Why intranasal? The problem of missing access
An injured, screaming toddler with a forearm fracture or scald is a challenge both in the prehospital setting and in the resuscitation room. Venepuncture in infants and young children is technically demanding and painful, and it delays analgesia. Every failed attempt also heightens fear and resistance. Intraosseous access is intended for resuscitation and critical circulatory situations. For analgesia alone in a haemodynamically stable child, it is disproportionate.
Intranasal analgesia in children closes this gap. The well-perfused nasal mucosa allows absorption that bypasses the first-pass effect. Administration is quick and almost painless, and it is considerably less distressing for the child than venepuncture. In many cases, successful analgesia is what makes subsequent venepuncture possible under calm conditions.
Indications in paediatric emergency analgesia
The intranasal route is an option when a rapid effect is required and no access is in place, or when establishing access would delay care. Typical situations in paediatric emergency analgesia are:
- Traumatic pain: fractures, dislocations and soft-tissue injuries, particularly before positioning, splinting or transport
- Burns and scalds: analgesia before wound care and cooling
- Procedural analgesia and anxiolysis: before wound care, reductions or establishing venous access
- Reversal: if opioid intoxication is suspected, an antidote can be given intranasally when no access is available.
The intranasal route is not suitable as a substitute for IV/IO access in resuscitation, shock or life-threatening conditions. According to ERC 2025, drugs in paediatric resuscitation are given intravenously or intraosseously.
Which drugs may be considered?
In practice, the following drug groups are mainly used for intranasal administration in children:
Opioids
Fentanyl is well suited to nasal absorption because of its high lipophilicity. It is used for severe acute pain. As with any opioid, watch for respiratory depression, reduced level of consciousness and nausea.
Ketamine or esketamine
Ketamine or esketamine has an analgesic effect and, at higher doses, a sedative effect. Protective reflexes and respiratory drive are largely preserved. Possible effects include hypersalivation, emergence agitation and vomiting. The distinction between the racemate and esketamine must be observed when calculating the dose.
Benzodiazepines
Intranasal midazolam is used for anxiolysis and sedation. It has no analgesic effect. Administration may cause a burning sensation in the nasal mucosa. Combining it with opioids markedly increases the risk of respiratory depression.
Other drugs
Other substances are also given intranasally, including sedatives and antidotes such as naloxone. Drug selection should be guided by the local standard operating procedure (SOP), the team's experience and the licensing status.
Dosing and licensing status
This article deliberately gives no intranasal doses. Dose recommendations vary by drug, concentration and indication. They should be taken from the current guideline, the summary of product characteristics and the local SOP.
Many intranasal uses in children are off-label. This requires careful assessment of the indication, information for those with parental responsibility as far as circumstances allow, and documentation. The quality of evidence varies by drug and indication and should be taken into account in the local SOP.
The basis of every dose: body weight
Intranasal doses are calculated by body weight. If known, always use the actual weight, for example as reported by the parents, from the child health record (Mutter-Kind-Pass) or by length-based tape. If the weight is unknown, the APLS formulae allow an estimate up to 12 years of age:
| Age group | Formula (APLS) | Example |
|---|---|---|
| Infant | 0.5 × months + 4 kg | 6 months ≈ 7 kg |
| 1–5 years | 2 × age + 8 kg | 3 years ≈ 14 kg |
| 6–12 years | 3 × age + 7 kg | 8 years ≈ 31 kg |
From 13 years of age, or from the onset of puberty, ask for the actual weight. Weight estimation is an approximation. It deviates relevantly in markedly slim or overweight children.
Using the atomiser: intranasal MAD in emergencies
Effectiveness depends on delivering the drug as a fine mist rather than as drops. This requires an atomiser attachment, often called an MAD (Mucosal Atomization Device), which is fitted to a Luer-lock syringe. The procedure for intranasal MAD in emergencies:
- Preparation: Check the drug and concentration. Calculate the dose from the weight and have it cross-checked by the team (four-eyes principle). Concentrated solutions allow small administration volumes, so dilution is generally unfavourable.
- Account for dead space: The atomiser attachment has a dead space. Take the exact figures from the manufacturer's information and include them when drawing up the drug.
- Positioning: Ideally, the child sits on a caregiver's lap with the head slightly raised and stabilised. Remove visible secretions beforehand or have the child blow their nose.
- Administration: Insert the attachment snugly into the nostril and angle it slightly upwards and laterally. Depress the syringe plunger quickly and firmly to produce a fine mist.
- Splitting the dose: Divide the dose between both nostrils. This enlarges the absorption surface and prevents run-off into the pharynx. The maximum useful volume per nostril is limited (follow the manufacturer's information and local SOP). Excessive volumes are swallowed and then subject to the first-pass effect.
- Follow-up: Wait for the onset of effect and reassess pain intensity using an age-appropriate scale. Review whether a further dose or venous access is indicated.
Monitoring after intranasal administration
Non-invasive administration does not change the risk profile of the drugs. After intranasal opioids, ketamine or benzodiazepines, the same safety standards apply as after intravenous administration:
- Monitoring: Continuously monitor pulse oximetry, respiratory rate and level of consciousness. During sedation, use capnography as well where possible.
- Know age-appropriate normal values: According to ERC 2025/RCUK 2025, the normal respiratory rate is 20–50/min at 1 year of age, 17–30/min at 5 years and 14–25/min at 10 years. A fall below the normal range after an opioid is a warning sign.
- Have equipment ready: Suction, oxygen, bag-mask ventilation in the appropriate size and antidotes must be immediately to hand. Airway management equipment should be available in child-appropriate sizes.
- Combinations: Combining sedative substances potentiates respiratory depression. Combinations require particular vigilance and should be used only by those with appropriate experience.
Limitations of the method
The intranasal route is a valuable addition but not a universal substitute for vascular access. Important limitations include:
- Unpredictable absorption: Rhinitis, increased secretions, epistaxis or anatomical obstruction can markedly reduce uptake.
- Contraindications and cautions: In facial trauma, suspected basal skull fracture or nasal injury, consider the intranasal route critically.
- Limited titratability: Compared with intravenous administration, fine titration is only possible to a limited extent. Onset and duration of action vary more.
- Volume limit: The limited administration volume restricts the choice to drugs available in sufficiently high concentrations.
- Not an emergency access route: In resuscitation, shock, anaphylaxis with circulatory involvement or status epilepticus, management follows the relevant algorithms. In paediatric resuscitation, ERC 2025 specifies IV/IO administration.
- Off-label use: Legal and organisational arrangements should be clarified through an agreed local SOP.
Practical conclusions
Intranasal drug administration allows early, child-friendly analgesia and anxiolysis without losing time on venepuncture. Safe use requires:
- a reliable body weight,
- correct atomiser technique with a limited volume per nostril,
- doses strictly in line with the current guideline and summary of product characteristics,
- monitoring to the same standard as after intravenous administration.
Where absorption or titratability is inadequate, or where there is a threat to life, intravenous or intraosseous access remains the standard. The paediatric emergency table in the "Notfall & Narkose" web app and pocket book summarises weight estimation and age-dependent normal values for rapid reference.
References
- Djakow J, Turner NM, Skellett S et al. European Resuscitation Council Guidelines 2025 Paediatric Life Support. Resuscitation 2025;215 Suppl 1:110767.
- Resuscitation Council UK. Paediatric advanced life support algorithm – 2025 Resuscitation Guidelines (Fassungen 10/2025 und V2 11/2025) sowie Paediatric Life Support Guideline 2025, Tabelle 1 „Approximate normal values“ (Wiedergabe in Medscape: Paediatric Life Support – RCUK 2025 Guideline Summary).
- Advanced Life Support Group (ALSG). Advanced Paediatric Life Support (APLS) – A Practical Approach to Emergencies. Altersformeln zur Gewichtsschätzung seit 2011.
- Luscombe M, Owens B. Weight estimation in resuscitation: is the current formula still valid? Arch Dis Child 2007;92:412–415.
- Fleming S, Thompson M, Stevens R et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet 2011;377:1011–1018.
This article does not replace clinical judgement in the individual case or the current summary of product characteristics and guidelines.
