Use of Intranasal Analgesia for Acute Pain in Pediatric Emergency Departments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND

Pain is one of the most common reasons for presentation to pediatric emergency departments, yet timely and effective analgesia remains inconsistently delivered. Intranasal (IN) analgesics offer a noninvasive alternative to injectable routes, but their comparative effectiveness, safety, and acceptability across agents and routes remain incompletely defined.

METHODS

We conducted a systematic review and network meta-analysis of randomized controlled trials evaluating IN analgesics for acute pain management in children aged 0-18 years presenting to emergency or prehospital settings. Eligible trials compared IN agents with alternative IN formulations, intravenous, intramuscular, oral analgesics, or placebo. Pain reduction measured using validated pediatric pain scales at predefined timepoints was the primary outcome. Secondary outcomes included need for rescue analgesia, adverse events, acceptability, and emergency department length of stay.

FINDINGS: Fifteen randomized controlled trials involving 1388 pediatric patients were included. Across all evaluated timepoints, including the primary outcome and assessments at 10, 15, 20, 30, and 60 min, no IN or intravenous analgesic demonstrated statistically superior pain reduction compared with IN fentanyl. Requirements for rescue analgesia were similarly comparable across treatments. IN ketamine was associated with a significantly higher risk of adverse events compared with standard-dose IN fentanyl, although events were predominantly mild and transient. Acceptability among patients, caregivers, and providers was high across IN agents, and available data indicated no clinically meaningful differences in emergency department length of stay.