Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Ibuprofen is a widely used painkiller and a new Cochrane review from January 2024 brings together the evidence on its use for postoperative pain in children. In this podcast, two of the co-authors, Sara Pessano from Gaslini Children's Hospital in Genoa Italy, and Natasha Gloeck from the Health Systems Research Unit at the South African Medical Research Council, tell us about the findings.

Sara: Hello Natasha. Let's begin with the importance of postoperative pain management in children and how ibuprofen might work for this purpose? 

Natasha: Of course, Sara, it would be my pleasure. It's common for children to experience pain after a surgical procedure or another painful treatment. This causes suffering and agitation, can delay their recovery and be distressing for their parents or carers. However, it is often challenging to evaluate and treat pain in children and the best way to achieve these goals is still to be defined. A common strategy involves the use of drugs, such as ibuprofen, which is a type of medicine called a 'non-steroidal anti-inflammatory drug', or NSAID for short, that can reduce inflammation and pain. 

Sara: Thanks, Natasha. Going deeper into the topic, if we're going to use a drug to manage pain, we naturally want to be sure that it's effective and that the benefits outweigh any possible unwanted effects, right?

Natasha: Exactly, and that's what we wanted to explore in our review. We compared ibuprofen with other pain treatments to assess their efficacy for treating pain and the chance of having adverse events that might be related to the therapy. We also looked for evidence about the most effective ways to administer ibuprofen to children but didn't find any relevant studies. So I'll pass back to you to tell listeners how much evidence we did find. 

Sara: Reviewing the literature, there were 43 eligible studies that had recruited nearly 4300 children with postoperative pain. We could use data on 3900 of these children, who were aged between a couple of months and 17 years. The studies were from many countries around the world and they had used ibuprofen to manage postoperative pain after 10 different types of surgery. The majority, 21 studies, were dental procedures but there were also eleven for ear, nose and throat operations. Natasha, perhaps you could summarize our main findings, in particular on the effects on pain in the two hours after the procedure and through the first full day.

Natasha: Sure. When looking at efficacy, ibuprofen is probably better than placebo at reducing pain intensity in the two hours after the operation and may reduce pain intensity for up to 24 hours. When compared to paracetamol, ibuprofen probably reduces pain intensity in the first two hours and also in the period up to 24 hours. We cannot be sure about any differences in unwanted effects between ibuprofen and either placebo and paracetamol, and there is probably little difference in the chances of bleeding with ibuprofen compared to paracetamol. When exploring the effect of ibuprofen versus morphine, ibuprofen probably leads to a reduction in any unwanted effects whilst, compared to ketorolac, it may lead to a reduction in overall harms. No studies reported pain intensity or serious unwanted effects for either morphine or ketorolac. That's the fine detail, how would you summarize the findings?

Sara: Firstly, since there are not enough large studies comparing ibuprofen to other alternatives, we are uncertain about the overall evidence for ibuprofen use in postoperative pain in children. In addition, because so few studies provided data about important benefits and unwanted effects for children experiencing pain following surgery, especially in the longer term, that suggests that more studies are needed and we have some suggestions for these.

Natasha: Yes. Future research should aim to assess the optimal mode and delivery of ibuprofen in children through exploring the effect of ibuprofen at different doses, different routes of administration, and different timing and schedules. Future studies also need to report adverse events, especially serious adverse events, in order to reduce the uncertainties in the current evidence base.

Sara: Thanks Natasha. If someone is interested in learning more about this topic, where can they find the review?

Natasha: It's available online via the Cochrane Library and a search for the title, 'ibuprofen for acute postoperative pain in children' can be used there to find it.