Midazolam for premedication in children: Nasal vs. rectal administration:

Efficacy and safety of intranasal midazolam versus intranasal ketamine as sedative premedication in pediatric patients: a meta-analysis of randomized controlled trials

BACKGROUND

Intranasal midazolam and ketamine have been widely used as sedative premedication in children. It is difficult to determine which one yields better sedative effects for clinical practice. We conducted the present meta-analysis by summarizing the evidences to evaluate the efficacy and safety of intranasal midazolam versus intranasal ketamine as sedative premedication in pediatric patients.

METHODS

We searched PubMed, Embase, and Cochrane Library from inception to April 2022. All randomized controlled trials (RCTs) used intranasal midazolam and ketamine as sedatives in children were enrolled. The risk of bias in RCTs was assessed by Cochrane risk of bias tool. Condition of parental separation, anesthesia induction or facemask acceptance, sedation level, different hemodynamic parameters and adverse events were considered as the outcomes in our study.

RESULTS

A total of 16 studies with 1066 patients were enrolled. Compared with midazolam, administration of intranasal ketamine might be associated with severer changes in hemodynamics parameters including mean blood pressure (SMD = -0.53, with 95% CI [-0.93, -0.13]) and heart rate (HR) (SMD = -1.39, with 95% CI [-2.84, 0.06]). Meanwhile, administration of intranasal midazolam was associated with more satisfactory sedation level (61.76% vs 40.74%, RR = 1.53, with 95%CI [1.28, 1.83]), more rapid onset of sedation (SMD = -0.59, with 95%CI [-0.90, -0.28]) and more rapid recovery (SMD = -1.06, with 95%CI [-1.83, -0.28]). Current evidences also indicated that the differences of various adverse effects between two groups were not significant.

CONCLUSIONS

Given that administration of midazolam via intranasal route provides more satisfactory sedative level with less fluctuation of hemodynamics parameters and more rapid onset and recovery, it might be considered as the preferred sedative premedication for pediatric patients compared to ketamine. However, the widespread evidences with low or moderate quality indicated that superiority of intranasal midazolam in pediatric sedation needs to be confirmed by more studies with high quality and large sample size in future.

TRIAL REGISTRATION

The protocol of present study was registered with PROSPERO (CRD42022321348).

Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review

Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.

Sedative and Behavioral Effects of Intranasal Midazolam in Comparison with Other Administrative Routes in Children Undergoing Dental Treatment - A Systematic Review

AIM

The aim of this study was to systematically identify and evaluate the available literature on the effectiveness of intranasal midazolam sedation compared with midazolam administered through other routes in the sedation and behavior management of children during dental treatment.

MATERIALS AND METHODS

The search was done using electronic databases such as PubMed Central, Cochrane Database of Systematic Reviews, LILACS, ScienceDirect, and SIGLE. All studies comparing the sedative effect and behavior management effectiveness of intranasal midazolam with midazolam administered through other routes in children were included.

RESULTS

Electronic database search identified 163 articles, out of which 143 were excluded after reading titles and removing duplication. The remaining 20 studies were evaluated in detail. A final of 13 studies were included based on the inclusion criteria. Among the 13 studies included in the present review, a high risk of bias was noted in all the 13 articles. There was no adequate blinding of personnel and participants in the study, allocation concealment was improper and presence of inadequate blinding of the outcome assessment. . Statistically, no significant difference was observed between intranasal midazolam and other midazolam routes on behavior and sedation level in the studies included in this review.

CONCLUSION

Limited studies are available pertaining to the sedative and behavioral effects of intranasal midazolam, and thus, this review recommends need for more research evaluating the sedative effect of intranasal midazolam in comparison with midazolam administered through other routes in the behavior management of children during dental treatment.

A randomized clinical trial comparing oral, aerosolized intranasal, and aerosolized buccal midazolam

STUDY OBJECTIVE

We determine whether aerosolized intranasal or buccal midazolam reduces the distress of pediatric laceration repair compared with oral midazolam.

METHODS

Children aged 0.5 to 7 years and needing nonparenteral sedation for laceration repair were randomized to receive oral, aerosolized intranasal, or aerosolized buccal midazolam. Patient distress was rated by blinded review of videotapes, using the Children's Hospital of Eastern Ontario Pain Score. Secondary outcomes included activity scores, sedation adequacy, sedation onset, satisfaction, and adverse events.

RESULTS

For the 169 subjects (median age 3.1 years) evaluated for the primary outcome, we found significantly less distress in the buccal midazolam group compared with the oral route group (P=.04; difference -2; 95% confidence interval -4 to 0) and a corresponding nonsignificant trend for the intranasal route (P=.08; difference -1; 95% confidence interval -3 to 1). Secondary outcomes (177 subjects) favored the intranasal group, including a greater proportion of patients with an optimal activity score (74%), a greater proportion of parents wanting this sedation in the future, and faster sedation onset. Intranasal was the route least tolerated at administration. Adverse events were similar between groups.

CONCLUSION

When comparing the administration of midazolam by 3 routes to facilitate pediatric laceration repair, we observed slightly less distress in the aerosolized buccal group. The intranasal route demonstrated a greater proportion of patients with optimal activity scores, greater proportions of parents wanting similar sedation in the future, and faster onset but was also the most poorly tolerated at administration. Aerosolized buccal or intranasal midazolam represents an effective and useful alternative to oral midazolam for sedation for laceration repair.

Intranasal delivery: physicochemical and therapeutic aspects

Interest in intranasal (IN) administration as a non-invasive route for drug delivery continues to grow rapidly. The nasal mucosa offers numerous benefits as a target issue for drug delivery, such as a large surface area for delivery, rapid drug onset, potential for central nervous system delivery, and no first-pass metabolism. A wide variety of therapeutic compounds can be delivered IN, including relatively large molecules such as peptides and proteins, particularly in the presence of permeation enhancers. The current review provides an in-depth discussion of therapeutic aspects of IN delivery including consideration of the intended indication, regimen, and patient population, as well as physicochemical properties of the drug itself. Case examples are provided to illustrate the utility of IN dosing. It is anticipated that the present review will prove useful for formulation scientists considering IN delivery as a delivery route.

Oral versus intranasal midazolam premedication for infants during echocardiographic study

Movement and anxiety during echocardiographic study may reduce the reliability and affect the quality of echocardiographic images. Thus, sedation is an essential component when it is performed in infants. This randomized, single-blinded, placebo-controlled study was undertaken to evaluate the acceptability and effectiveness of intranasal midazolam (INM) versus oral midazolam (OM) in infants during transthoracic echocardiography. Eighty patients between the ages of 6 mo and 3 y who presented for elective echocardiographic study were divided into 3 groups: the OM group received 0.4 mg/kg of injectable midazolam mixed with an equal volume of cherry juice, the INM group received 0.2 mg/kg as drops,and the control group was given oral cherry juice or intranasal serum physiologic. A blinded clinician assessed and scored the level of sedation and comfort during the procedure for each child, and a score for ease of administration was recorded by the nurse. The intranasal route was more acceptable to infants than the oral route (P<.001). No significant difference in the effects of sedation was observed between the OM group and the INM group (P=.583), but significant differences were observed between the sedated groups and the control group (P<.001). The procedure was significantly more comfortable in groups given OM and INM than in the control group (P<.001). Although no difference in sedation score was seen between the oral and nasal routes, INM was better accepted by infants than OM. Echocardiography was performed more reliably and comfortably in those given midazolam than in those in the control group.

Evaluation of intranasal midazolam in refraction and fundus examination of young children with strabismus

PURPOSE

To determine the clinical sedative effect and dosage of intranasal midazolam in refraction and fundus examination of children with strabismus.

PATIENTS AND METHODS

Refraction and fundus examination with (n = 28) and without (n = 24) sedation were performed in 52 children with strabismus whose ages ranged from 7 to 26 months. We delivered a 5-mg/mL solution of midazolam via a syringe for 60 seconds to provide a dose of 0.2 mg/kg. We repeated the dose to a maximum of 0.3 mg/kg if there was no clinical sedative response after 10 to 15 minutes. The ease of examination and sedation for each patient was scored by a blinded observer. The groups were evaluated for ease of examination and the time needed to complete it.

RESULTS

We obtained clinically adequate sedation at a mean (+/- standard deviation) of 15 minutes (+/- 2.69 minutes). Sedation was achieved with a mean dose of 2.64 mg/kg (+/- 0.66 mg/kg). Children receiving midazolam had significantly calmer examination scores. The time needed to complete the examination was statistically significantly shorter for these children than for children not receiving sedation (P < .05).

CONCLUSIONS

Intranasal midazolam is a beneficial drug and method of delivery for the sedation of anxious children with strabismus undergoing refraction and fundus examination. Sedation prior to examination is effective in reducing the anxiety and time associated with ophthalmologic examination of children with strabismus.

Potential new methods for antiepileptic drug delivery

Use of novel drug delivery methods could enhance the efficacy and reduce the toxicity of antiepileptic drugs (AEDs). Slow-release oral forms of medication or depot drugs such as skin patches might improve compliance and therefore seizure control. In emergency situations, administration via rectal, nasal or buccal mucosa can deliver the drug more quickly than can oral administration. Slow-release oral forms and rectal forms of AEDs are already approved for use, nasal and buccal administration is currently off-label and skin patches for AEDs are an attractive but currently hypothetical option. Therapies under development may result in the delivery of AEDs directly to the regions of the brain involved in seizures. Experimental protocols are underway to allow continuous infusion of potent excitatory amino acid antagonists into the CSF. In experiments with animal models of epilepsy, AEDs have been delivered successfully to seizure foci in the brain by programmed infusion pumps, acting in response to computerised EEG seizure detection. Inactive prodrugs can be given systemically and activated at the site of the seizure focus by locally released compounds. One such drug under development is DP-VPA (or DP16), which is cleaved to valproic acid (sodium valproate) by phospholipases at the seizure focus. Liposomes and nanoparticles are engineered micro-reservoirs of a drug, with attached antibodies or receptor-specific binding agents designed to target the particles to a specific region of the body. Liposomes in theory could deliver a high concentration of an AED to a seizure focus. Penetration of the blood-brain barrier can be accomplished by linking large particles to iron transferrin or biological toxins that can cross the barrier. In the near future, it is likely that cell transplants that generate neurotransmitters and neuromodulators will accomplish renewable endogenous drug delivery. However, the survival and viability of transplanted cells have yet to be demonstrated in the clinical setting. Gene therapy also may play a role in local drug delivery with the use of adenovirus, adeno-associated virus, herpesvirus or other delivery vectors to induce brain cells to produce local modulatory substances. New delivery systems should significantly improve the therapeutic/toxic ratio of AEDs.

Premedication with midazolam in young children: a comparison of four routes of administration

BACKGROUND

We undertook a study to determine the effects of four routes of administation on the efficacy of midazolam for premedication.

METHODS

In a randomized double-blind study, 119 unmedicated children, ASA I-II, aged 1.5-5 years, who were scheduled for minor elective surgery and who had been planned to received midazolam as a premedicant drug, were randomly assigned to one of four groups. Group I received intranasal midazolam 0.3 mg.kg-1; group II, oral midazolam 0.5 mg x kg(-1); group III, rectal midazolam 0.5 mg x kg(-1); and group IV, sublingual midazolam 0.3 mg x kg(-1). A blinded observer assessed the children for sedation and anxiolysis every 5 min prior to surgery. Quality of mask acceptance for induction, postanaesthesia care unit behaviour and parents' satisfaction were evaluated. Thirty patients were enrolled in each of groups I, III and IV. Twenty-nine patients were enrolled in group II.

RESULTS

There were no significant differences in sedation and anxiety levels among the four groups. Average sedation and anxiolysis increased with time, achieving a maximum at 20 min in group I and at 30 min in groups II-IV. Patient mask acceptance was good for more than 75% of the children. Although the intranasal route provides a faster effect, it causes significant nasal irritation. Seventy-seven percent of the children from this group cried after drug administration. Most parents in all groups (67-73%) were satisfied with the premedication.

CONCLUSIONS

Intranasal, oral, rectal and sublingual midazolam produces good levels of sedation and anxiolysis. Mask acceptance for inhalation induction was easy in the majority of children, irrespective of the route of drug administration.

S(+)-ketamine for rectal premedication in children

Our purpose for this prospective, randomized, and double-blinded study was to evaluate the anesthetic efficacy of S(+)-ketamine, an enantiomer of racemic ketamine, compared with a combination of S(+)-ketamine and midazolam, and plain midazolam for rectal premedication in pediatric anesthesia. Sixty-two children, ASA physical status I and II, scheduled for minor surgery, were randomly assigned to be given rectally one of the following: 1.5 mg/kg preservative-free S(+)-ketamine, a combination of 0.75 mg/kg preservative-free S(+)-ketamine and 0.75 mg/kg midazolam, or 0.75 mg/kg midazolam. Preoperative anesthetic efficacy was graded during a period of 20 min by using a five-point scale from 1 = awake to 5 = asleep. Tolerance during anesthesia induction via face mask was graded by using a four-point scale from 1 = very good to 4 = bad. A sufficient anesthetic level (> or = 3) after rectal premedication was reached in 86% in midazolam/S(+)-ketamine premedicated children, in 75% in midazolam premedicated children, but only in 30% in S(+)-ketamine premedicated children (P < 0.05 S(+)-ketamine versus midazolam/S(+)-ketamine and midazolam groups). The incidence of side effects after rectal premedication was rare. Whereas the mask acceptance score was comparable in the three study groups, a 25% rate of complications during anesthesia induction via face was observed in the S(+)-ketamine study group (P < 0.05 versus other study groups). Our conclusions are that S(+)-ketamine for rectal premedication in the dose we chose shows a poor anesthetic effect and a frequent incidence of side effects during induction of anesthesia via face mask compared with the combination of midazolam/S(+)-ketamine and plain midazolam. Dose-response studies of S(+)-ketamine for rectal premedication in pediatric anesthesia may be warranted.

Nasal midazolam effects on childhood acute seizures

Sixteen children, aged from 2 months to 14 years, with a diagnosis of acute seizures and seen at Dr. Sami Ulus Child Health and Disease Center, were included in this study. Midazolam (5 mg/mL) 0.2 mg/kg was administered intranasally in 30 seconds by an injector. The heart rate, respiratory rate, blood pressure, and oxygen saturation were recorded at 0, 5, and 10 minutes after administration. The seizures of three (18.7%) patients terminated within 1 minute, of seven (43.7%) patients in 1 to 2 minutes, and of three (18.7%) patients in 2 to 5 minutes. However, three (18.7%) patients did not respond to treatment. As a result, it was concluded that intranasal midazolam administration is easy and effective. The half-life of midazolam is shorter than diazepam, and midazolam has fewer complications when compared with diazepam. It is easier to use in nasal drop and spray forms.

Intranasal midazolam as an alternative to general anaesthesia in the management of children with oral and maxillofacial trauma

The study assessed the dosage, clinical sedative effect, and safety of intranasal midazolam in 32 children. Data were complete for 29 patients (21 with lacerations and 8 cases of dental trauma). Sedation was adequate to ensure successful completion of treatment under local with or without topical anaesthetic in 22 of the 29 cases (76%). They became sedated at a mean (SD) of 14 (5) minutes, with completion of treatment at 20 (13) minutes. Sedation was achieved with a mean (SD) of 5 (2)mg of midazolam. There were no signs of respiratory depression or of oxygen desaturation below 94% on pulse oximetry. No supplemental oxygen was required and there were no other complications. We conclude that intranasal midazolam is a safe and effective alternative to general anaesthesia in the definitive treatment of children with oral and maxillofacial injuries.

Midazolam nasal spray reduces procedural anxiety in children

OBJECTIVE

Anxiety and pain even in minor procedures are still great problems in pediatrics, not least in pediatric oncology. Conscious sedation is indicated when other means to overcome a child's fear fail. The aim of this study was to investigate whether intranasal administration of midazolam given before insertion of a needle in a subcutaneously implanted central venous port could reduce anxiety, discomfort, pain, and procedure problems.

METHOD

Forty-three children with cancer participated in this randomized, double-blind, placebo-controlled, crossover study in which nasal administration of midazolam spray,.2 mg/kg body weight, was compared with placebo. Children, parents, and nurses completed a visual analog scale questionnaire to evaluate efficacy.

RESULTS

Parents and nurses reported reduced anxiety, discomfort, and procedure problems for children in the midazolam group and would prefer the same medication at next procedure. They also reported pain reduction. Children reported reduced anxiety and procedure problems but reduction of pain and discomfort was not significant. No serious or unexpected side effects occurred. Nasal discomfort was the most common side effect (17/38 approximately 45%) and the primary reason for dropouts (8/43 approximately 19%). Anxiety varied with age but not with gender. When anxiety increased, the differences between midazolam and placebo increased.

CONCLUSION

Nasal midazolam spray offers relief to children anxious about procedures, such as insertion of a needle in a subcutaneously implanted intravenous port, venous blood sampling, venous cannulation, etc. Its use, however, may be limited by nasal discomfort in some patients for whom rectal and oral routes might be alternatives.

Incidence and therapy of midazolam induced hiccups in paediatric anaesthesia

A prospective, randomized and double blind study was undertaken to determine the incidence and a possible dose- or age-dependence of hiccups in children premedicated with rectal midazolam and to investigate the treatment of hiccups by intranasal ethyl chloride spray application. Two hundred ASA physical status 1 and 2 children, weighing 3.0 to 15.0 kg, scheduled for minor surgery, were randomly assigned to be given either 0.5 mg.kg-1 midazolam(n=100) or 1.0 mg. kg-1 midazolam (n=100) administered rectally. If hiccups were observed during a period of 20 min after premedication with midazolam, these children were treated after 3 min of hiccups with two short intranasal applications of ethyl chloride spray. Hiccups occurred in 22% of children in the 0.5 mg.kg-1 group and 26% in the 1.0 mg.kg-1 group (n.s.). The intranasal application with ethyl chloride was successful in 100% in both groups. The mean age levels between children with or without hiccups were 5+/-9 months vs 21+/-19 months (P<0.01) in the 0.5 mg.kg-1 group and 6+/-7 months vs 20+/-14 months (P<0.01) in the 1.0 mg.kg-1 group. Intranasal application of ethyl chloride spray seems to be an effective therapy for midazolam induced hiccups in paediatric anaesthesia. The incidence of these hiccups is highly age significant, but not dose dependent.