Nasal diamorphine in children
Date First Published:
January 17, 2001
Last Updated:
October 30, 2003
Report by:
Mark Davies, Specialist Registrar (Manchester Royal Infirmary)
Search checked by:
Ian Crawford, Manchester Royal Infirmary
Three-Part Question:
In [children with acute pain] is [nasal diamorphine or injected morphine] better at [providing safe, acceptable and effective analgesic]?
Clinical Scenario:
An 8 year old boy attends the emergency department following a fall at school. Clinically he has a displaced fracture of the right radius and ulna. He is in a lot of pain and so needs analgesia before X-ray. You have heard of the use of nasal diamorphine for pain relief but wonder whether there is evidence to show whether it is as effective as injected morphine.
Search Strategy:
Medline 1966-01/01 using the OVID interface.
Search Details:
[(exp heroin OR heroin.mp OR diamorphine.mp OR exp narcotics OR narcotics.mp OR opioids.mp OR opiate.mp OR narcotics.mp) AND (exp nose OR nose.mp OR exp administration, intranasal OR intranasal.mp)]
Outcome:
125 papers found of which only two were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy. Wilson JA, Kendall JM, Cornelius P. 1996, UK | 58 children age 3-16 with suspected limb fractures. 0.1mg/kg nasal diamorphine vs 0.2mg/kg IM morphine |
PRCT | Parental satisfaction | p < 0.0001 | Small numbers Not blinded |
| Proportion of children with no pain | 100 vs 55% | ||||
| Degree of analgesia at 5,10,20 and 30 mins | No clinical or statistical difference | ||||
| Side effects | None reported | ||||
| Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures Kendall JM, Reeves BC, Latter VS. 2001, UK | 404 children aged 3 to 16yrs with clinical fracture of an upper or lower limb. 0.1mg/kg nasal diamorphine vs 0.2mg/kg IM morphine |
PRCT | Parental satisfaction | Greater in nasal (p < 0.0001) | Clinical significance of different analgesic effect not reported |
| Degree of analgesia at 30 mins | No significant difference | ||||
| Degree of analgesia at 20 mins | Less in nasal (p < 0.002) | ||||
| Staff satisfaction | Greater in nasal (p< 0.0001) | ||||
| Side effects | Nil serious reported | ||||
| Degree of analgesia at 10 mins | Less in nasal (p < 0.003) | ||||
| Degree of analgesia at 5 mins | Less in nasal (p < 0.04) |
Author Commentary:
These two papers would suggest that intranasal diamorphine is as effective as intramuscular morphine and is much better tolerated by children with no apparent increased risk of side effects. Further work comparing intranasal diamorphine with oral morphine would be useful.
Bottom Line:
Nasal diamorphine is a safe and effective analgesic in children with acute muscoskeletal pain and is to be recommended.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Wilson JA, Kendall JM, Cornelius P.. Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy.
- Kendall JM, Reeves BC, Latter VS.. Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures