By and large, children hate needles. Children in pain have a sympathetic response causing vasoconstriction rendering venous access somewhat more technically challenging than usual. Venous access in children presenting for anaesthesia is not always easy; nor is it always necessary for simple short procedures using inhalational anaesthesic agents. Similarly, children presenting to an emergency department with pain from a damaged limb require effective analgesia, and this can be delivered without resort to an immediate intravenous injection. Alternative routes for early analgesic administration are available. After all, adults commonly self-administer drugs with analgesic properties using mucous surfaces or the nasal cavity for recreational purposes. Neri and colleagues1 describe their own positive experience using sublingual tramadol and ketorolac.

The oral route of drug administration is a stalwart for elective procedural sedation. There are often time delays before the drug is absorbed in the small intestine, and further delays before the drug in plasma reaches its site of action. The latter is commonly known as the effect compartment, and it is drug concentration in this effect compartment that correlates with response rather than drug concentration in the plasma. Sedative and analgesic administration can be timed to take advantage of absorption characteristics, therapeutic effect compartment concentrations or metabolites. Ketamine, for example, is reported satisfactory for dressing changes in children suffering burns. Formation of its metabolite norketamine after oral absorption is advantageous because it also has analgesic properties, but for many drugs, the oral route is less than ideal in the emergency room. Pain relief is desired reasonably quickly. Trauma may cause delayed gastric emptying, slowing delivery and …