Intranasal opioids for severe, acute nociceptive pain in children 1 year or older
The intranasal route of administration is preferred to oral or subcutaneous opioid administration for severe, acute nociceptive pain in children because the fast onset of effect provides prompt analgesia. Intranasal fentanyl should only be administered in hospitals with staffing and resources that allow immediate resuscitation of a child with opioid-induced ventilatory impairment, see Using opioids in hospital. Intranasal fentanyl should rarely be used outside critical care areas (eg emergency departments). Always refer to local protocols when they are available.
Intranasal fentanyl should be used in addition to paracetamol and an NSAID for severe, acute nociceptive pain. If oral paracetamol or an NSAID is not appropriate, see Alternative routes of administration if oral paracetamol or NSAIDs cannot be used.
Establish an alternative route of administration as soon as possible because children who are distressed by intranasal administration or who experience a bitter taste following administration may refuse or resist subsequent doses. Oral administration should be used for ongoing analgesia. If the oral route is not appropriate in children, refer to local protocols—nurse- or patient-controlled analgesia may be considered, seek expert advice.
If intranasal fentanyl is indicated for a child 1 year or older with severe, acute nociceptive pain, due to an acute illness or following trauma, as a three-drug regimen, use:
paracetamol immediate-release 15 mg/kg (for overweight children, use ideal body weight) up to 1 g orally, 4-to 6-hourly. Maximum 60 mg/kg up to 4 g in 24 hours acute pain, severe (children receiving intranasal opioids) paracetamol
PLUS ONE OF THE FOLLOWING NSAIDS
1 ibuprofen 5 to 10 mg/kg (for overweight children, use ideal body weight) up to 400 mg orally, 8-hourly. Maximum 30 mg/kg up to 1.2 g in 24 hours acute pain, severe (children receiving intranasal opioids) ibuprofen
OR
2 celecoxib 2 to 4 mg/kg (for overweight children, use ideal body weight) up to 100 mg orally, 12-hourly. Maximum 8 mg/kg up to 200 mg in 24 hours acute pain, severe (children receiving intranasal opioids) celecoxib
OR
2 naproxen 5 mg/kg (for overweight children, use ideal body weight) up to 500 mg orally, 12-hourly. Maximum 10 mg/kg up to 1 g in 24 hours acute pain, severe (children receiving intranasal opioids) naproxen
PLUS
fentanyl 0.5 to 1.5 micrograms/kg (for overweight children, use ideal body weight) up to 75 micrograms intranasally, via atomiser attached to a small syringe. Use the lower end of the dose range if the child has risk factors for opioid-induced ventilatory impairment (eg recent airway surgery, tonsillectomy or adenoidectomy, sleep apnoea, concomitant sedative drugs) acute pain, severe, intranasal dosing (children fentanyl
if using 50 micrograms/mL solution, spray up to 0.3 mL (15 micrograms) into each nostril, alternating between nostrils up to the required dose12
after each dose, wait 5 minutes then assess the child for signs of opioid-induced ventilatory impairment (using sedation score and respiratory rate) and determine whether pain relief is adequate. If the child does not have signs of opioid-induced ventilatory impairment and pain relief is inadequate, a repeat dose can be given while establishing an alternative route of administration.