May 26, 2025
Contributor: Aaron Lessen, MD
Educational Pearls:
How do we take care of kids in severe pain?
- There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated.
- These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl.
- Intranasal fentanyl has many advantages:
- Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes equivalent to other pain control options
- Total adverse effects were also lower with IN fentanyl, including low rates of nausea and vomiting
- To administer, use the IV formulation with an atomizer and spray into the nose; therefore, you do not need an IV line
- Dose is 1-2 micrograms per kilogram, can be redosed once at 10 minutes.
- Don’t forget about gabapentinoids for neuropathic pain, muscle relaxants for muscle spasms, and nerve blocks when appropriate. (Disclaimer: muscle relaxers have not been well studied in children)
References
- Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752. doi: 10.1097/PEC.0000000000003187. Epub 2024 Apr 11. PMID: 38713846.
- Bailey B, Trottier ED. Managing Pediatric Pain in the Emergency Department. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. PMID: 27260499.
- Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439.
