Paediatric Acute care Guidelines PMH Emergency Department



  • Pain relief in children in moderate – severe pain requiring opiate analgesia
  • No IV cannula in place as yet


  • Known fentanyl hypersensitivity
  • Altered conscious state: GCS < 15
  • Bilateral occluded nasal passages
  • Epistaxis
  • MAOI anti-depressant within 14 days


Adverse effects are uncommon, but may include:

  • Respiratory depression
  • Hypotension
  • Nausea and vomiting
  • Itch
  • Chest wall rigidity (only reported in rapid large IV doses)


  • Age: 1 – 18 years  (Use with caution in children < 12 months)
  • Dose: 1.5 micrograms/kg per dose, intra-nasally
  • Repeat after 5 – 10 minutes, if required
  • If further analgesia required after the second dose, obtain medical review and consider alternative analgesia
  • It is acceptable to prescribe multiple dosages if efficacy is good


  • Draw up calculated dose of Fentanyl according to weight, plus an extra 0.1ml in a 1ml syringe to load atomiser
  • Attach atomiser (MAD device WolfeTory ®) to the 1ml syringe
  • Prepare atomiser by priming with 0.1ml of fentanyl
  • Position patient either sitting up at 45° or with head to one side
  • Administer dose by inserting into nostril loosely and aim for centre of nasal cavity prior to squirting
  • If the dose is > 0.25mL, split between both nostrils to prevent loss of solution by sneezing or swallowing
  • Depress the plunger quickly
  • Hold atomiser in place for further 5 secs to prevent medication from dribbling out of nostril



  • Time of administration
  • Baseline pre-narcotic observations if possible: HR, RR, BP, oxygen saturations
  • Observe closely for adverse effects and over sedation

Treatment of overdose:

  • Support airway
  • Oxygen
  • Assist ventilation
  • Consider Naloxone  as reversal agent:
    • Naloxone is available in the Resus Room
    • Should be administered for excess sedation or respiratory depression
    • Dose – 1-5 micrograms/kg IV, maximum dose of 100 micrograms, may be repeated every 2-3 minutes if required
    • Has short duration of action – approximately 30 minutes, may necessitate repeat doses or infusion


PMH ED Guideline – Intranasal Fentanyl: Last Updated July 2014
AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2014 July. Available from:




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