Rethinking Pain Management for Children: Insights from the No OUCH Study

For many pediatricians, the challenge of managing children’s pain is both routine and deeply personal. For Dr. Samina Ali, those moments at the bedside became the catalyst for a research program aimed at doing better for children and families. Sprains and fractures are the most common injuries in childhood, with nearly one in five children sustaining a fracture before age 18. Despite this prevalence, uncertainty has persisted around the most effective—and safest—ways to manage pain for these injuries. The No OUCH study was designed to address this gap directly.

A Family-Centred Study Design

Grounded in Dr. Ali’s clinical experience, the No OUCH study used a novel approach known as a preference-informed complementary trial (PICT) design. Rather than enrolling families into a single randomized trial, the research team ran two trials simultaneously across six Canadian pediatric emergency departments, including the Stollery. One trial included an opioid-containing regimen, while the other did not.

This design acknowledged an important reality: families often have strong preferences and concerns about opioid use in children. By allowing families to choose which trial to participate in, the study respected those preferences while still generating high-quality comparative evidence.

Key Findings: Effectiveness Without Added Risk

The study enrolled nearly 700 children with non-operative musculoskeletal injuries. The findings were clear: Ibuprofen alone was just as effective as ibuprofen combined with acetaminophen or ibuprofen combined with oral hydromorphone, the most potent oral opioid available for children. Children who received ibuprofen plus hydromorphone experienced four to five times more adverse effects than those treated with ibuprofen alone.

In short, opioids did not provide additional pain relief for simple fractures and sprains—but they did significantly increase the risk of side effects.

Implications for Clinical Practice

The results have immediate relevance for prescribing practices in pediatric emergency and acute care settings. For children with uncomplicated sprains and fractures, first-line pain management should consist of:

• Ibuprofen
• Appropriate immobilization (splints, casts, or bandaging)
• Non-pharmacologic supports such as ice, heat, and distraction

Acetaminophen can be used for breakthrough pain between ibuprofen doses. Importantly, the study does not suggest eliminating opioids from pediatric care. Children with severe injuries or those requiring surgery may still benefit from intravenous or intranasal opioids when clinically appropriate. The goal is not avoidance, but responsible, evidence-informed use.

Opioid-Sparing Care

While the No OUCH study focused on pharmacologic treatment, it reinforces the need to explore multimodal pain management strategies further. Many children do not achieve mild pain levels with medication alone, highlighting an opportunity for future research into physical and psychological interventions that can complement analgesics.

Looking Ahead

Dr. Ali and her collaborators are already working to translate these findings into practice and policy. Planned next steps include:

• Working to update acute injury algorithms and clinical decision-support tools to list ibuprofen as the first-line medication
• Partnering with knowledge mobilization networks such as TREKK and SKIP to share findings with families
• Integrating results into TREKK’s Bottom Line Recommendations

Continuing research that keeps family preferences and goals at the centre of study design
The No OUCH study exemplifies how clinically grounded, family-centred research can lead to safer, more effective care—and meaningful change in how pediatric pain is managed across emergency medicine.