Midazolam premedication in children: a pilot study comparing intramuscular and intranasal administration

Comparing the Sedative Effect of Oral and Intranasal Midazolam and their Effect on Behavior in Pediatric Dental Patients

Aim

To systematically identify and evaluate the available literature based on the sedative effect of oral midazolam compared with midazolam administered intranasally and also compare their effect on behavior of pediatric dental patients.

Objective

This systematic review compares the sedative effect and the effect on behavior with oral midazolam and intranasal midazolam.

Methods

A search was undertaken through PubMed Central, Cochrane Database of Systematic Reviews, Lilacs, Science Direct and SIGLE. All the studies included the comparison of the sedative effect of oral and intranasal midazolam. Database search identified 178 articles. 165 articles were excluded based on titles and duplication. Abstract and complete text of 13 articles were thoroughly evaluated. Four articles were included based on the inclusion criteria to meet the criteria. The selected studies analyzed the children's behavior or anxiety by oral midazolam in comparison to intranasal midazolam administration.

Results

Among the four studies included in the present review, risk of bias was high in all the articles. The high risk was obtained due to inadequate blinding of personnel and participants in the study, improper allocation concealment and inadequacy in blinding of the outcome assessment. Also, difference observed between oral and intranasal midazolam routes on behavior and sedation level in the studies included in this review was not statistically significant.

Conclusion

Studies comparing the effect on behavior of oral and intranasal midazolam in children are limited. More number of high-quality clinical trials evaluating the sedative effect and effect on behavior of oral and intranasal midazolam in pediatric dental patients is required.

How to cite this article

Kotian N, Subramanian EMG, Jeevanandan G. Comparing the Sedative Effect of Oral and Intranasal Midazolam and their Effect on Behavior in Pediatric Dental Patients. Int J Clin Pediatr Dent 2022;15(1):128-134.

Sedation and Anesthesia for the Adolescent Dental Patient

This article focuses on sedation/anesthesia of adolescent patients in the dental setting. Preoperative evaluation, treatment planning, monitoring, and management are critical components to successful sedation. The authors discuss commonly administered agents and techniques to adolescents, including nitrous oxide/oxygen analgesia. The levels and spectrum of sedation and anesthesia are reviewed. Common comorbidities are also presented as they relate to sedation of the adolescent dental patient.

Sedation of children undergoing dental treatment

BACKGROUND

Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012.

OBJECTIVES

To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 22 February 2018); MEDLINE Ovid (1946 to 22 February 2018); and Embase Ovid (1980 to 22 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted, in duplicate, information regarding methods, participants, interventions, outcome measures and results. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. Cochrane statistical guidelines were followed.

MAIN RESULTS

We included 50 studies with a total of 3704 participants. Forty studies (81%) were at high risk of bias, nine (18%) were at unclear risk of bias, with just one assessed as at low risk of bias. There were 34 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Studies were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data for the primary outcome (behaviour) was possible for studies investigating oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo; standardized mean difference (SMD) favoured midazolam (SMD 1.96, 95% confidence interval (CI) 1.59 to 2.33, P < 0.0001, I2 = 90%; 6 studies; 202 participants). It was not possible to draw conclusions regarding the secondary outcomes due to inconsistent or inadequate reporting or both.

AUTHORS' CONCLUSIONS

There is some moderate-certainty evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is a need for further well-designed and well-reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Effect of Intranasal Sedation Using Ketamine and Midazolam on Behavior of 3-6 Year-Old Uncooperative Children in Dental Office: A Clinical Trial

OBJECTIVES

The aim of the present study was to compare the effects of intranasal ketamine and midazolam on behavior of 3-6 year-old children during dental treatments.

MATERIALS AND METHODS

In this randomized cross-over clinical trial, 17 uncooperative children requiring at least two dental treatments were selected and randomly received ketamine (0.5mg/kg) or midazolam (0.2mg/kg) prior to treatment. The other medication was used in the next visit. The children's behavioral pattern was determined according to the Houpt's scale regarding sleep, movement, crying and overall behavior. Physiological parameters were also measured at different time intervals. The data were subjected to Wilcoxon Signed Rank test and two-way repeated measures ANOVA.

RESULTS

The frequency of crying decreased significantly following ketamine administration compared to midazolam (P=0.002); movement of children decreased with fewer incidence of treatment interruption (P=0.001) while their sleepiness increased (P=0.003). Despite higher success of sedation with ketamine compared to midazolam, no significant differences were found between the two regarding patients' overall behavior (P>0.05). The patients had higher heart rate and blood pressure with ketamine; however, no significant difference was found regarding respiratory rate and oxygen saturation (P>0.05).

CONCLUSIONS

Ketamine (0.5mg/kg) led to fewer movements, less crying and more sleepiness compared to midazolam (0.2mg/kg). No significant differences were found between the two drugs regarding children's overall behavior and sedation efficiency. Both drugs demonstrated positive efficacy for sedation of children during dental treatments.

Premedication with midazolam in intellectually disabled dental patients: intramuscular or oral administration? A retrospective study

Background

The use of midazolam for dental care in patients with intellectual disability is poorly documented. The purpose of this study was to determine which method of premedication is more effective for these patients, 0.15 mg/kg of intramuscular midazolam or 0.3 mg/kg of oral midazolam.

Material and Methods

This study was designed and implemented as a non-randomized retrospective study. The study population was composed of patients with intellectual disability who required dental treatment under ambulatory general anesthesia from August 2009 through April 2013. Patients were administered 0.15 mg/kg of midazolam intramuscularly (Group IM) or 0.3 mg/kg orally (Group PO). The predictor variable was the method of midazolam administration. The outcome variables measured were Observer’s Assessment of Alertness/ Sedation (OAA/S) Scale scores, the level of cooperation when entering the operation room and for venous cannulation, post-anesthetic agitation and recovery time.

Results

Midazolam was administered intramuscularly in 23 patients and orally in 21 patients. More patients were successfully sedated with no resistance behavior during venous cannulation in Group PO than in Group IM (p=0.034). There were no differences in demographic data and other variables between the groups.

Conclusions

The results of this study suggest that oral premedication with 0.3 mg/kg of midazolam is more effective than 0.15 mg/kg of midazolam administered intramuscularly, in terms of patient resistance to venous cannulation. If both oral and intramuscular routes of midazolam are acceptable in intellectually disabled patients, the oral route is recommended.

Key words:Premedication, midazolam, intellectual disability.

Comparison of Oral and Intranasal Midazolam/Ketamine Sedation in 3-6-year-old Uncooperative Dental Patients

Background and aims. There are several known sedative drugs, with midazolam and ketamine being the most commonly used drugs in children. The aim of this study was to compare the effect of intranasal and oral midazolam plus ketamine in children with high levels of dental anxiety.

Materials and methods.A crossover double-blind clinical trial was conducted on 23 uncooperative children aged 3-6 (negative or definitely negative by Frankel scale), who required at least two similar dental treatment visits. Cases were randomly given ketamine (10 mg/kg) and midazolam (0.5 mg/kg) through oral or intranasal routes in each visit. The sedative efficacy of the agents was assessed by an overall success rate judged by two independent pediatric dentists based on Houpt’s scale for sedation. Data analysis was carried out using Wilcoxon test and paired t-test.

Results. Intranasal administration was more effective in reduction of crying and movement during dental procedures compared to oral sedation (P<0.05). Overall behavior control was scored higher in nasal compared to oral routes at the time of LA injection and after 15 minutes (P<0.05). The difference was found to be statistically significant at the start and during treatment. However, the difference was no longer significant after 30 minutes, with the vital signs remaining within physiological limits. Recovery time was longer in the intranasal group (P<0.001) with a more sleepy face (P=0.004).

Conclusion.. Intranasal midazolam/ketamine combination was more satisfactory and effective than the oral route when sedating uncooperative children.

Considerations for submucosal midazolam administration in combination with oral and inhaled medications for sedation of pediatric dental patients

Sedation allows patients to maintain their airway independently and respond appropriately to physical stimulation and verbal command while maintaining a minimum depressed level of consciousness. Drugs commonly used for sedation of pediatric dental patients include a combination of chloral hydrate, hydroxyzine, and nitrous oxide-oxygen. Midazolam is a benzodiazepine and currently one of the most commonly used intravenous sedative agents. It can be easily titrated to provide a wide range of sedation, from conscious sedation to deep sedation, and exhibits a wide safety margin without severe respiratory and circulatory depression. At an appropriate dose, it also decreases patient anxiety and induces amnesia. We found that the submucosal administration of midazolam combined with chloral hydrate provided increased sedative effects and decreased the postoperative vomiting response compared with conventional chloral hydrate administration, with no significant difference in physiological responses. The depth of sedation can be titrated using this technique.

Preanesthetic sedation of preschool children: Comparison of intranasal midazolam versus oral promethazine

Background:

Ensuring adequate preoperative sedation and anxiolysis is essential, especially in pediatric surgery. Various drugs and routes of administration have been evaluated to determine the optimal method of sedation.

Materials and Methods:

We selected hundred preschool children undergoing elective surgery and sedated them with either intranasal midazolam or oral promethazine syrup in the preoperative period. They were assessed with respect to their levels of sedation till the period of mask placement for induction of general anesthesia.

Results:

Both groups had comparable heart rates, respiratory rates, sedation scores, and emotional scores at all points of assessment (P>0.05). However, intranasal midazolam had a significantly shorter onset of sedation as well as time to reach maximal sedation (P<0.001).

Conclusion:

We conclude that either drug may be used with ease in preschool children undergoing elective surgery.

Comparison of oral and buccal midazolam for pediatric dental sedation: a randomized, cross-over, clinical trial for efficacy, acceptance and safety

OBJECTIVE

Providing a safe and efficient dental treatment for a young patient is a challenge for the dentist and the child. The purpose of this study was to investigate the effectiveness, safety and acceptability of buccal midazolam in dental pediatric patients and to compare it with oral Midazolam.

METHODS

Eighteen uncooperative healthy children aged 2.5-6 years were randomized to each of buccal midazolam (0.3mg/kg) or oral midazolam (0.5mg/kg) at the first visit, the alternative has been used at the second visit in a cross-over manner. The study took place at pediatric dentistry clinic of Shahed University, Tehran, from November 2011 to June 2012. The patients' vital signs and behavioral scores were recorded. The patient, the operator and the observer were blinded to the applied medication. Post operatively, patients' and parents' satisfaction were assessed by Visual Analogue Score and a questionnaire respectively. The P-value was set at 0.05 for significance level.

FINDINGS

There were no significant differences in physiologic factors in the medication groups at time 0, 10, 20, 30 minutes and discharge. There was also no significant difference between the two groups in behavioral parameters. The majority of parents rated both sedative agents as "effective" or "very effective" and their children mostly were without anxiety or with minor anxiety.

CONCLUSION

Buccal midazolam may be safely and efficiently used in sedation of pediatric dental patients.

Dexmedetomidine vs midazolam for premedication of pediatric patients undergoing anesthesia

BACKGROUND

Dexmedetomidine, an α(2)-receptor agonist, provides sedation, analgesia, and anxiolytic effects, and these properties make it a potentially useful anesthetic premedication. In this study, we compared the effects of intranasal dexmedetomidine and midazolam on mask induction and preoperative sedation in pediatric patients.

METHODS

Ninety children classified as ASA physical status I, aged between 2 and 9, who were scheduled to undergo an elective adenotonsillectomy, were enrolled for a prospective, randomized, and double-blind controlled trial. All of the children received intranasal medication approximately 45-60 min before the induction of anesthesia. Group M (n = 45) received 0.2 mg·kg(-1) of intranasal midazolam, and Group D (n = 45) received 1 μg·kg(-1) of intranasal dexmedetomidine. All of the patients were anesthetized with nitrous oxide, oxygen, and sevoflurane, administered via a face mask. The primary end point was satisfactory mask induction, and the secondary end points included satisfactory sedation upon separation from parents, hemodynamic change, postoperative analgesia, and agitation score at emergence.

RESULTS

Satisfactory mask induction was achieved by 82.2% of Group M and 60% of Group D (P = 0.01). There was no evidence of a difference between the groups in either sedation score (P = 0.36) or anxiety score (P = 0.56) upon separation from parents. The number of patients who required postoperative analgesia was higher in the midazolam group (P = 0.045).

CONCLUSION

Intranasal dexmedetomidine and midazolam are equally effective in decreasing anxiety upon separation from parents; however, midazolam is superior in providing satisfactory conditions during mask induction.

Sedation of children undergoing dental treatment

BACKGROUND

Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective.

OBJECTIVES

To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry.

SEARCH METHODS

Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Dissertation Abstracts, SIGLE, the World Wide Web (Google) and the Community of Science Database were conducted for relevant trials and references up to 4th August 2011. Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched.

SELECTION CRITERIA

Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. Crossover trials were excluded.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. The Cochrane Collaboration statistical guidelines were followed.

MAIN RESULTS

Thirty-six studies were included with a total of 2810 participants. Thirty trials (83%) were at high risk of bias and six (17%) were at unclear risk of bias. There were 28 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Trials were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data was possible for studies investigating oral midazolam vs placebo only. There is weak evidence from five small clinically heterogeneous trials at high risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 0.75 mg/kg is associated with more co-operative behaviour compared to placebo; standardised mean difference (SMD) favoured midazolam (SMD 2.98, 95% confidence interval (CI) 1.58 to 4.37, P < 0.001, I² = 91%), which translates to an increase of approximately 1.8 points on the six-point Houpt behaviour scale. There is very weak evidence from two trials which could not be pooled that inhalational nitrous oxide is more effective than placebo.

AUTHORS' CONCLUSIONS

There is some weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is very weak evidence that nitrous oxide inhalation may also be effective. There is a need for further well designed and well reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

What is the evidence for paediatric dental sedation?

BACKGROUND AND RATIONALE

Sedation can be used to relieve anxiety and manage behaviour in children, unfortunately it is difficult to determine from published research which agents, dosages and techniques are effective.

OBJECTIVE

To evaluate the relative efficacy of the various conscious sedation techniques and dosages for behaviour management in paediatric dentistry. DESIGN AND KEY METHODS: Relevant databases and reference lists from articles were searched up to December 2005. Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in anxious children up to 16 years of age.

RESULTS

Sixty-five studies were included with 3372 subjects in total. Overall quality of studies was found to be disappointing with poor reporting often the main problem.

CONCLUSIONS

Authors were not able to reach any definitive conclusion on which was the most effective drug or method of sedation used for anxious children due to issues with the quality and validity of published studies to date.