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Three Part Question

In [children with pain] is [intranasal fentanyl] an [effective analgesic]

Clinical Scenario

A four year old child is brought to the emergency department in moderate to severe pain. You have a protocol for using intra-nasal diamorphine1 in such children, but have been unable to apply it for some time because of a nationwide shortage2. You wonder whether any other opiate could be administered in a similar manner ?

Search Strategy

MEDLINE 1950-date using Dialog Datastar interface
({ fentanyl AND HUMAN=YES AND ( CHILD# OR ADOLESCENT.DE. OR INFANT# )) AND (intranasal$ AND HUMAN=YES AND ( CHILD# OR ADOLESCENT.DE. OR INFANT# ))) AND (( (pain) OR (PAIN.W..DE.) ) AND LG=EN }). EMBASE 1974-date using Dialog Datastar interface. ({fentanyl AND HUMAN=YES AND CHILD=YES) AND (intranasal$ AND HUMAN=YES AND CHILD=YES)) AND (PAIN.W..DE.)) AND LG=EN }). The Cochrane Library 2006 Issue 1 ({intranasal AND fentanyl in Title, Abstract or Keywords})

Search Outcome

Altogether 50 articles were found on all three databases, of which four were relevant to the question (Borland 2002, Borland 2005, Manjushree, Young). These are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Borland et al, 2002, Australia	45 children (3-12yrs) in acute pain attending ED	Observational study	Pain scores at 10 minutes	Significant reduction in pain score at 10minutes.	Not blinded, no controls
			Physiological parameters (Pulse, resps, SaO2, BP)	No significant alteration in physiological parameters
Borland et al, 2005, Australia	24 children (<15yrs) with burns attending ED	Randomised double blinded 2 treatment crossover (i/nasal fentayl vs oral morphine)	Pain scores	Analgesic equivalence with oral morphine	Small study
			Sedation, co-operation, time to resume age appropriate activities/ fluid intake	Fewer side effects n=5 (with i/nasal fentanyl) vs n=10 (oral morphine) No statistical difference in time to resumption of fluid intake
Manjushree R et al, 2002, Canada	32 children (4-8yrs) post-operative analgesia	Randomised double blinded prospective RCT (i/nasal fentanyl vs i.v. fentanyl)	Pain score Physiological parameters (Pulse, BP, resps, SaO2) Side effects (nausea, vomit, itching, excess sedation)	No significant difference between either arm of trial, other than larger requirement of fentanyl i/nasally
Young et al, 1999, Australia	47 children (3-10yrs) with clinical fracture	Prospective RCT 2 arm (i.m morphine vs i/nasal fentanyl)	Tolerance of administration Pain score Adverse events Physiological data	Pain scores not significantly different. i/nasal significantly better tolerated	Not blinded. Control group not a current standard UK therapy

Clinical Bottom Line

Intranasal fentanyl is a proven, safe and effective method of rapid analgesia in children. Given the current shortages experienced with diamorphine, departments and Trusts should consider introducing guidelines substituting intranasal fentanyl for intranasal diamorphine.

References

1. BAEM [Online] Guideline for Management of Pain in Children www.library.nhs.uk/SpecialistLibraries/Download.aspx?resID=37261 (Accessed 22/09/06)
2. NHS Purchasing & Supply Agency[Online] Ongoing shortfall in the availability of diamorphine- an update 16th June 2006 Rapid alerts - pharma http://www.pasa.doh.gov.uk/pharma/rapid_alerts.stm (Accessed 04/10/06)
3. Borland et al. Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emergency Medicine Sep 2002 14, no.3, p275-280
4. Borland M.L et al. Intranasal Fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study. Burns Nov 2005 31, no.7, p 831-837
5. Manjushree R et al. Intranasal fentanyl provides adequate postopertive analgesia in pediatric patients. Canadian Journal of Anaesthesia Feb 2002 49, no.2, p190-3
6. Young PA et al. A prospective randomised pilot comparison of intranasal fentanyl and intramuscular morphine for analgesia in children presenting to the emergency department with clinical fractures. Emergency Medicine 1999 11, no.2, p90-4