See also

Acute pain management 

Pain assessment and management 

Procedural sedation

Key points

1. Intranasal (IN) fentanyl is a safe, non-invasive and effective analgesic for children with moderate to severe pain
2. Fentanyl should be used in combination with non-pharmacological and other pharmacological pain management
3. It can be used in conjunction with nitrous oxide for procedural sedation

Background

Fentanyl is a rapid acting synthetic opioid, with an onset of action within 5 minutes and a duration of action of approximately 30-60 minutes. The intranasal route of administration is convenient and relatively non-invasive in children with moderate/severe pain who do not have IV access. It should be prescribed in consultation with a senior clinician.

IN fentanyl can be used on its own as an analgesic agent, but it is also frequently used with nitrous oxide when performing painful procedures such as fracture reductions or burns dressings. It should be given 5 minutes before commencing nitrous oxide sedation. There is an increased risk of vomiting when fentanyl and nitrous oxide are used in combination.

Indications

Initial analgesia for any child (aged 12 months and older) in moderate to severe pain, without IV access.

Commonly

• Painful injuries such as
  • Fractures, dislocations, amputations
  • Burns
  • Significant lacerations
• Painful procedures under nitrous oxide
• Medical causes of acute severe pain eg sickle cell crisis
• Surgical causes of pain

Use in conjunction with other non-pharmacological and pharmacological pain management.

IN fentanyl should not be given in isolation

Contraindications

• Age under 12 months
• Known fentanyl hypersensitivity
• Altered conscious state
• Bilateral occluded nasal passage
• Active epistaxis

Procedure

Pre-procedure

Prior to administration, all children require documented baseline:

• Pain score (see Acute pain management)
• Sedation score (see table below)
• Set of observations

Monitoring

Refer to local hospital policy for monitoring children who receive parenteral opioids:

• Heart rate, respiratory rate, oxygen saturation, pain score and sedation score
• The child should be awake or easily roused to voice prior to each dose (UMSS 0-1)
• If sedated or abnormal vital signs, inform treating clinician and continue observations and sedation scores until return to baseline
• After the last dose has been given, two further sets of observations at 5-minute intervals should be completed
• The effectiveness of the analgesia should be recorded in the child's medical record and/or on the general observation chart

Administration

• Attach the mucosal atomiser device (MAD) on to the end of the syringe
• Draw up appropriate dose for weight plus 0.1 mL extra for the first dose, to account for priming the dead space in the device
• Do not draw up 0.1 mL extra for second dose when re-using the MAD
• Prepare atomiser by slowly priming the additional 0.1 mL, leaving the calculated dose in the syringe for administration
• With the child sitting at approximately 45 degrees or with head to one side, insert the device loosely into the nostril and press the plunger quickly (if depressed too slowly the medication will drip rather than atomise)
• Ask the child to only gently sniff, as a vigorous inhalation will result in swallowing the medication rather than true intranasal administration
• Dose should be divided between nostrils

     Equipment required

    Mucosal atomiser device

Dosage

• First dose: 1.5 microg/kg dose (max 100 microg) of 300 microg/mL nasal solution
  • Usual maximum is 75 micrograms due to volume limitations with 100 microg/2 mL concentration
  • A maximum of 100 micrograms may be given if using 300 microg/mL (available in hospitals only)
• For overweight children, use ideal bodyweight
• A second dose may be administered 5-10 minutes after the first to provide adequate analgesia
• Second dose: 0.75-1.5 microg/kg (max 75-100 microg)
• After second dose, review and consider IV access for additional analgesia if required

Potential side effects and management

Side effects are uncommon, but may include:

• Sedation
• Respiratory depression
• Hypotension
• Nausea and vomiting (increased risk when combined with nitrous oxide)
• Chest wall rigidity (only reported in large intravenous doses)
• Pruritus

Treatment of opioid toxicity/overdose

• Immediate senior clinician review, move to resuscitation area
• Cease additional opioid administration
• Support airway and provide oxygenation
• Assist ventilation as required
• Administer naloxone bolus
  • 1-5 microg/kg (max 100 microg) IM or IV for excessive sedation (UMSS 3), repeat 2-3 minutely if required
  • 10 microg/kg (max 400 microg) for acute overdose (UMSS 4)
  • 100 microg/kg (maximum 2 mg) in an emergency if lack of response to 10 microg/kg

Consider discharge when

• Sedation score and observations have returned to baseline
• Minimal pain score, which can be managed with simple analgesics

Parent information

If used in conjunction with nitrous oxide: Sedation for procedures

Last updated October 2025