Hospital Pharmacy - April 2020 - 126

828335
research-article2019

HPXXXX10.1177/0018578719828335Hospital PharmacyKaushal et al

Original Article

Intranasal Fentanyl Use in Neonates

Hospital Pharmacy
2020, Vol. 55(2) 126-129
© The Author(s) 2019
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https://doi.org/10.1177/0018578719828335
DOI: 10.1177/0018578719828335
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Sonia Kaushal1, Jennifer L. Placencia2, Salvador R. Maffei1,
and Corrie E. Chumpitazi1

Abstract
Background: The recent addition of intranasal medication options for procedural sedation and analgesia has decreased the
need for additional painful procedures such as intravenous lines for medication administration. Intranasal fentanyl (INF) has
been used in the prehospital setting, as well as in the emergency department for several years, and is increasingly utilized in
other locations such as the neonatal intensive care unit (NICU). A paucity of data exists in these smallest children, so we
sought to explore trends in INF use in our NICU. Objective: The objective of the study was to describe INF use in the
NICU from December 2014 to December 2017. Design/Methods: A retrospective cohort study was conducted of patients
receiving INF in the NICU of a large free-standing quaternary inner-city children's hospital from December 2014 to 2017.
Demographic data were abstracted from the medical record including gestational age on administration, post-menstrual age,
day of life on administration, sex, medication initial and total dose, reported indication, and documented adverse events.
This study was approved by our local institutional review board. Results: A total of 54 patients received a total of 67 INF
administrations: 32 women (59%), median day of life on administration = 57.1 (interquartile range [IQR] = 33.7-110.4),
median weeks gestation = 26.0 (IQR = 24.1-36.1), post-menstrual age = 38.1 weeks (IQR = 33.1-45.4). Initial doses of
medications were 1.49 µg/kg/dose INF (range = 0.5-2 µg/kg). Conclusions: Intranasal adjuncts are increasingly used in the
NICU. Starting dose of INF is 1.5 µg/kg/dose, and typically, one dose is given.
Keywords
analgesics, adverse drug reactions reporting/monitoring, clinical pathways, clinical services, drug/medical use evaluation,
pediatrics, pain management

Introduction
Patients in the neonatal intensive care unit (NICU) are frequently subjected to invasive painful procedures during their
hospitalization. This includes, but is not limited to, intubation, lumbar puncture, chest tube placement, and intravenous
(IV) line placement. Due to the immaturity of the central nervous system, preterm infants are recognized to be particularly vulnerable to the effects of pain.1 Multiple studies have
identified that repeated painful stimuli may lead to permanent changes in brain processing and impaired brain development including altered pain sensitivity later in life.2-4
Neonatal intubation is one of the most common painful procedures performed in the NICU. A study assessing the use of
premedication prior to nonemergent intubations found only
43.6% of institutions always provided premedication.5 In
2010, the American Academy of Pediatrics published guidelines emphasizing that the alleviation of pain in neonates
should be the goal of all caregivers and encouraging the use
of analgesia for all nonemergent intubations.6 Despite this,
the use of the analgesia for painful procedures in the NICU
remains suboptimal.7 Potential reasons for this include lack

of IV access, the potentially emergent nature of procedures,
medical conditions in which obtaining access may exacerbate the underlying condition, cultural practice in the NICU,
and the lack of studies investigating the safety profile of
medications for this patient population.
The recent addition of intranasal (IN) medication options
for procedural sedation and analgesia has decreased the need
for additional painful procedures such as IV lines for medication administration. Intranasal fentanyl (INF) has been
used in the prehospital and emergency department settings
for several years. It has shown to be equivalent or superior to
IV morphine by decreasing time to analgesia administration
and time to pain relief.8-10 This evidence, along with the significant ease of administration and no requirement for IV
line placement or injection for administration, makes it a
1

Baylor College of Medicine, Houston, TX, USA
Texas Children's Hospital, Houston, TX, USA

2

Corresponding Author:
Corrie E. Chumpitazi, Baylor College of Medicine, 1102 Bates Street,
Houston, TX 77030, USA.
Email: corriec@bcm.edu
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