Midazolam nasal spray reduces procedural anxiety in children

Bibliometric analysis of pediatric dental sedation research from 1993 to 2022

Statement of problem

Bibliometric analysis methods were used to evaluate pediatric dental sedation research and to identify topical hotspots using quantitative and qualitative methodologies.

Purpose

To conduct bibliometric analysis on the retrieved data and to foresee the development of trends and hotspots in this research area.

Material and methods

We retrieved appropriate research articles from the Web of Science Core Collection on January 1, 2023. VOSviewer, Citespace and the Bibliometrics website were used to conduct bibliometric analysis on the retrieved data. GraphPad Prism 10.0 (GraphPad, San Diego, CA, USA) was used to conduct the statistical analysis.

Results

A total of 396 publications on pediatric sedation in dentistry, published between 1993 and 2022, were retrieved from online databases. The USA published most papers. Furthermore, the most frequent countries who cooperated were the USA and Canada. Six of the top ten publishing establishments were USA based. Papers on the research have appeared primarily in the journals of Dentistry and Anesthesiology. Keyword co-occurrence and co-citation cluster analysis revealed that the most common topics mainly were: dental anxiety; conscious sedation; dental caries; midazolam; propofol; hypoxemia.

Conclusions

During the three decades, the focus of pediatric sedation research has been on drugs, dental anxiety and procedural sedation. Keyword burst detection indicated that procedural sedation; adverse event; respiratory depression is an emerging research hotspot.

A Systematic Review of Self-Report Instruments for the Measurement of Anxiety in Hospitalized Children with Cancer

Anxiety has been identified as one of the most severe and long-lasting symptoms experienced by hospitalized children with cancer. Self-reports are especially important for documenting emotional and abstract concepts, such as anxiety. Children may not always be able to communicate their symptoms due to language difficulties, a lack of developmental language skills, or the severity of their illness. Instruments with sufficient psychometric quality and pictorial support may address this communication challenge. The purpose of this review was to systematically search the published literature and identify validated and reliable self-report instruments available for children aged 5–18 years to use in the assessment of their anxiety to ensure they receive appropriate anxiety-relief intervention in hospital. What validated self-report instruments can children with cancer use to self-report anxiety in the hospital setting? Which of these instruments offer pictorial support? Eight instruments were identified, but most of the instruments lacked pictorial support. The Visual Analogue Scale (VAS) and Pediatric Quality of Life (PedsQL™) 3.0 Brain Tumor Module and Cancer Module proved to be useful in hospitalized children with cancer, as they provide pictorial support. It is recommended that faces or symbols be used along with the VAS, as pictures are easily understood by younger children. Future studies could include the adaptation of existing instruments in digital e-health tools.

Children's Anxiety and Factors Related to the COVID-19 Pandemic: An Exploratory Study Using the Children's Anxiety Questionnaire and the Numerical Rating Scale

The repercussions of the COVID-19 pandemic on children's lives deserve attention. This study aimed to assess the prevalence of anxiety among Brazilian children and its associated factors during social distancing during COVID-19. We used a cross-sectional design with an online survey from April to May 2020 in Brazil. We included children aged 6-12 years and their guardians. The Children's Anxiety Questionnaire (CAQ; scores 4-12) and the Numerical Rating Scale (NRS; scores 0-10) were used to measure anxiety. We enrolled 157 girls and 132 boys, with a mean age of 8.84 (±2.05) years; 88.9% of respondents were mothers. Based on CAQ ≥ 9, the prevalence of anxiety was 19.4% (n = 56), and higher among children with parents with essential jobs and those who were social distancing without parents. In logistic regression, the following variables were associated with higher CAQ scores: social distancing without parents; more persons living together in home; and education level of guardians. Based on NRS > 7, the prevalence of anxiety was 21.8% (n = 63); however, no associations with NRS scores were found with the investigated variables. These findings suggest the necessity of implementing public health actions targeting these parents and their children at the population level.

Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline

BACKGROUND

Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress.

METHODS

Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents.

RESULTS

The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.

CONCLUSION

In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.

Reducing pain in children with cancer: Methodology for the development of a clinical practice guideline

Although pain is one of the most prevalent and bothersome symptoms children with cancer experience, evidence-based guidance regarding assessment and management is lacking. With 44 international, multidisciplinary healthcare professionals and nine patient representatives, we aimed to develop a clinical practice guideline (following GRADE methodology), addressing assessment and pharmacological, psychological, and physical management of tumor-, treatment-, and procedure-related pain in children with cancer. In this paper, we present our thorough methodology for this development, including the challenges we faced and how we approached these. This lays the foundation for our clinical practice guideline, for which there is a high clinical demand.

Nurses' experiences of prehospital care encounters with children in pain

BACKGROUND

Pain relief in children is a complex issue, partly an ethical dilemma and due to a lack of nursing competence. There are few studies regarding prehospital care encounters with children in pain.

AIM

The aim of this study was to describe nurses' experiences in prehospital care encounters with children in pain and the specific related challenges.

METHOD

This study has a qualitative design. Eighteen Swedish nurses participated in three focus group interviews analysed using qualitative content analysis.

FINDINGS

The findings consist of a theme, "A challenge to shift focus and adjust to the child", and three categories describing prehospital care encounters with children in pain: "Being receptive and focusing on care," "Developing a trusting relationship," and "Providing professional nursing care." Caring for children in pain was stressful for the nurses. The nurses described how they had to shift focus and used different methods to build trust, such as playfulness, making eye contact, attracting curiosity, and using the parents to create trust. The also had to adjust to the child regarding dosages and materials.

CONCLUSION

Nurses has to be practically, mentally, and theoretically prepared to care for children with prehospital pain. It is essential to evaluate the administration of adequate pain relief to children, and more evidence-based knowledge is necessary concerning the different modes of administering pain-relieving drugs to prehospital children.

Determination of the maximum tolerated dose of intranasal sufentanil and midazolam in Chinese: a pilot study

BACKGROUND

The purpose of this study was to determine the maximum tolerated dose (MTD, the dose of causing 10% respiratory depression) of intranasal sufentanil (SUF) and midazolam (MID) for sedation during gastroscopy by continual reassessment method (CRM).

METHODS

Patients (18-65 years old) scheduled for gastroscopy were recruited in this study. Subjects received intranasal SUF and MID for sedation. The dose of MID (5 mg) was fixed, while the dose of SUF was increased progressively (six incremental doses ranging from 0-0.60 μg/kg, n = 3 for each dose). The first cohort received a conservative, predetermined dose of 5 mg MID and 0 μg/kg SUF, subsequent cohorts received doses of SUF that were determined by the responses of all previous patients using Bayesian-based software. The dose allocated to the next cohort is the one with an updated posterior response probability closest to 10%.

RESULTS

Thirty Chinese patients scheduled for gastroscopy were included. Probability of respiratory depression at each dose was as follows: 5 mg MID + 0 μg/kg SUF, 0.4%; 5 mg MID + 0.1 μg/kg SUF, 0.8%; 5 mg MID + 0.2 μg/kg SUF, 1.8%; 5 mg MID + 0.3 μg/kg SUF, 3.7%; 5 mg MID + 0.4 μg/kg SUF, 9.9%; 5 mg MID + 0.5 μg/kg SUF, 17.8%; 5 mg MID + 0.6 μg/kg SUF, 36.0%.

CONCLUSION

The MTD of intranasal MID and SUF for sedation during gastroscopy causing 10% respiratory depression is 5 mg MID + 0.4 μg/kg SUF, based on CRM.

Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair

BACKGROUND

Atomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing.

OBJECTIVES

We describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair.

METHODS

Children 11 months to 7 years of age and weighing <26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events.

RESULTS

Sixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7-10.8 min), and the median time to the procedure was 26 min (interquartile range 21-34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients.

CONCLUSIONS

Atomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was >90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.

Serial Casting as an Adjunct to Botulinum Toxin Type A Treatment in Children With Cerebral Palsy and Spastic Paraparesis With Scissoring of the Lower Extremities

The purpose of this study was to examine whether combination therapy of serial casting and botulinum toxin type A injection can further enhance the effects of botulinum toxin type A in children with cerebral palsy with scissoring of both legs. This study was a prospective and randomized trial. The children were divided into 2 groups, one of which received serial casting after botulinum toxin type A (n = 40), and the other which only received botulinum toxin type A (n = 40). Serial casting started 3 weeks after the botulinum toxin type A. Both groups received physiotherapy. Groups were assessed at baseline then compared at 6 and 12 weeks following the intervention. Significant improvements in Gross Motor Function Measure-66 and Caregiver Health Questionnaire were recorded in both groups ( P < .001). The modified Ashworth scale improved significantly following botulinum toxin type A in the serial casting group ( P < .05), but not in botulinum toxin type A only group. These results suggest that serial casting after botulinum toxin type A can enhance the benefits of botulinum toxin type A in children with cerebral palsy.

Use of sedative drugs at reducing the side effects of voiding cystourethrography in children

BACKGROUND

Imaging of the kidneys and urinary tract has a significant and critical role for diagnosis of genitourinary system diseases. Although technological progress goes toward less invasive approaches, some of the current methods are still invasive and annoying. Voiding cystourethrography (VCUG) is the best and most accurate method for diagnosis and grading of vesicoureteral reflux. VCUG is a distressful procedure that gives serious anxiety and pain in a large proportion of children and fear for parents; therefore, using effective sedative drugs with the least side effects is necessary and should be considered.

MATERIALS AND METHODS

In this review article, importance and efficacy of different drugs before catheterization VCUG be compared in the base of literature survey on EMBASE, PubMed, and Cochrane source.

RESULTS

We found that the treatment should be based on nonpharmacological and pharmacological methods; nonpharmacological treatment includes the psychological preparation before procedures as a safety precaution with little or no risk modality, as well as reassuring support. The presence of parents during painful procedures cannot alleviate children distress. Pharmacological methods include oral midazolam (0.5 mg/kg) and intranasal use (0.2 mg/kg) that had been used 10 min before the procedure can effect on anterograde amnesia and sedation without considerable effect on accuracy and grade of reflux. Nitric oxide has a shorter recovery time versus midazolam but has a potential risk for deep sedation and may interfere with the child's voiding phase.

CONCLUSION

In summary, oral midazolam of 0.5-0.6 mg/kg or 0.2 mg/kg intranasal is acceptable drug that can be used before VCUG.

Lidocaine Pretreatment Reduces the Discomfort of Intranasal Midazolam Administration: A Randomized, Double-blind, Placebo-controlled Trial

OBJECTIVE

Intranasal (IN) midazolam is a commonly prescribed medication for pediatric sedation and anxiolysis. One of its most frequently encountered adverse effects is discomfort with administration. While it has been proposed that premedicating with lidocaine reduces this undesirable consequence, this combination has not been thoroughly researched. The objective of our study was to assess whether topical lidocaine lessens the discomfort associated with IN midazolam administration.

METHODS

This was a double-blind, randomized, placebo-controlled trial performed in an urban, academic pediatric emergency department. Children 6-12 years of age who were receiving IN midazolam for procedural sedation received either 4% lidocaine or 0.9% saline (placebo) via mucosal atomizer. Subjects were subsequently given IN midazolam in a similar fashion and then rated their discomfort using the Wong-Baker FACES Pain Rating Scale (WBS). The primary endpoint of WBS score was analyzed with a two-tailed Mann-Whitney U-test, with p < 0.05 considered statistically significant.

RESULTS

Seventy-seven patients were enrolled over a consecutive 8-month period. One child was excluded from analysis due to a discrepancy in recording the drug identification number. Study groups were similar in regard to demographic information and indication for sedation. Subjects who received IN lidocaine reported less discomfort with IN midazolam administration (median WBS = 3, interquartile range [IQR] = 0-6) than those who received placebo (median WBS = 8, IQR = 2-9; p = 0.006).

CONCLUSIONS

Premedication with topical lidocaine reduces the discomfort associated with administration of IN midazolam (ClinicalTrials.gov, NCT02396537).

Pharmacokinetics and pharmacodynamics of a new highly concentrated intranasal midazolam formulation for conscious sedation

AIM

To evaluate the pharmacokinetics, pharmacodynamics, nasal tolerance and effects on sedation of a highly concentrated aqueous intranasal midazolam formulation (Nazolam) and to compare these to intravenous midazolam.

METHODS

In this four-way crossover, double-blind, double-dummy, randomized, placebo-controlled study, 16 subjects received 2.5 mg Nazolam, 5.0 mg Nazolam, 2.5 mg intravenous midazolam or placebo on different occasions. Pharmacokinetics of midazolam and α-hydroxy-midazolam were characterized and related to outcome variables for sedation (saccadic peak velocity, the Bond and Lader visual analogue scale for sedation, the simple reaction time task and the observer's assessment of alertness/sedation). Nasal tolerance was evaluated through subject reporting, and ear, nose and throat examination.

RESULTS

Nazolam bioavailability was 75%. Maximal plasma concentrations of 31 ng ml^-1 (CV, 42.3%) were reached after 11 min (2.5 mg Nazolam), and of 66 ng ml^-1 (coefficient of variability, 31.5%) after 14 min (5.0 mg Nazolam). Nazolam displayed a significant effect on OAA/S scores. Sedation onset (based on SPV change) occurred 1 ± 0.7 min after administration of 2.5 mg intravenous midazolam, 7 ± 4.4 min after 2.5 mg Nazolam, and 4 ± 1.8 min after 5 mg Nazolam. Sedation duration was 118 ± 95.6 min for 2.5 mg intravenous midazolam, 76 ± 80.4 min for 2.5 mg Nazolam, and 145 ± 104.9 min for 5.0 mg Nazolam. Nazolam did not lead to nasal mucosa damage.

CONCLUSIONS

This study demonstrates the nasal tolerance, safety and efficacy of Nazolam. When considering the preparation time needed for obtaining venous access, conscious sedation can be achieved in the same time span as needed for intravenous midazolam. Nazolam may offer important advantages in conscious sedation.

Comparison of preanesthetic sedation in pediatric patients with oral and intranasal midazolam

BACKGROUND AND AIMS

Preoperative anxiety in children leading to postoperative negative changes and long-term behavioral problems needs better preanesthetic sedation. Across the world, midazolam is the most commonly used premedicant in pediatric patients. The fact that no single route has achieved universal acceptance for its administration suggests that each route has its own merits and demerits. This study compares oral midazolam syrup and intranasal midazolam spray as painless and needleless systems of drug administration for preanesthetic sedation in children.

MATERIAL AND METHODS

With randomization, Group O (30 children): Received oral midazolam syrup 0.5 mg/kg and Group IN (30 children): Received intranasal midazolam spray 0.2 mg/kg. Every child was observed for acceptance of drug, response to drug administration, sedation scale, separation score, acceptance to mask, recovery score and side effects of drug. Data were analyzed using Student's t-test, standard error of the difference between two means and Chi-square test.

RESULTS

In Group O and IN, 15/30 children (50%) and 7/30 children (23%) accepted drug easily (P < 0.05); 4/22 children (18%) in Group O and 11/20 children (55%) in Group IN cried after drug administration (P < 0.05). In both the groups, sedation at 20 min after premedication (Group O [80%] 24/30 vs. Group IN [77%] 23/30), parental separation and acceptance to mask were comparable (P > 0.05); 12/30 children (40%) in Group IN showed transient nasal irritation.

CONCLUSION

Oral midazolam and intranasal midazolam spray produce similar anxiolysis and sedation, but acceptance of drug and response to drug administration is better with oral route.

A randomised, double-blind controlled trial of intranasal midazolam for the palliation of dyspnoea in patients with life-limiting disease

PURPOSE

Anxiety is a major component of breathlessness and is often palliated with benzodiazepines. Midazolam is a short-acting water-soluble benzodiazepine with a rapid onset of action and short half-life. Intranasal midazolam had been shown to be of marked clinical benefit in an uncontrolled pilot study for the control of dyspnoea. A blinded randomised controlled study was therefore undertaken across four Australasian palliative care services.

METHODS

All participants received six numbered study nasal spray (SNS) bottles, three of which contained midazolam and three placebo. They were instructed to use one SNS bottle on each day they were breathless, for 6 days within 2 weeks. Dyspnoea scores were recorded before and at set time intervals following the first use of each SNS bottle.

RESULTS

Across all SNS bottles, the maximum change of 2.1 on an 11-point numerical rating scale was seen at 60 min. There was no difference in dyspnoea score between the two arms. Approximately 50 % of participants in each arm had a positive response (i.e. ≥2 point change in dyspnoea score from baseline). Anxiety scores at baseline were low. The most common adverse event was local nasal reactions.

CONCLUSION

Intranasal midazolam had no clinical benefit over intranasal placebo for the control of dyspnoea. The low level of anxiety at baseline and dose of active drug delivered may have been important factors. Many participants found the SNS bottles to be a challenging mode of drug delivery. This study confirms the importance of placebo-controlled trials for defining best clinical practise.

Comparison of Efficacy and Side Effects of Oral Baclofen Versus Tizanidine Therapy with Adjuvant Botulinum Toxin Type A in Children With Cerebral Palsy and Spastic Equinus Foot Deformity

This retrospective study aimed to compare the therapeutic response, including side effects, for oral baclofen versus oral tizanidine therapy with adjuvant botulinum toxin type A in a group of 64 pediatric patients diagnosed with static encephalopathy and spastic equinus foot deformity. Following botulinum toxin A treatment, clinical improvement led to the gradual reduction of baclofen or tizanidine dosing to one-third of the former dose. Gross Motor Functional Measure and Caregiver Health Questionnaire scores were markedly elevated post-botulinum toxin A treatment, with scores for the tizanidine (Gross Motor Functional Measure: 74.45 ± 3.72; Caregiver Health Questionnaire: 72.43 ± 4.29) group significantly higher than for the baclofen group (Gross Motor Functional Measure: 68.23 ± 2.66; Caregiver Health Questionnaire: 67.53 ± 2.67, P < .001). These findings suggest that the combined use of botulinum toxin A and a low dose of tizanidine in treating children with cerebral palsy appears to be more effective and has fewer side effects versus baclofen with adjuvant botulinum toxin A.

Options and Considerations for Procedural Sedation in Pediatric Imaging

As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.

Intranasal medications in pediatric emergency medicine

Intranasal medication administration in the emergency care of children has been reported for at least 20 years and is gaining popularity because of ease of administration, rapid onset of action, and relatively little pain to the patient. The ability to avoid a needle stick is often attractive to practitioners, in addition to children and their parents. In time-critical situations for which emergent administration of medication is needed, the intranasal route may be associated with more rapid medication administration. This article reviews the use of intranasal medications in the emergency care of children. Particular attention will be paid to anatomy and its impact on drug delivery, pharmacodynamics, medications currently administered by this route, delivery devices available, tips for use, and future directions.

Effects of massage therapy on pain and anxiety arising from intrathecal therapy or bone marrow aspiration in children with cancer

Cancer and its treatment are stressful and reduce the quality of life in children. The aim of this study was to investigate the effect of massage therapy on pain and anxiety arising from intrathecal therapy or bone marrow aspiration in children with cancer. We conducted a controlled pretest/posttest quasi-experimental study at a paediatric oncology unit in Turkey. Twenty-five children were enrolled in this study. Their pain and anxiety were determined using a visual analogue scale. When the pretest and posttest pain and anxiety levels of the groups were compared, no statistically significant difference was found (P > 0.05). It was determined that pain and anxiety levels in the experimental group decreased significantly. This study provides preliminary evidence for the effectiveness in children of massage in reducing pain and anxiety arising from intrathecal therapy or bone marrow aspiration.

Comparison of nasal Midazolam with Ketamine versus nasal Midazolam as a premedication in children

Background:

This study was done to compare effects of intranasal midazolam and intranasal midazolam with ketamine for premedication of children aged 1-12 yrs undergoing intermediate and major surgeries.

Aims:

Midazolam and Ketamine have already been used as premedicants in children. Our aim was to find out advantage of combination of midazolam with ketamine over midazolam by nasal route.

Methods:

Sixty children of age group 1-12 yrs of American Society of Anesthesiologists (ASA) grade 1 and 2 were selected. Group A- midazolam (0.2 mg/kg), Group B- midazolam (0.15 mg/kg + ketamine 1 mg/kg). Both groups received drug intranasally 30 min before surgery in recovery room with monitored anesthesia care. Onset of sedation, sedation score, emotional reaction, intravenous cannula acceptance, and mask acceptance were studied.

Statistical Analysis:

Unpaired t test and chi square test.

Results:

Sedation score, anxiolysis, attitude, reaction to intravenous cannulation, face mask acceptance, and emotional reaction were significantly better in midazolam with ketamine group. Intra operatively, in both groups, pulse rate, oxygen saturation, and respiratory rate had no significant difference; also, post operatively, no significant difference was observed in above parameters, post operative analgesia was significantly better in midazolam with ketamine group.

Conclusions:

Intra nasal premedication allows rapid and predictable sedation in children. Midazolam as well as combination of Midazolam with ketamine gives good level of sedation and comfort. But quality of sedation, analgesia, and comfort is significantly better in midazolam with ketamine group. No significant side effects were observed in both groups.

Clinical pharmacology of midazolam in neonates and children: effect of disease-a review

Midazolam is a benzodiazepine with rapid onset of action and short duration of effect. In healthy neonates the half-life (t_1/2) and the clearance (Cl) are 3.3-fold longer and 3.7-fold smaller, respectively, than in adults. The volume of distribution (Vd) is 1.1 L/kg both in neonates and adults. Midazolam is hydroxylated by CYP3A4 and CYP3A5; the activities of these enzymes surge in the liver in the first weeks of life and thus the metabolic rate of midazolam is lower in neonates than in adults. Midazolam acts as a sedative, as an antiepileptic, for those infants who are refractory to standard antiepileptic therapy, and as an anaesthetic. Information of midazolam as an anaesthetic in infants are very little. Midazolam is usually administered intravenously; when minimal sedation is required, intranasal administration of midazolam is employed. Disease affects the pharmacokinetics of midazolam in neonates; multiple organ failure reduces the Cl of midazolam and mechanical ventilation prolongs the t_1/2 of this drug. ECMO therapy increases t_1/2, Cl, and Vd of midazolam several times. The adverse effects of midazolam in neonates are scarce: pain, tenderness, and thrombophlebitis may occur. Respiratory depression and hypotension appear in a limited percentage of infants following intravenous infusion of midazolam. In conclusion, midazolam is a safe and effective drug which is employed as a sedative, as antiepileptic agent, for infants who are refractory to standard antiepileptic therapy, and as an anaesthetic.

Intubation in the delivery room: experience with nasal midazolam

BACKGROUND

Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible.

AIMS

To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR.

STUDY DESIGN

Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant.

SUBJECTS

Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea.

OUTCOME MEASURES

Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min.

RESULTS

Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011).

CONCLUSION

nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.

Management of agitation in individuals with autism spectrum disorders in the emergency department

Individuals with autism spectrum disorder (ASD) presenting with acute agitation in emergency departments (ED) during a crisis situation present both diagnostic and treatment challenges for ED personnel, families, caregivers, and patients seeking treatment. This article describes the challenges that individuals with ASD face when receiving treatment in crisis and emergency settings. Additionally, this article provides information for emergency physicians, ED personnel, and crisis response teams on a systematic, minimally restrictive approach when assessing and providing treatment to patients with ASD presenting with acute agitation in ED settings.

Premedication with midazolam nasal spray: an alternative to oral midazolam in children

Background:

Midazolam is a water soluble benzodiazepine which is frequently administered by intravenous and oral routes in our institution. Its nasal spray has become recently available.

Objectives:

To compare the efficacy of midazolam administered orally and by intranasal spray, with the specific objective of assessing their efficacy in terms of acceptability to the patients, whether they achieve a satisfactory sedation score, and the overall ease of inducing general anesthesia.

Patients and Methods:

Sixty healthy children of ASA grade I or II, aged 2–6 years who were undergoing elective surgery of approximately 30 minutes duration, were assigned to receive midazolam premedication in a randomized controlled trial. They were divided into 2 groups of 30 patients each. Group I: 30 patients received midazolam orally (parenteral solution mixed in honey). Group II: 30 patients received a commercially available midazolam nasal spray.

Results:

The study shows that children better accepted the drug when administered orally than when administered intranasally, although satisfactory sedation scores at 10 and 20 minutes were better in the nasal spray group than in the oral group [i.e., 6 (20%) vs. 0 (0%) at 10 min and 16 (53.3%) vs. 13 (43.3%), respectively]. Satisfactory ease of induction scores [24 (80%) vs. 13 (43.3%)], recovery times [11.63 ± 4.19 minutes vs. 25.20 ± 9.36 minutes], and post-anesthesia recovery scores were better in the nasal spray group (group II) than in the oral group (group I).

Conclusions:

On the basis of our study, we conclude that nasal midazolam spray is acceptable and is a good alternative to oral midazolam as premedication in the pediatric population.

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 medication delivery for children: a brief review and update

With the exception of oral medications, most traditional forms of drug delivery outside the operating suite require an injection with a needle-a process that is painful and anxiety-provoking, risks needle stick injury, and consumes valuable staff time. In addition, intravenous access in pediatrics may be difficult for inexperienced providers. Intranasal medication delivery offers an alternative method of drug delivery that is often as fast in onset as intravenous medication, usually painless, inexpensive, easy to deliver, and effective in a variety of acute pediatric medical conditions. This article briefly reviews the most common uses for intranasal medication delivery in pediatrics: pain control, anxiolysis, and seizure control.

Pharmacotherapy for anxiety disorders in children and adolescents

BACKGROUND

Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders.

OBJECTIVES

To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%).

AUTHORS' CONCLUSIONS

Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.

Influence of adapted environment on the anxiety of medically treated children with developmental disability

OBJECTIVES

To examine the influence of a sensory adapted environment (SAE) on the behavior and arousal levels of children with developmental disability in comparison with typical children, during a stress-provoking medical situation.

STUDY DESIGN

Sixteen children (6-11 years old) with developmental disability and 19 age-matched typical children participated in a cross-over trial measuring behavioral and psychophysiological variables, performed during a dental intervention.

RESULTS

Both groups performed better in the SAE compared with the regular environment (RE), by comparing: the mean duration of anxious behaviors in the SAE and RE (5.26 and 13.56 minutes; P <or= .001); the mean electrodermal activity for arousal levels, before commencement of treatment in the SAE and RE (784 and 349 Kohms; P= .002); and the mean electrodermal activity during treatment in the SAE and RE (830 and 588 Kohms; P= .001). A significant group by environment interaction was revealed, indicating that the difference in the 2 environments was greater in children with developmental disability than typical children in all 3 measures.

CONCLUSIONS

These findings indicate the importance of environment in determining the comfort level of all children. The greater difference in the 2 environments observed in children with developmental disability suggests that this group benefits more from sensory adapted environments.

Botulinum toxin type A with oral baclofen versus oral tizanidine: a nonrandomized pilot comparison in patients with cerebral palsy and spastic equinus foot deformity

The objective of this study was to compare the effectiveness of baclofen versus tizanidine as adjuvant treatment of botulinum toxin type A botulinum toxin type A in the management of children with spasticity. Thirty children with gastrocnemius spasticity were retrospectively reviewed at Gaziantep University Hospital, Gaziantep, Turkey. All patients were treated with localized botulinum toxin injections and baclofen or tizanidine for spasticity and were followed at 2- to 4-week intervals and evaluated for a total of 12 weeks; 17 children (57%) received baclofen and 13 (43%) received tizanidine. The mean score of Gross Motor Functional Measurement (76.63 +/- 5.88 vs 68.17 +/- 1.99; P < .001) and caregiver questionnaire scores (70.23 +/- 4.76 vs 66.59 +/- 3.53; P = .03) for the tizanidine group were significantly higher as compared with the baclofen group. This study suggests that combination of botulinum toxin type A with oral tizanidine is more effective with fewer side effects than combination of botulinum toxin type A and oral baclofen for spastic cerebral palsy.

Pain, distress, and adult-child interaction during venipuncture in pediatric oncology: an examination of three types of venous access

This study examined pain and distress from needles in children undergoing blood sampling as a function of adult-child interaction and type of venous access (i.e., central external venous lines, internalized ports, or peripheral access via venipuncture). Participants were 55 pediatric oncology patients, aged 3-18 years, who were undergoing routine blood work. Pain ratings were obtained using the Faces Pain Scale-Revised (FPS-R) and conversation during the procedure was audio taped for coding using the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R). Children's ratings of pain using the FPS-R were similar in the port (M=2.57/10, standard deviation [SD]=3.46) and peripheral (M=2.56/10, SD=3.24) groups, despite the fact that most children with internal ports were given a topical anesthetic. Similarly, there were no differences between port and peripheral groups in rates of child coping or distress, or parent and nurse observations of child pain. As would be expected, external line access was not associated with pain or distress, even among very young children, suggesting that they appropriately understood the pain rating scale. Results of the transcribed CAMPIS-R data indicate that the influences in adult-child interaction are bidirectional. Support was found for the well-established positive relationship between child distress and adult reassurance and empathy. Implications for intervention and selection of central venous access devices are discussed.

Anxiety in children undergoing VCUG: sedation or no sedation?

BACKGROUND

Voiding cystourethrograms are distressing for children and parents. Nonpharmacological methods reduce distress. Pharmacological interventions for VCUG focus on sedation as well as analgesia, anxiolysis, and amnesia. Sedation has cost, time, and safety issues. Which agents and route should we use? Are we sure that sedation does not influence the ability to diagnose vesicoureteric reflux?

METHODS

Literature search of Medline, EMBASE, and the Cochrane Database. Review of comparative studies found.

RESULTS

Seven comparative studies including two randomised controlled trials were reviewed. Midazolam given orally (0.5-0.6 mg/kg) or intranasally (0.2 mg/kg) is effective with no apparent effect on voiding dynamics. Insufficient evidence to recommend other sedating agents was found. Deeper sedating agents may interfere with voiding dynamics.

CONCLUSION

Midazolam reduces the VCUG distress, causes amnesia, and does not appear to interfere with voiding dynamics. Midazolam combined with simple analgesia is an effective method to reduce distress to children undergoing VCUG.

How physicians and nurses handle fear in children with cancer

Previous research on fear in children with cancer has often focused on interventions to alleviate fear related to medical procedures and less on how to meet the challenges related to existential fear. This study aimed to describe how experienced nurses and physicians handle fear in children with cancer. Ten nurses and physicians with more than 10 years of experience in child oncology from a university hospital in Sweden were interviewed, and a qualitative content analysis was performed on the data. Nurses' and physicians' handling of fear encompasses commitment and closeness and yet also a distancing from fear and its expressions.

Probing for nasolacrimal duct obstruction using intranasal midazolam sedation as an alternative to general anesthesia

OBJECTIVE

To investigate the effectiveness of topical anesthesia with sedation using intranasal midazolam in patients with symptomatic congenital nasolacrimal duct obstruction undergoing probing.

PATIENTS AND METHODS

In this prospective study, probing was performed with general anesthesia (30 cases) and with topical anesthesia using intranasal midazolam (0.3 mg/kg; 44 cases) in 74 patients who were divided into two groups, those 6 to 36 months old and those older than 36 months. The groups were compared after 12 to 48 months (mean, 18.2 months).

RESULTS

For the patients 6 to 36 months old, the success rate was 80% in the group who received general anesthesia and 88.9% in the group who received topical anesthesia with intranasal midazolam; the difference between the two groups was not statistically significant (P > .05). For the patients older than 36 months, the success rate was 20% in the group who received general anesthesia and 25% in the group who received topical anesthesia with intranasal midazolam; there was no statistically significant difference between the two groups (P > .05).

CONCLUSIONS

Probing with topical anesthesia in the office setting is usually recommended for patients younger than 8 months. Our results show that this is suitable for children until 4 years of age with the support of intranasal midazolam sedation. Probing under topical anesthesia with intranasal midazolam is cost-effective, safe, and comparable in efficacy to probing under general anesthesia but with less risk.

Cyclic voiding cystouretrography without the use of fluoroscopic monitoring

PURPOSE

To determine whether cyclic voiding cystourethrography (VCUG) examinations can be performed without using real-time fluoroscopic monitoring.

MATERIALS AND METHODS

VCUG examinations were performed in 209 children (133 girls and 76 boys). In each child, it was performed in a cyclic manner (three consecutive cycles) without using fluoroscopic monitoring and one radiograph was taken in each cycle of the examination. All patients were sedated by midazolam prior to examination. The degree of vesicoureteric reflux (VUR) was graded for each of the kidney ureter units (KUU) (total 418 KUU) separately. Statistical analysis included the comparison of the presence and absence of VUR and three ordinal-matched comparisons of each cycle.

RESULTS

VCUG was detected in 37.3% of the children (78/209) and 28.7% (120/418) of the KUU. The absence of or same degree of VUR in three consecutive cycles were obtained in 345 KUU and the agreement was calculated as 82.5%. The same degree and presence of reflux were found in 85 and 89 refluxing KUU, the same negative findings (absence of VUR) in 306 and 298 KUU, and discordant findings in 27 and 31 KUU (between the first and second and between first and third cycles), respectively. Therefore, the agreement was 93.5 and 92.5% between the first and second cycles (p=0.70) and between the first and the third cycles (p=0.15), respectively.

CONCLUSION

Both the cyclic nature of this study and the results indicated that VCUG without real-time fluoroscopic monitoring could be used where adequate fluoroscopic examination is not possible for children in whom VUR detection is necessary and impacts treatment. However, the responsibility of pediatric radiologist always must also include the task to provide proper equipment for imaging children with suspected VUR.

Oral clonidine pretreatment prior to venous cannulation

Clonidine is a preferential alpha-2 agonist drug that has been used for over 35 years to treat hypertension. Recently, it has also been used as a preoperative medication and as a sedative/anxiolytic drug. This randomized, double-blind, placebo-controlled crossover clinical trial characterized the effects of oral clonidine pretreatment on intravenous catheter placement in 13 patients. Parameters measured included the bispectral index (BIS), Observer's Assessment of Alertness/Sedation Scale (OAA/S), frontal temporal electromyogram (EMG), 30-Second Blink Count (Blink), Digit Symbol Substitution Test (DSST), State Anxiety Inventory (SAI), fingertip versus forearm skin temperatures, and multiple questionnaires. Oral clonidine significantly decreased SAI scores, OAA/S, EMG, and Blink, but did not cause statistically significant BIS or DSST reductions. Subjects preferred oral clonidine pretreatment prior to venipuncture compared to placebo. Questionnaires also indicated that clonidine provided minimal sedation, considerable anxiolysis, and some analgesia. Fingertip versus forearm skin temperature differentials were decreased. Reduced fingertip versus forearm temperature differentials suggest increased peripheral cutaneous blood flow prior to venous cannulation. Oral clonidine pretreatment not only helped control patient anxiety and pain but also provided cardiovascular stability.

Premedication during micturating cystourethrogram to achieve sedation and anxiolysis

Micturating cystourethrogram (MCUG) is an imaging technique indicated in the diagnosis and follow-up of many diseases. We investigated the reliability and the efficacy of midazolam and chloral hydrate in sedation and anxiolysis during micturating cystourethrogram. Fifty-three children of similar ages (39 girls, 14 boys, mean age of 5.8+/-3.5 years) were randomized to midazolam (n=17), chloral hydrate (n=18) and control groups (n=18). Oral midazolam 0.6 mg/kg or chloral hydrate 25 mg/kg or saline were administered to the study groups 15-30 min prior to the urinary catheterization. Brietkopf and Buttner, Frankl and Houpt scales and Spielberger's State Anxiety Inventory and parent's impressions were used to assess the level of sedation and anxiety. The Brietkopf and Buttner classification of emotional status and Houpt behavior rating scale demonstrated a significantly better emotional status and sedation in the midazolam group when compared to controls (P=0.01 and P=0.018, respectively). The catheterization was described as a more unpleasant and distressing event by the parents of the control and the chloral hydrate groups when compared to the parents of the midazolam group (P<0.05). Bladder capacity and frequency of detection of residual urine were not statistically different between the three study groups (P>0.05). Vital signs did not change significantly in any child. Sedation with midazolam does not have adverse effects on the results of micturating cystourethrogram, while it reduces the discomfort in children undergoing this radiological technique.

Propofol or propofol--alfentanil anesthesia for painful procedures in the pediatric oncology ward

BACKGROUND

For children with cancer receiving curative treatment, the pain of diagnostic and therapeutic procedures is often worse than that of the disease itself. In order to evaluate if light propofol anesthesia in the pediatric oncology ward (POW) could improve the management of procedure pain and anxiety, a questionnaire was developed.

METHODS

After prolonged EMLA application, 65 propofol anesthetics were performed successfully in 28 children during lumbar puncture and/or bone marrow aspiration in the POW, with short recovery time and without major adverse events. The questionnaire was mailed to the parents of the 28 children who were included in the survey.

RESULTS

The return of questionnaire compliance was 89% (25 of 28), 12 females and 13 males, mean age was 7 years (range 2-16). Among those who replied, the diagnoses were acute lymphatic leukemia in 21, lymphoma in two and tumor in the other two. In the questionnaire, all parents/patients reported advantages with anesthesia in the POW compared with the operating room. In the list of stated advantages, 88% marked 'familiar nurses and doctors', 84% 'familiar environment', 80% 'closer to own room', 68% 'the child more calm', 72% 'shorter waiting-time', 60% 'faster recovery', 44% 'shorter fasting-time' and 44% 'parents more calm', as benefits. For future procedures requiring anesthesia to reduce pain, discomfort and/or anxiety, 92% of the parents/patients preferred anesthesia in the POW.

CONCLUSIONS

If anesthesia is chosen for invasive procedures, this study suggest that propofol anesthesia in the POW is preferred by parents and children.

Oral high-dose midazolam premedication for infants and children undergoing cardiovascular surgery

BACKGROUND

The purpose of this study was to determine whether oral midazolam 1.5 mg x kg(-1) is a safe and effective alternative to standard-dose midazolam (0.5-1.0 mg x kg(-1)) premedication for infants and children with congenital heart disease.

METHODS

A total of 193 infants and children (4 months to 2 years) undergoing cardiovascular surgery were studied. Each patient received 0.5, 1.0, or 1.5 mg x kg(-1) of oral midazolam. The level of sedation was assessed with a 5-point scale and vital signs were measured including blood pressure (BP), heart rate (HR) and oxyhaemoglobin saturation (SpO2) before and after the medication.

RESULTS

Infants and children premedicated with oral midazolam 1.5 mg x kg(-1) were better sedated than those with standard-dose midazolam: 4% of infants and children given 1.5 mg x kg(-1) of midazolam became agitated compared with 14% given 1.0 mg x kg(-1) and 26% in those given 0.5 mg x kg(-1). Ninety percentage of infants and children given 1.5 mg x kg(-1) of midazolam achieved satisfactory sedation (calm, drowsy, or asleep) in 30 min, whereas 68% in those given 1.0 mg x kg(-1) and 35% in those given 0.5 mg x kg(-1). Midazolam 1.5 mg x kg(-1) did not cause any statistically significant decrease in BP, HR, or SpO2, although eight infants and children showed > or =20% drop in systolic BP and six infants and children showed >5% drop in SpO2. No 'spelling attacks', seizure-like activity, apnoea, nor laryngospasm were observed in any infants and children during and after the medication.

CONCLUSIONS

Oral midazolam 1.5 mg x kg(-1) is excellent for preanaesthetic medication for infants and children undergoing cardiovascular surgery.

Pain and stress management in the Neonatal Intensive Care Unit — A national survey in Austria

Neonates are sensitive to pain and vulnerable to both its short-term and long-term effects. Management of analgesia is thought to be hampered by lack of awareness that newborns are capable of experiencing pain and by fears about adverse effects associated with analgesics. The purpose of this study was to assess current medical practice in preventive analgesia and sedation in the neonate throughout Austria. This report details the results of a survey in 28 neonatal intensive care units (NICUs) in Austria. Data collection took place from October to December 2001. All NICUs reported the capability of newborns to experience and express pain and nearly all stated the possibility of pain affecting morbidity. Validated scores for pain assessment were used by 11% of NICUs, standardized protocols for analgesia existed in 75%, and 100% practiced non-pharmacological treatment strategies. The use of preventive measures in routinely performed painful procedures ranged from 8% to 96%. For example, only 8% of NICUs prevent distress and pain prior to umbilical vessel catheterization, 29% prior to subcutaneous injections and 46% prior to heel lancing. Nearly all NICUs apply analgesia before lumbar puncture and thoracic-drain placement, and all use analgesic and/or sedative medication in elective intubation.

CONCLUSION

There is widespread awareness among neonatologists of the importance and effects of distress caused by pain in newborns. However, the necessity of providing sufficient analgesia is underestimated. Further information on the safety of analgesic drugs in neonatology is imperative.

Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres

At least two randomized controlled trials (RCTs) have shown botulinum toxin type A (BtxA) to be efficacious and safe when used in the management of muscle spasticity in children. However, the need to use standard treatment protocols in these studies obscures some aspects of routine clinical practice that may have important effect on clinical outcomes. The purpose of this study was to seek additional information on the use of BtxA that is not usually captured by RCTs. This was performed by reviewing the clinical practice of practitioners in 17 treatment centres in Europe. The details of treatment with BtxA, including the dose, site and frequency of injections and the use of anaesthesia or sedation, were abstracted from the patient's records. Information was also obtained on the response to treatment and the occurrence and severity of adverse events. The data on 758 children who received a total of 1,594 treatments in 17 different clinics in Europe were analysed. Ninety-four per cent of patients had cerebral palsy. There was a general agreement on the indications for treatment but the average dose of BtxA used varied between centres. One treatment centre used general anaesthesia (GA) prior to injections in most patients. The reported efficacy and adverse events profile was similar for all centres. The evidence from routine clinical practice for the efficacy and safety of BtxA in the management of muscle spasticity in children, as described in this study, is in agreement with that of most of the open-label and RCTs published to date. The present study also demonstrates the disagreement between clinicians on the optimal dose of BtxA for individual muscles and confirms that the injections can be carried out without GA in almost all cases.

Sedation with midazolam for voiding cystourethrography in children: a randomised double-blind study

BACKGROUND

Sedation with midazolam facilitates the performance of diagnostic procedures in children, including voiding cystourethrography (VCUG). However, the influence of sedation on voiding and imaging results have not been adequately evaluated.

OBJECTIVE

Midazolam and placebo were compared to assess discomfort during VCUG and to evaluate if sedation influenced the outcome of the examination.

MATERIALS AND METHODS

The study was prospective, randomised and double-blind, and included 95 children, 48 in the midazolam group (median age 2.2 years) and 47 in the placebo group (median age 3.2 years). The evaluation included the child's/parent's experience of the VCUG, as well as the examination results.

RESULTS

The children/parents in the midazolam group experienced the VCUG as less distressing compared to those in the placebo group ( P<0.001). Forty-six of 48 children sedated with midazolam could void during the imaging procedure compared to 38 of 47 children given placebo ( NS). There was no difference in frequency or grade of vesicoureteric reflux or bladder emptying between the groups.

CONCLUSIONS

When sedation is required to perform VCUG in children, midazolam can be used without negative effect on the outcome of the examination.

Pediatric anesthesia in dermatologic surgery: when hand-holding is not enough

BACKGROUND

Dermatologic procedures in children may require the use of topical and local anesthetics, sedatives, and general anesthesia.

OBJECTIVE

To review developments in topical and local anesthetics, sedatives, and general anesthesia relevant to dermatologic procedures in children.

METHODS

Review of the medical literature.

RESULTS

Topical anesthetics, including EMLA and liposome-encapsulated lidocaine cream, amethocaine, cetacaine, and benzocaine products may be useful for decreasing the pain of cutaneous procedures including intra-lesional lidocaine infiltration. A variety of sedative and hypnotic agents may be utilized for pediatric dermatology procedures, and guidelines for their appropriate use have been published. General anesthesia for dermatologic procedures in the pediatric population is appropriate for a variety of procedures including laser treatment of capillary malformations.

CONCLUSION

A variety of anesthetic, analgesic, and sedatives may be useful for pediatric cutaneous surgery.