Don’t Poke It, Spray It: The Intranasal Medication Playbook

Mar 29, 2026

A clinical case of a four-month-old needing MRI sedation sparks a discussion of needle-free intranasal drug use. They explore nasal anatomy and pharmacology that enable rapid nose-to-brain delivery. Practical tips cover atomizer technique, dosing limits per nostril, and how intranasal options compare with oral and IV routes. Common pediatric intranasal drugs and monitoring considerations are reviewed.

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ANECDOTE

Infant MRI Without IV Using Intranasal Sedation

A four-month-old infant with a prenatally detected brain cyst needed a 40-minute MRI and feeding/bundling failed because she wasn't hungry.
The sedation team chose intranasal medications to avoid placing a peripheral IV for a non-contrast short MRI, prioritizing family preference and minimal invasiveness.

INSIGHT

Nose Brain Pathway Enables Rapid CNS Delivery

Intranasal drugs reach systemic circulation via highly vascular nasal mucosa and can access the CNS directly through olfactory and trigeminal pathways.
Drugs may bypass the blood-brain barrier and reach CSF rapidly, sometimes faster than IV, but inflamed mucosa or vasoconstrictors limit absorption.

ADVICE

Administer Intranasal Drugs With An Atomizer Upright

Use an atomizer to convert medication into a 30–100 micron mist, seat the patient upright, and angle the tip away from the septum for optimal mucosal absorption.
Divide doses so ≤1 mL per nostril, spray each nare separately, and approach from the side to minimize patient anxiety.

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In this episode of "PICU Doc on Call," Drs. Monica Gray, Pradip Kamat, and Rahul Damania discuss the use of intranasal medications in pediatric intensive care. Using the case of a four-month-old infant needing an MRI, they explore when and why intranasal drugs are preferred over IV access, the science behind nasal drug delivery, safe administration techniques, and common medications used. The episode highlights the benefits of intranasal sedation—such as rapid onset and needle-free delivery—while emphasizing teamwork and careful monitoring for safe, effective pediatric care.

Show Highlights:

Use of intranasal medications in pediatric intensive care settings
Case study of a four-month-old infant requiring sedation for an MRI.
Advantages of intranasal delivery over IV access
Pharmacokinetics and neuroanatomy related to intranasal drug absorption
Techniques for safe and effective administration of intranasal medications
Comparison of intranasal dosing to oral and IV routes
Common intranasal medications used in the pediatric ICU
Importance of timing and monitoring during sedation procedures
Teamwork and communication in administering intranasal medications
Clinical applications and implications for patient comfort and care delivery

References:

Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
Reference 1: Tsze DS, Woodward HA, McLaren SH, Leu CS, Venn AMR, Hu NY, Flores-Sanchez PL, Stefan BR, Shen ST, Ekladios MJ, Cravero JP, Dayan PS. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025 Sep 1;179(9):979-986. doi: 10.1001/jamapediatrics. 2025.2181.
Reference 2: Prescott MG, Iakovleva E, Simpson MR, Pedersen SA, Munblit D, Vallersnes OM, Austad B. Intranasal analgesia for acute moderate to severe pain in children - a systematic review and meta-analysis. BMC Pediatr. 2023 Aug 18;23(1):405. doi: 10.1186/s12887-023-04203-x.
Reference 3: Chabowski L, Mahboobi Z, Navolokina A. Intranasal ketamine for procedural sedation in children. Am J Emerg Med. 2023 Jun;68:195. doi: 10.1016/j.ajem.2023.04.013.
Reference 4: Sulton C, Kamat P, Mallory M, Reynolds J. The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Emerg Care. 2020 Mar;36(3):138-142. doi: 10.1097/PEC.0000000000001199.