Key messages
- The current evidence on the effectiveness of painkillers, alone or together, in relieving ear pain in children with acute middle ear infection (acute otitis media (AOM)) is limited.
- Both paracetamol (acetaminophen) and ibuprofen as standalone treatments may be more effective than placebo in relieving short-term ear pain in children with AOM. We are uncertain if there is a difference in effect between ibuprofen and paracetamol and between ibuprofen plus paracetamol and paracetamol alone, thereby preventing any firm conclusions.
- Further research is needed into the role of ibuprofen as an add-on treatment to paracetamol, as well as on other pain relievers such as analgesic eardrops, for children with AOM.
What is AOM?
AOM, or acute middle ear infection, is one of the most common childhood infections and is usually preceded by a viral upper respiratory tract infection. Ear pain is the key symptom and central to children's and parents' experience of the illness.
What did we want to find out?
We wanted to find out if painkillers are effective for relieving ear pain in children with AOM and which drugs, alone or together, provide the most effective pain relief.
What did we do?
We searched for studies that looked at the effectiveness of paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), alone or combined, compared with placebo (dummy treatment) or no treatment in relieving pain in non-hospitalised children aged six months to 16 years with AOM. We also wanted to evaluate the effectiveness of NSAIDs as compared with paracetamol in these children. We compared and summarised the results of these studies, and rated our confidence in the evidence based on factors such as study methods and effect sizes.
What did we find?
Very limited information was available to assess how useful painkillers are for relieving ear pain in children with AOM. One trial compared paracetamol versus placebo (148 children) and NSAIDs versus placebo (146 children). We found that when used alone, paracetamol and ibuprofen may be more effective than placebo in relieving ear pain at 48 hours (25% of children receiving placebo had pain at 48 hours versus 10% in the paracetamol and 7% in the ibuprofen group). Four trials (411 children) compared ibuprofen versus paracetamol in children with AOM. The evidence is very uncertain about the effect of ibuprofen versus paracetamol in relieving short-term ear pain in children with AOM. The evidence is very uncertain about the effects of paracetamol and ibuprofen on adverse events.
The very limited number of participants prevented us from drawing any firm conclusions on the effects of ibuprofen plus paracetamol versus paracetamol alone.
What are the limitations of the evidence?
Due to such issues as study limitations and questions about the applicability of the evidence, we have low confidence in the evidence for all comparisons.
How up-to-date is this evidence?
The evidence in this review is current to 23 May 2023.
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.
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.
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.
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).
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.
We used standard methodological procedures expected by Cochrane. We rated the overall certainty of evidence for each outcome of interest using the GRADE approach.
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).