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Intranasal Fentanyl for Paediatric Pain Control

24 Sep, 15 | by BMJ Clinical Evidence

Ken MilneBy Ken Milne

An eleven year-old girl falls while playing football. She presents to A&E with a painful wrist, and you suspect a fracture. Prior to her going for x-rays you wonder what you can give for pain management.

This is a common dilemma which highlights why paediatric patients are at greater risk of oligoanalgesia – the lack of, or inadequate, pain control. For example despite earlier RCT evidence finding ibuprofen alone may not be effective pain relief for children with musculoskeletal injuries, a recent retrospective study found it still to be the analgesic most commonly given, albeit this was set in a single emergency department.

However, there are many options available to treat paediatric pain both pharmacologically and non-pharmacologically. Sucrose, possibly combined with warmth, has been shown to be effective at reducing pain in newborn infants undergoing single painful events such as heel stick or vaccination. And music has been shown to have some benefit in children aged 3-11 undergoing intravenous catheter placement.

When considering ‘stronger’ pharmacological treatments, intranasal fentanyl (INF) is one which is of particular interest as the route of administration is likely to cause minimal distress. But can INF be used in paediatric patients to safely help control pain?

A recent Cochrane review looked for randomised controlled trial (RCT) evidence for the effect of INF in children in acute moderate to severe pain caused by injury or medical illness (excluding children younger than 3 months or preemptive treatment of pain as part of procedural sedation). There were three studies (313 children) included in this systematic review. One study compared INF to intramuscular morphine, another INF to intravenous morphine and the last compared INF given in two different concentrations. No RCTs were found comparing it to other drug or to non-pharmacological treatments.

Because of the differences in methodology, combining data sets was not possible.
When INF was compared to intramuscular morphine, INF was found to have no significant difference in pain control, except at 10 minutes when INF had a lower pain score (p<0.014). When INF was compared to intravenous morphine, there were no significant differences noted in pain reduction between groups.

No adverse events or deaths were noted in any of the studies. There was one participant who experienced a bad taste and another who vomited from the INF group. In comparison, one patient in the intravenous morphine group experienced flushing of the IV site.

So how does this help us with our clinical decision? This was a well-performed systematic review with a thorough search strategy. However, only three studies could be identified and their methodology was different enough that the data could not be combined. This limits the ability to comment on INF as non-inferior, equivalent or superior to intramuscular or intravenous morphine.

In addition, none of the INF studies included children of less than three years of age or children who had pain caused from a medical issue (e.g. abdominal pain), and there were no studies comparing it to non-opioid or non-pharmacological analgesics. All of these issues may limit the generalisability and applicability of the evidence.

Despite these limitations, all three studies point towards INF being an effective and safe method of managing moderate to severe paediatric pain.

Thank you to Dr. Anthony Crocco from for helping with this review. 

Remember to be skeptical of anything you learn, even if you heard if from the Skeptics’ Guide to Emergency Medicine.

Dr. Milne is the Chief of Staff at South Huron Hospital in Exeter, Ontario, Canada. He has been doing research for over 30 years publishing on a variety of topics. He is passionate about skepticism, medical education and evidence based medicine. He is the creator of the knowledge translation project, The Skeptics’ Guide to Emergency Medicine. When not working he is trying hard to be an endurance athlete. Dr. Milne is married to Barb and has three amazing children.

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