Intranasal Fentanyl Toolkit

Last modified by Lisa Stromquist on 2017/09/15 15:48

** Current best evidence for the use of intranasal fentanyl in children suggests that it is a promising option for the treatment of moderate to severe pain. However, the most recent Cochrane Database of Systematic Reviews suggests that further study is required before its use can be routinely recommended in children.**

Welcome to the toolbox about how intranasal fentanyl can be used to treat moderate- severe acute pain and procedural pain for short, minor procedures in children. Please note that while other toolkits included within this project provide recommendations for well-established techniques with a robust evidence base, the evidence for the use of intranasal fentanyl is less mature. However, our CAPHC Community of Practice environmental scan (2014) strongly supported the creation of this toolbox, as intranasal fentanyl use was reported as widely used is many settings. Current best evidence supports the use of intranasal fentanyl for children aged 1 to 18 years


“The importance of providing optimal pain treatment has been echoed by several national and international policy statements. In addition to the mandate by the World Health Organization (WHO) that adequate pain treatment should be a fundamental human right, the American Academy of Pediatrics (AAP) recently reaffirmed its position that adequate analgesia be provided for children. Moreover, untreated pain in childhood has been reported to lead to long-term negative outcomes such as anxiety, hyperesthesia, and needle phobia.” (Poonai et al., CJEM, 2016). 

While intranasal fentanyl is a good choice for the pharmacologic treatment of moderate to severe pain, especially when an intravenous is not feasible in a timely manner, it does not need to be used in isolation. Distraction can also be used in conjunction with such pharmacological pain management, to help address the pain and distress associated with illness and injury. Links to recommendations and resources for distraction techniques can be found through the main webpage for the CAPHC acute procedural pain toolboxes.

The purpose of this toolbox is to make using intranasal fentanyl in clinical practice easier. The contents, which have been provided by your clinical colleagues around the country, can help confirm that you are using intranasal fentanyl in the safest and most effective manner, help create a policy for its use in your organization, support clinical education in intranasal fentanyl use, and provide clinical resources to make intranasal fentanyl easier to use. Use as many of the resources as you need and modify them to fit your organizational context. 

Examples of policies are provided for reference purposes, only. We encourage all users of the toolbox who wish to adopt a similar policy at their institution to review, adapt, and modify the examples, as needed. The providers of these examples do not endorse their use outside of the institution for which it was originally created.

** Please note that hemodynamic and sedation monitoring should be provided for any child receiving an opioid medication. We urge all practitioners to follow their health care institution’s recommended guidelines for monitoring. **


In this kit you’ll find:

  • Clinical resourcesincluding a quick tip sheet and a pocket reference guide to make intranasal fentanyl safer and more accessible to you and your patients.
  • An example of both French and English hospital policy  for the use of intransal fentanyl for acute pain treatment. This policy can be used to create your own organizational policy based on your needs and context
  • Clinical PowerPoint developed by your clinical colleagues to support education about using intranasal fentanyl. This slide deck can be modified and delivered for your needs and context.
  • Background articles outlining the current best research evidence to support using intranasal fentanyl for the treatment of moderate-severe acute pain

If you have any comments, questions or additions for the box, please contact CAPHC at 

Thank you for supporting the CAPHC Pain Community of Practice’s mission to improve health outcomes for infants and children by reducing pain experienced during medical procedures, healthcare interventions and chronic conditions, disease or disability. 

Clinical ResourcesAtomizer Instructions
IN Fentanyl Summary Sheet
IN Fentanyl Cheat Card 
Hospital PolicyExample from Alberta Children's Hospital - EN
Example from CHEO - Opioid Analgesia - ENExample from CHUS Ste Justine, Guideline - FR
Example from CHUS Ste. Justine - FR 
 Clinical PowerPointGetting in the nose: Intranasal Fentanyl - PowerPoint
Getting in the Nose: Intranasal Fentanyl - PDF
Background ArticlesComplete list of background articles PDF

Intranasal fentanyl for the management of acute pain in children.Murphy A, O'Sullivan R, Wakai A, Grant TS, Barrett MJ, Cronin J, McCoy SC, Hom J, Kandamany N.Cochrane Database Syst Rev. 2014 Oct 10;10:CD009942. doi: 10.1002/14651858.CD009942.pub2. Review.PMID: 25300594

Intranasal fentanyl for pain management in children: a systematic review of the literature.Mudd S.J Pediatr Health Care. 2011 Sep-Oct;25(5):316-22. doi: 10.1016/j.pedhc.2010.04.011. Epub 2010 Jun 17. Review.PMID: 21867860

The PICHFORK (Pain InCHildren Fentanyl OR Ketamine) trial comparing the efficacy of intranasalketamine and fentanyl in the relief of moderate to severe pain in children with limb injuries: study protocol for a randomized controlled trial.Graudins A, Meek R, Egerton-Warburton D, Seith R, Furness T, Chapman R.Trials. 2013 Jul 10;14:208. doi: 10.1186/1745-6215-14-208.PMID:23842536

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Bet 4: is intranasal fentanyl better than parenteral morphine for managing acute severe pain in children?Kusre SR.Emerg Med J. 2011 Dec;28(12):1077-8. doi: 10.1136/emermed-2011-200892. Review.PMID:22101600

Equivalency of two concentrations of fentanyl administered by the intranasal route for acuteanalgesia in children in a paediatric emergency department: a randomized controlled trial.Borland M, Milsom S, Esson A.Emerg Med Australas. 2011 Apr;23(2):202-8. doi: 10.1111/j.1742-6723.2011.01391.x. Epub 2011 Feb 8.PMID: 21489168

The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency department reduces time to analgesic administration.Holdgate A, Cao A, Lo KM.Acad Emerg Med. 2010 Feb;17(2):214-7. doi: 10.1111/j.1553-2712.2009.00636.x.PMID:20070272

Intranasal fentanyl in 1-3-year-olds: a prospective study of the effectiveness of intranasalfentanyl as acute analgesia.Cole J, Shepherd M, Young P.Emerg Med Australas. 2009 Oct;21(5):395-400. doi: 10.1111/j.1742-6723.2009.01216.x.PMID:19840089

 Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain.Saunders M, Adelgais K, Nelson D.Acad Emerg Med. 2010 Nov;17(11):1155-61. doi: 10.1111/j.1553-2712.2010.00905.x.PMID:21175512
Created by Lisa Stromquist on 2015/12/23 20:55