Sedation of children with ADHD: trazodone or midazolam?

Analysis of application of dental sedation in attention deficit hyperactivity disorder (ADHD) patients using the Korean National Health Insurance data

Background

Attention deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. It has a worldwide pooled prevalence of 5.29%. The characteristics of ADHD can increase the probability of dental treatment, while special behavior management can be required to allow proper treatment. In South Korea, the use of sedation in dental treatment has rapidly increased in recent decades. The present study aimed to investigate the trend and effects of sedation in patients with ADHD undergoing dental treatment in South Korea.

Methods

The study used customized health information data provided by the Korean National Health Insurance Service. Among patients with the record of sedative use during the period from January 2007 to September 2019, those with International Classification of Diseases-10 codes for ADHD (F90, F91) were selected; the data of their overall insurance claims for dental treatment were then analyzed. The patients' age, gender, sedative use, and dental treatment were analyzed per year. The annual number of general anesthesia or sedation cases was also analyzed, and changes in the method of behavior management with increasing age were examined.

Results

The study involved 7,654 patients with ADHD (6,270 males; 1,384 females). The total number of dental treatments was 137,778, while the number of sedation cases was 16,109, among which 13,052 involved male patients and 3,057 female patients. The number of general anesthesia cases was 631, among which 538 involved male patients and 93 female patients. The most frequently used sedation method in the dental treatment of patients with ADHD was N₂O inhalation. The percentage of sedation cases was highest in patients aged 4 years, and it decreased with increasing age.

Conclusion

In South Korea, both sedation and dental treatments were slightly more common in patients with ADHD than in the general population. With increasing age, the frequency of dental treatments and the percentage of sedation cases decreased.

Anaesthesiological approach to the floppy child

Children with symptoms of hypotonia (reduction of postural tone of lower limbs and trunk with or without changes in phasic tone) are frequently anaesthetized for diagnostic and therapeutic interventions. This review outlines the underlying causes and classifications, and the anaesthesiologic pre- and peri-operative management of hypotonic children. Hypotonia may have a large range of aetiologies that be categorized into central and/or peripheral hypotonia. A multidisciplinary approach towards the (differential) diagnosis of the underlying cause of the symptoms in cooperation with a paediatrician and/or paediatric neurologist is emphasized. Anaesthetic management involves the anticipation of an increased risk in difficult airway management because of macroglossia, reduced mouth opening, obesity and limited neck mobility, which increases with age. There are no specific restrictions towards the use of intravenous or inhalational anaesthetics. Short acting opioids and hypnotics, avoiding neuromuscular blockade, and locoregional techniques are preferred. Most patients are sensitive to the cardiac and depressive effects of anaesthetics and all dystrophic myopathies are considered at risk of malignant hyperthermia. Depolarizing neuromuscular blockers are contraindicated. The use of a peripheral nerve stimulator is recommended to detect the severity of muscle relaxation before extubating. Accurate control and management of IV fluids, electrolytes and temperature is mandatory. Adequate postoperative pain treatment is essential to limit stress and metabolic alteration. Preferably a locoregional technique is used to reduce the increased risk of respiratory depression. A multidisciplinary preoperative approach taking into account the differential diagnosis of the underlying disease of the floppy child is recommended.

Midazolam for sedation before procedures

BACKGROUND

Midazolam is used for sedation before diagnostic and therapeutic medical procedures. It is an imidazole benzodiazepine that has depressant effects on the central nervous system (CNS) with rapid onset of action and few adverse effects. The drug can be administered by several routes including oral, intravenous, intranasal and intramuscular.

OBJECTIVES

To determine the evidence on the effectiveness of midazolam for sedation when administered before a procedure (diagnostic or therapeutic).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL to January 2016), MEDLINE in Ovid (1966 to January 2016) and Ovid EMBASE (1980 to January 2016). We imposed no language restrictions.

SELECTION CRITERIA

Randomized controlled trials in which midazolam, administered to participants of any age, by any route, at any dose or any time before any procedure (apart from dental procedures), was compared with placebo or other medications including sedatives and analgesics.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and assessed risk of bias for each included study. We performed a separate analysis for each different drug comparison.

MAIN RESULTS

We included 30 trials (2319 participants) of midazolam for gastrointestinal endoscopy (16 trials), bronchoscopy (3), diagnostic imaging (5), cardioversion (1), minor plastic surgery (1), lumbar puncture (1), suturing (2) and Kirschner wire removal (1). Comparisons were: intravenous diazepam (14), placebo (5) etomidate (1) fentanyl (1), flunitrazepam (1) and propofol (1); oral chloral hydrate (4), diazepam (2), diazepam and clonidine (1); ketamine (1) and placebo (3); and intranasal placebo (2). There was a high risk of bias due to inadequate reporting about randomization (75% of trials). Effect estimates were imprecise due to small sample sizes. None of the trials reported on allergic or anaphylactoid reactions. Intravenous midazolam versus diazepam (14 trials; 1069 participants)There was no difference in anxiety (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.39 to 1.62; 175 participants; 2 trials) or discomfort/pain (RR 0.60, 95% CI 0.24 to 1.49; 415 participants; 5 trials; I² = 67%). Midazolam produced greater anterograde amnesia (RR 0.45; 95% CI 0.30 to 0.66; 587 participants; 9 trials; low-quality evidence). Intravenous midazolam versus placebo (5 trials; 493 participants)One trial reported that fewer participants who received midazolam were anxious (3/47 versus 15/35; low-quality evidence). There was no difference in discomfort/pain identified in a further trial (3/85 in midazolam group; 4/82 in placebo group; P = 0.876; very low-quality evidence). Oral midazolam versus chloral hydrate (4 trials; 268 participants)Midazolam increased the risk of incomplete procedures (RR 4.01; 95% CI 1.92 to 8.40; moderate-quality evidence). Oral midazolam versus placebo (3 trials; 176 participants)Midazolam reduced pain (midazolam mean 2.56 (standard deviation (SD) 0.49); placebo mean 4.62 (SD 1.49); P < 0.005) and anxiety (midazolam mean 1.52 (SD 0.3); placebo mean 3.97 (SD 0.44); P < 0.0001) in one trial with 99 participants. Two other trials did not find a difference in numerical rating of anxiety (mean 1.7 (SD 2.4) for 20 participants randomized to midazolam; mean 2.6 (SD 2.9) for 22 participants randomized to placebo; P = 0.216; mean Spielberger's Trait Anxiety Inventory score 47.56 (SD 11.68) in the midazolam group; mean 52.78 (SD 9.61) in placebo group; P > 0.05). Intranasal midazolam versus placebo (2 trials; 149 participants)Midazolam induced sedation (midazolam mean 3.15 (SD 0.36); placebo mean 2.56 (SD 0.64); P < 0.001) and reduced the numerical rating of anxiety in one trial with 54 participants (midazolam mean 17.3 (SD 18.58); placebo mean 49.3 (SD 29.46); P < 0.001). There was no difference in meta-analysis of results from both trials for risk of incomplete procedures (RR 0.14, 95% CI 0.02 to 1.12; downgraded to low-quality evidence).

AUTHORS' CONCLUSIONS

We found no high-quality evidence to determine if midazolam, when administered as the sole sedative agent prior to a procedure, produces more or less effective sedation than placebo or other medications. There is low-quality evidence that intravenous midazolam reduced anxiety when compared with placebo. There is inconsistent evidence that oral midazolam decreased anxiety during procedures compared with placebo. Intranasal midazolam did not reduce the risk of incomplete procedures, although anxiolysis and sedation were observed. There is moderate-quality evidence suggesting that oral midazolam produces less effective sedation than chloral hydrate for completion of procedures for children undergoing non-invasive diagnostic procedures.

Procedural sedation for MRI in children with ADHD

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 5-8% of children. It has been observed that these children have poor sedation experiences; however, to date there is minimal research on procedural sedation in this population.

AIM

To examine whether children with ADHD required larger doses of propofol for magnetic resonance imaging (MRI) sedation.

METHODS

The hospital's administrative billing database was used to identify all billing codes for MRI brain scans (with and without contrast) in children aged between 5 and 12 years over the preceding 5.5 years. The hospital's electronic medical record database provided baseline demographics. The sedation record was reviewed for propofol dose, psychostimulant use, and prescribed dose. All children received a standard weight-based dose of midazolam prior to receiving the necessary amount of propofol. Primary outcome was the dose of propofol administered (mg·kg(-1) ) to achieve adequate sedation.

RESULTS

A total of 258 procedures met the inclusion criteria. The sample was 52% male, 74% White, 7.8% Black, 7.8% Hispanic, 4.3% Asian, and 6.2% other. ADHD was documented for 49 procedures with a prevalence of 18.5%. Patients with ADHD were older, more likely to be male, Hispanic, or to report race as 'Refused/Unknown'. Indications for MRI for patients with ADHD varied significantly, with 'Behavioral' and 'Neurocutaneous' being significantly overrepresented in the ADHD group. The average sedative dose for all patients was 2.8 mg·kg(-1) (95% CI 2.62-2.94). Sedative dose was similar among children with and without ADHD diagnosis.

CONCLUSIONS

Our study illustrates that children with ADHD do not have higher sedative requirements to achieve a successful brain MRI.

The sedating antidepressant trazodone impairs sleep-dependent cortical plasticity

Background

Recent findings indicate that certain classes of hypnotics that target GABA_A receptors impair sleep-dependent brain plasticity. However, the effects of hypnotics acting at monoamine receptors (e.g., the antidepressant trazodone) on this process are unknown. We therefore assessed the effects of commonly-prescribed medications for the treatment of insomnia (trazodone and the non-benzodiazepine GABA_A receptor agonists zaleplon and eszopiclone) in a canonical model of sleep-dependent, in vivo synaptic plasticity in the primary visual cortex (V1) known as ocular dominance plasticity.

Methodology/Principal Findings

After a 6-h baseline period of sleep/wake polysomnographic recording, cats underwent 6 h of continuous waking combined with monocular deprivation (MD) to trigger synaptic remodeling. Cats subsequently received an i.p. injection of either vehicle, trazodone (10 mg/kg), zaleplon (10 mg/kg), or eszopiclone (1–10 mg/kg), and were allowed an 8-h period of post-MD sleep before ocular dominance plasticity was assessed. We found that while zaleplon and eszopiclone had profound effects on sleeping cortical electroencephalographic (EEG) activity, only trazodone (which did not alter EEG activity) significantly impaired sleep-dependent consolidation of ocular dominance plasticity. This was associated with deficits in both the normal depression of V1 neuronal responses to deprived-eye stimulation, and potentiation of responses to non-deprived eye stimulation, which accompany ocular dominance plasticity.

Conclusions/Significance

Taken together, our data suggest that the monoamine receptors targeted by trazodone play an important role in sleep-dependent consolidation of synaptic plasticity. They also demonstrate that changes in sleep architecture are not necessarily reliable predictors of how hypnotics affect sleep-dependent neural functions.