lutje, Vittoria</creatorcontrib><creatorcontrib>Hay, Alastair D</creatorcontrib><creatorcontrib>Little, Paul</creatorcontrib><creatorcontrib>Schilder, Anne GM</creatorcontrib><creatorcontrib>Venekamp, Roderick P</creatorcontrib><collection>Wiley-Blackwell Cochrane Library</collection><collection>Cochrane Library</collection><collection>Cochrane Library (Open Aceess)</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Cochrane database of systematic reviews</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Damoiseaux, Roger AMJ</au><au>Sévaux, Joline L.H.</au><au>Damoiseaux, Roger AMJ</au><au>de Pol, Alma C</au><au>Lutje, Vittoria</au><au>Hay, Alastair D</au><au>Little, Paul</au><au>Schilder, Anne GM</au><au>Venekamp, Roderick P</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Paracetamol (acetaminophen) or non‐steroidal anti‐inflammatory drugs, alone or combined, for pain relief in acute otitis media in children</atitle><jtitle>Cochrane database of systematic reviews</jtitle><addtitle>Cochrane Database Syst Rev</addtitle><date>2023-08-18</date><risdate>2023</risdate><volume>2023</volume><issue>8</issue><spage>CD011534</spage><pages>CD011534-</pages><issn>1465-1858</issn><issn>1469-493X</issn><eissn>1465-1858</eissn><eissn>1469-493X</eissn><abstract>Background
Acute otitis media (AOM) is one of the most common childhood infectious diseases. Pain is the key symptom of AOM and central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non‐steroidal anti‐inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management. This is an update of a review first published in 2016.
Objectives
Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs as compared with paracetamol in children with AOM.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 5, April 2023; MEDLINE (Ovid, from 1946 to May 2023), Embase (from 1947 to May 2023), CINAHL (from 1981 to May 2023), LILACS (from 1982 to May 2023), and Web of Science Core Collection (from 1955 to May 2023). We searched the WHO ICTRP and ClinicalTrials.gov for completed and ongoing trials (23 May 2023).
Selection criteria
We included randomised controlled trials comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in non‐hospitalised children aged six months to 16 years with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. We extracted and summarised data for the following comparisons: paracetamol versus placebo, NSAIDs versus placebo, NSAIDs versus paracetamol, and NSAIDs plus paracetamol versus paracetamol alone.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. We rated the overall certainty of evidence for each outcome of interest using the GRADE approach.
Main results
We included four trials (411 children) which were assessed at low to high risk of bias.
Paracetamol versus placebo
Data from one trial (148 children) informed this comparison. Paracetamol may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 10% versus 25%, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.17 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 7; low‐certainty evidence). The evidence is very uncertain about the effects of paracetamol on fever at 48 hours (RR 1.03, 95% CI 0.07 to 16.12; very low‐certainty evidence) and adverse events (RR 1.03, 95% CI 0.21 to 4.93; very low‐certainty evidence). No data were available for our other outcomes of interest.
NSAIDs versus placebo
Data from one trial (146 children) informed this comparison. Ibuprofen may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 7% versus 25%, RR 0.28, 95% CI 0.11 to 0.70; NNTB 6; low‐certainty evidence). The evidence is very uncertain about the effect of ibuprofen on fever at 48 hours (RR 1.06, 95% CI 0.07 to 16.57; very low‐certainty evidence) and adverse events (RR 1.76, 95% CI 0.44 to 7.10; very low‐certainty evidence). No data were available for our other outcomes of interest.
NSAIDs versus paracetamol
Data from four trials (411 children) informed this comparison. The evidence is very uncertain about the effect of ibuprofen versus paracetamol in relieving ear pain at 24 hours (RR 0.83, 95% CI 0.59 to 1.18; 2 RCTs, 39 children; very low‐certainty evidence); 48 to 72 hours (RR 0.91, 95% CI 0.54 to 1.54; 3 RCTs, 183 children; low‐certainty evidence); and four to seven days (RR 0.74, 95% CI 0.17 to 3.23; 2 RCTs, 38 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol on mean pain score at 24 hours (0.29 lower, 95% CI 0.79 lower to 0.20 higher; 3 RCTs, 111 children; very low‐certainty evidence); 48 to 72 hours (0.25 lower, 95% CI 0.66 lower to 0.16 higher; 3 RCTs, 108 children; very low‐certainty evidence); and four to seven days (0.30 higher, 95% CI 1.78 lower to 2.38 higher; 2 RCTs, 31 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol in resolving fever at 24 hours (RR 0.69, 95% CI 0.24 to 2.00; 2 RCTs, 39 children; very low‐certainty evidence); 48 to 72 hours (RR 1.18, 95% CI 0.31 to 4.44; 3 RCTs, 182 children; low‐certainty evidence); and four to seven days (RR 2.75, 95% CI 0.12 to 60.70; 2 RCTs, 39 children; very low‐certainty evidence).
The evidence is very uncertain about the effect of ibuprofen versus paracetamol on adverse events (RR 1.71, 95% CI 0.43 to 6.90; 3 RCTs, 281 children; very low‐certainty evidence); reconsultations (RR 1.13, 95% CI 0.92 to 1.40; 1 RCT, 53 children; very low‐certainty evidence); and delayed antibiotic prescriptions (RR 1.32, 95% CI 0.74 to 2.35; 1 RCT, 53 children; very low‐certainty evidence).
No data were available on time to resolution of pain.
NSAIDs plus paracetamol versus paracetamol alone
Data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone came from two trials that provided crude subgroup data for 71 children with AOM. The small sample provided imprecise effect estimates, therefore we were unable to draw any firm conclusions (very low‐certainty evidence).
Authors' conclusions
Despite explicit guideline recommendations on the use of analgesics in children with AOM, the current evidence on the effectiveness of paracetamol or NSAIDs, alone or combined, in children with AOM is limited. Paracetamol and ibuprofen as monotherapies may be more effective than placebo in relieving short‐term ear pain in children with AOM. The evidence is very uncertain for the effect of ibuprofen versus paracetamol on relieving short‐term ear pain in children with AOM, as well as for the effectiveness of ibuprofen plus paracetamol versus paracetamol alone, thereby preventing any firm conclusions. Further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol, and other analgesics such as anaesthetic eardrops, for children with AOM.</abstract><cop>Chichester, UK</cop><pub>John Wiley & Sons, Ltd</pub><pmid>37594020</pmid><doi>10.1002/14651858.CD011534.pub3</doi><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1465-1858 |
| ispartof | Cochrane database of systematic reviews, 2023-08, Vol.2023 (8), p.CD011534 |
| issn | 1465-1858 1469-493X 1465-1858 1469-493X |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_10436353 |
| source | MEDLINE; Cochrane Library; EZB-FREE-00999 freely available EZB journals; Alma/SFX Local Collection |
| subjects | Acetaminophen Acetaminophen - therapeutic use Acute otitis media Anti-Bacterial Agents Anti-Inflammatory Agents, Non-Steroidal Anti-Inflammatory Agents, Non-Steroidal - therapeutic use Child Child health Ear Ear infections Ear, nose & throat Fever Fever - drug therapy Humans Ibuprofen Ibuprofen - therapeutic use Infectious disease Medicine General & Introductory Medical Sciences Middle ear infection (acute otitis media) Other therapies Otitis Media Otitis Media - complications Otitis Media - drug therapy Pain Treatment |
| title | Paracetamol (acetaminophen) or non‐steroidal anti‐inflammatory drugs, alone or combined, for pain relief in acute otitis media in children |
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