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Nasal diamorphine in children

Three Part Question

In [children with acute pain] is [nasal diamorphine or injected morphine] better at [providing safe, acceptable and effective analgesic]?

Clinical Scenario

An 8 year old boy attends the emergency department following a fall at school. Clinically he has a displaced fracture of the right radius and ulna. He is in a lot of pain and so needs analgesia before X-ray. You have heard of the use of nasal diamorphine for pain relief but wonder whether there is evidence to show whether it is as effective as injected morphine.

Search Strategy

Medline 1966-01/01 using the OVID interface.
[(exp heroin OR OR OR exp narcotics OR OR OR OR AND (exp nose OR OR exp administration, intranasal OR]

Search Outcome

125 papers found of which only two were relevant.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Wilson JA et al,
58 children age 3-16 with suspected limb fractures. 0.1mg/kg nasal diamorphine vs 0.2mg/kg IM morphinePRCTParental satisfactionp < 0.0001Small numbers Not blinded
Proportion of children with no pain100 vs 55%
Degree of analgesia at 5,10,20 and 30 minsNo clinical or statistical difference
Side effectsNone reported
Kendall JM et al,
404 children aged 3 to 16yrs with clinical fracture of an upper or lower limb. 0.1mg/kg nasal diamorphine vs 0.2mg/kg IM morphinePRCTParental satisfactionGreater in nasal (p < 0.0001)Clinical significance of different analgesic effect not reported
Degree of analgesia at 30 minsNo significant difference
Degree of analgesia at 20 minsLess in nasal (p < 0.002)
Staff satisfactionGreater in nasal (p< 0.0001)
Side effectsNil serious reported
Degree of analgesia at 10 minsLess in nasal (p < 0.003)
Degree of analgesia at 5 minsLess in nasal (p < 0.04)


These two papers would suggest that intranasal diamorphine is as effective as intramuscular morphine and is much better tolerated by children with no apparent increased risk of side effects. Further work comparing intranasal diamorphine with oral morphine would be useful.

Clinical Bottom Line

Nasal diamorphine is a safe and effective analgesic in children with acute muscoskeletal pain and is to be recommended.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.


  1. Wilson JA, Kendall JM, Cornelius P. Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy. J Accid Emerg Med 1997;14:70-2.
  2. Kendall JM, Reeves BC, Latter VS. Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures BMJ 2001;322:261-65.