Perri A, Fattore S, Sbordone A, Rotunno G, De Matteis A, Papacci P, D'Andrea V, Vento G
Department of Woman and Child Health Sciences, Child Health Area, University Hospital Agostino Gemelli, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Lazio, Italy.
Department of Woman and Child Health Sciences, Child Health Area, Catholic University of Sacred Heart Seat of Rome, Rome, Lazio, Italy.
Paediatr Drugs. 2025 Mar;27(2):191-199. doi: 10.1007/s40272-024-00672-4. Epub 2024 Dec 11.
The prevention, recognition, and treatment of pain is crucial in the management of neonates. Infants do not tolerate pain better than adults; indeed, the immaturity of the endogenous antalgic system means they exhibit an increased stress response. Pain has been associated with worse cognitive and motor scores, reduced growth trend, reduced brain maturation, and altered corticospinal tract structure. The use of the intranasal route for drug delivery is currently expanding because it has many advantages. In certain contexts, it is preferable over the oral route because of the faster entry of drugs into the circulation, the absence of structural changes by the gastrointestinal environment, and the absence of the hepatic first-pass effect. The pharmacokinetics and pharmacodynamics of drugs commonly used for pain management have peculiar characteristics in infants, especially premature infants. In this article, we summarise the evidence regarding pain management in infants using intranasally administered drugs. We then provide a practical guide to the use of intranasal drugs currently being studied in the neonatal population, focusing on appropriate dosages and indications. Intranasal fentanest appears to be an attractive therapeutic alternative for procedural and palliative neonatal pain management when intravenous access is unavailable in preterm infants. Intranasal midazolam is a valid alternative to consider in term or near-term neonates, especially when the aim is to obtain sedation (and not analgesia, i.e. during magnetic resonance imaging), ketamine has favourable cardiovascular effects and should be considered in specific patients and situations. Intranasal dexmedetomidine is well tolerated in premature neonates. Additionally, endonasal dexmedetomidine can be used in combination with other anaesthetic, sedative, hypnotic, and opioid drugs to allow for dose reduction in sedated neonates.
疼痛的预防、识别和治疗在新生儿管理中至关重要。婴儿对疼痛的耐受并不比成人更好；事实上，内源性镇痛系统的不成熟意味着他们会表现出更强的应激反应。疼痛与较差的认知和运动评分、生长趋势降低、大脑成熟度降低以及皮质脊髓束结构改变有关。目前，鼻内给药途径的应用正在扩大，因为它具有许多优点。在某些情况下，由于药物进入循环更快、不受胃肠道环境结构变化影响以及不存在肝首过效应，所以它比口服途径更可取。常用于疼痛管理的药物在婴儿尤其是早产儿中的药代动力学和药效学具有独特特征。在本文中，我们总结了关于使用鼻内给药进行婴儿疼痛管理的证据。然后，我们提供了一份关于目前在新生儿群体中研究的鼻内药物使用的实用指南，重点关注合适的剂量和适应症。当早产儿无法建立静脉通路时，鼻内芬太尼似乎是用于新生儿程序性和姑息性疼痛管理的一种有吸引力的治疗选择。鼻内咪达唑仑是足月儿或近足月儿可考虑的有效替代药物，特别是当目的是获得镇静效果（而非镇痛，即在磁共振成像期间）时，氯胺酮具有良好的心血管效应，应在特定患者和情况下考虑使用。鼻内右美托咪定在早产儿中耐受性良好。此外，鼻内右美托咪定可与其他麻醉、镇静、催眠和阿片类药物联合使用，以减少镇静新生儿的用药剂量。
