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Acute pain management: acetaminophen and ibuprofen are often under-dosed


Most children with pain are managed by either acetaminophen or ibuprofen. However, no study has so far investigated if children are prescribed adequate doses of acetaminophen or ibuprofen in emergency department. Aim of this retrospective study was to investigate the prevalence of under-dosage of these drugs in children presenting with pain in emergency department. Children initially prescribed with acetaminophen or ibuprofen for pain management were included. The χ 2 automatic interaction detection method was used considering the percentage variation from the minimum of the appropriate dose as dependent variable while prescribed drug, age, gender, body weight, type of hospital (pediatric or general), and availability of internal guidelines on pediatric pain management in the emergency department as independent variables. Data on 1471 children managed for pain were available. Under-dosage was prescribed in 893 subjects (61%), of whom 577 were prescribed acetaminophen and 316 ibuprofen. The use of acetaminophen suppositories, body weight <12 kg or >40 kg, and the use of oral ibuprofen identified clusters of children associated with under-dosage prescription.

Conclusion: Prescription of acetaminophen and ibuprofen was frequently under-dosed. The use of suppositories, lower and higher body weight, and the use of ibuprofen were associated with under-dosage. Under-dosing may reflect prescription of anti-pyretic doses.

Clinical trial registration : Agenzia Italiana del Farmaco–Observational Study Register (RSO). Registration code: PIERRE/1

What is Known:
• Pain is frequent in children presented to emergency department.
• International recommendations on pain management are often not implemented.
What is New:
• Acetaminophen and ibuprofen were frequently underdosed in children prescribed for pain in the Italian emergency departments.
• Under-dosage may be related to the habit of using acetaminophen and ibuprofen in the recommended range for fever treatment.

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The authors would also like to thank Dr. Alec Villa for his assistance in the linguistic revision. Furthermore, they would like to thank the PIERRE GROUP STUDY: F Benini, T Zangardi, (Dipartimento di Salute della Donna and del Bambino, Università di Padova, Padua, Italy); A Nocerino, G Crichiutti (Azienda Ospedaliera Universitaria, Udine, Italy); E Barbi, G Messi, A Delise (Istituto Materno Infantile Burlo Garofolo, Trieste, Italy); P Biban, D. Silvagni (Azienda Ospedaliera Universitaria Integrata, Veron, Italy); A Arrighini (Azienda Ospedaliera Spedali Civili PO di Brescia, Italy); AF Podestà, C Scalfaro (Azienda Ospedaliera S. Carlo Borromeo, Milan, Italy); C Stringhi, S Rotta, (ICP PO Buzzi, Milan, Italy); EF Fossali, L Dellera, GP Milani (IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy); E Castagno, A Urbino, (AOU Città della Salute and della Scienza di Torino–Ospedale Infantile Regina Margherita, Turine, Italy); C Marciano, A Ribotti (Azienda Ospedaliera SS Antonio and Biagio and C Arrigo, Alessandria, Italy); L Manfredini, L Piccotti, S Forti (Istituto Giyearsna Gaslini, IRCCS, Genoa, Italy); L Calistri, A Messeri, S Masi (AOU A. Meyer, Florence, Italy); A Chiaretti, Claudia Fantacci (Policlinico Agostino Gemelli, Rome, Italy); F Fucà, R Parrino (Bari ARNAS, Palermo); F Bernardi, I Corsini (Policlinico S.Orsola-Malpighi, Bologna, Italy); MR Govoni, A. Fumarola (Ospedale S. Anna, Ferrara, Italy); S Barca, R Picchi (Azienda Ospedaliera S. Anna, Como, Italy) P Bertolani (Azienda Ospedaliera Universitaria, Modena, Italy).

Author information





All authors contributed in the study design and data interpretation, were accountable for all aspects of the work and approved the final manuscript as submitted. Dr. Milani coordinated the study. Dr. Benini, Dr. Dell’Era, Dr. Silvagni, Dr. Mancusi, and Dr. Fossali wrote the initial draft. Dr. Fossali supervised the study. Dr. Mancusi performed the statistical analysis. Dr. Podestà gave significant scientific inputs in his area of expertise.

Corresponding author

Correspondence to Gregorio P. Milani.

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No external funding for this manuscript.

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The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Communicated by Mario Bianchetti

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Milani, G.P., Benini, F., Dell’Era, L. et al. Acute pain management: acetaminophen and ibuprofen are often under-dosed. Eur J Pediatr 176, 979–982 (2017).

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  • Paracetamol
  • Pain treatment
  • Oligoanalgesia
  • Barriers
  • Dose errors
  • Fever