Three Part Question
In [children with acute pain] is [nasal diamorphine or injected morphine] better at [providing safe, acceptable and effective analgesic]?
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.
Medline 1966-01/01 using the OVID interface.
[(exp heroin OR heroin.mp OR diamorphine.mp OR exp narcotics OR narcotics.mp OR opioids.mp OR opiate.mp OR narcotics.mp) AND (exp nose OR nose.mp OR exp administration, intranasal OR intranasal.mp)]
125 papers found of which only two were relevant.
|Author, date and country
||Study type (level of evidence)
|Wilson JA et al,|
|58 children age 3-16 with suspected limb fractures.
0.1mg/kg nasal diamorphine vs 0.2mg/kg IM morphine||PRCT||Parental satisfaction||p < 0.0001||Small numbers
|Proportion of children with no pain||100 vs 55%|
|Degree of analgesia at 5,10,20 and 30 mins||No clinical or statistical difference|
|Side effects||None 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 morphine||PRCT||Parental satisfaction||Greater in nasal (p < 0.0001)||Clinical significance of different analgesic effect not reported|
|Degree of analgesia at 30 mins||No significant difference|
|Degree of analgesia at 20 mins||Less in nasal (p < 0.002)|
|Staff satisfaction||Greater in nasal (p< 0.0001)|
|Side effects||Nil serious reported|
|Degree of analgesia at 10 mins||Less in nasal (p < 0.003)|
|Degree of analgesia at 5 mins||Less 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.
- Wilson JA, Kendall JM, Cornelius P. Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy. J Accid Emerg Med 1997;14:70-2.
- 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.