Is the nasal route a viable option for relieving acute pain in pediatric emergency medicine? A literature review

In recent years, the nasal route has increasingly been viewed as an alternative option for the delivery of analgesia, especially when the traditional ways are complicated or time-intensive. However, little is known about the value of this intervention in acute pain management in pediatric emergency medicine. This evidence-based analysis review aims to assess the current evidence regarding the use, safety, and effectiveness of intranasal analgesics in acutely painful conditions encountered in Pediatric Emergency Departments (PEDs). A systemic electronic searching of Cochrane library, PubMed, and EMBASE databases from the beginning of each database until October 2018 was conducted using a maximally sensitive searching strategy. Only randomized controlled trials (RCTs) or quasirandomized controlled trials that evaluated the use of intranasal analgesia for acute pain in children in the Emergency Department and published between January 1990 and October 2018 were included. The methodological quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria. Risks of bias within each included study were evaluated according to the Cochrane Risk of Bias Tool for RCTs. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses statement. Seven RCTs and one quasi-randomized study met the inclusion criteria. Five studies compared an intranasal analgesic and an alternative intervention, two compared intranasal fentanyl against ketamine, and one compared two different concentrations of intranasal fentanyl. All included trials reported reductions in pain scores, especially within the first 10 to 30 minutes post-intervention; however, pain reduction was maintained to 60 minutes in only one study. No evidence of significant adverse events was associated with the administration of any intranasal analgesic in any of the included studies. This review identified eight articles that discussed the intranasal analgesia as a possible route of analgesia in the PED. While no paper was entirely perfect, the findings support the idea that intranasal analgesia may be an effective analgesic for the treatment of children (3-18 years) with acute moderate to severe pain, and its administration appears to cause minimal adverse effects.