Comparison of Oral Melatonin and Midazolam as Premedication in Children Undergoing General Anesthesia for Dental Treatment

Successful treatment of cranial dystonia using a Zolpidem+Melatonin combination: A video case-series

INTRODUCTION

Cranial dystonias (CrD) are challenging to treat. Oral pharmacotherapy is often sub-optimal, while delicate anatomy and limited availability of skilled botulinum toxin injectors makes this approach risky, and often difficult to access; neurosurgical options e.g. deep brain stimulation, are high-risk in the elderly populations most affected. We observed significant improvement in CrD in 2 patients prescribed Zolpidem+Melatonin combination treatment for insomnia, and therefore trialled this treatment in a further 4 patients with CrD.

METHODS

Six patients were treated with Zolpidem+Melatonin. Pre- and post-treatment videotaped clinical examinations were blindly rated by an independent assessor (EM) and scored using the 'Facial and Oral Movements' section of the abnormal involuntary movements scale (AIMS), as well as the Jankovic rating scale for blepharospasm.

RESULTS

Dystonic features, as measured by the abnormal involuntary movements scale (AIMS) improved by an average of 75% after treatment (6.5±3.1 before treatment to 1.7 +/- 0.8 after treatment). Improvements were also observed in blepharospasm severity scores, and in cervical dystonic features.

CONCLUSION

Zolpidem+Melatonin combination treatment represents a safe and effective treatment for CrD. Low cost and wide availability makes it an attractive option, particularly in resource-constrained healthcare settings, or in patients who have failed, or lack access to alternatives.

Anxiolytic and Sedative Properties of Melatonin Premedication in Pediatrics Undergoing Elective Cardiac Catheterization: A Randomized Placebo Study

BACKGROUND

Preoperative anxiety in children has been linked to various postoperative consequences, such as postoperative regressive behavioral issues, extended distress during the recovery period, eating disorders, and bedwetting. The current study aimed to investigate the efficacy of low-dose oral melatonin in alleviating preoperative anxiety among children in the Iraqi population.

STUDY DESIGN

A randomized, double-blinded comparative study was undertaken, involving children aged four to 14 years scheduled for elective cardiac catheterization under general anesthesia. The study comprised a total of 80 children. The involved individuals were randomly assigned to two groups, each with 40 subjects. Group A received 0.5 mg/kg melatonin as premedication, while Group B received a placebo.

RESULTS

The two groups demonstrated similarity in mean age, weight, cardiac disease, and gender distribution. Statistically significant reductions in anxiety scores were observed in the melatonin group compared to the placebo group. Particularly, children administered 0.5 mg/kg melatonin exhibited the most substantial anxiolysis and venipuncture compliance (P < 0.05). Additionally, children who were premedicated with melatonin experienced decreased cognition, maximum sedation, successful parental separation, and psychomotor impairment (P < 0.05).

CONCLUSIONS

Melatonin demonstrated an effective sedation level without significant side effects, making it a preferred choice due to its efficacy, safety, current availability, and cost-effectiveness compared to other anesthetic agents used in premedication procedures.

Comparison of different sedatives in children before general anaesthesia for selective surgery: A network meta-analysis

WHAT IS KNOWN AND OBJECTIVE

It is estimated that 60% of children undergoing anaesthesia develop severe preoperative anxiety. The anxiety is associated with adverse reactions. Sedatives such as dexmedetomidine, midazolam, clonidine, ketamine, and melatonin can be used as premedication against preoperative anxiety. However, no consensus has been reached on the choice of pre-anaesthetic sedatives in children before selective surgery. Therefore, the current network meta-analysis (NMA) was carried out to evaluate different sedatives in children aged between 1 and 7 before general anaesthesia for selective surgery.

METHODS

Randomized clinical trials (RCTs) were retrieved from Pubmed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases from inception to October 22, 2021. Primary outcomes showed satisfactory sedation at parent separation and also at induction or mask acceptance. Secondary outcomes were those related to added benefits and side effects. The present NMA was conducted using the R software. Results of the study were reported as Relative Risk (RR) or Mean Difference (MD) at a 95% credible intervals (CrIs).

RESULTS AND DISCUSSION

A total of 48 trials were included in the present study. It was found that the effectiveness of dexmedetomidine, midazolam, clonidine, and ketamine were superior to that of placebo in satisfactory sedation at parent separation and induction or mask acceptance. There was no significant difference between melatonin and placebo in satisfactory sedation at induction or mask acceptance. Dexmedetomidine, ketamine, clonidine, and melatonin were superior to placebo in reducing emergence delirium (ED). In addition, midazolam prolonged the length of stay in the post anaesthesia care unit (PACU) as compared with placebo. Dexmedetomidine caused a significant reduction in systolic blood pressure (SBP) and heart rate (HR). Nevertheless, it was noted that the hemodynamic changes were roughly within safety limits.

WHAT IS NEW AND CONCLUSION

It was evident that the studied drugs can provide effective sedation with exception of melatonin and placebo. However, it was found that midazolam, ketamine, and clonidine lead to several side effects. The findings of the present study supported that dexmedetomidine, especially intranasal administration, has potential in the optimal selection of the sedatives for premedication in children. This is because the drug has effective sedation, reduced incidence of ED, side effects, and onset time.

Melatonin for pre-medication in children: a systematic review

Background

Melatonin’s effectiveness as an anxiolytic medication has been confirmed in adults; however, its efficacy in a paediatric population is unclear. A number of small studies have assessed its use in children as a pre-operative anxiolytic, with conflicting results.

Methods

We undertook a systematic review of pre-operative melatonin use in children. Four databases (MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Web of Science), and ‘ClinicalTrials.gov’ were searched for ongoing and completed clinical trials of relevance. Citation tracking reference lists and relevant articles were also accessed. The review was unrestricted by comparator or outcomes. Eleven studies were judged eligible for inclusion. There were high levels of heterogeneity in melatonin administration (in terms of dose and timing). Variable outcomes were reported and included: anxiety; anaesthetic success; analgesia; sedation; post-operative recovery; and safety. Outcomes were not always assessed with the same measures.

Results

Evidence to support melatonin’s anxiolytic properties in this setting is conflicting. Melatonin was associated with reduced sedative effects, post-operative excitement and improved emergence behaviour, compared to comparator drugs. One study reported the benefit of melatonin use on sleep disturbance at two weeks post-surgery. No adverse safety events were identified to be significantly associated with melatonin, affirming its excellent safety profile.

Conclusion

Despite potential advantages, including improved emergence behaviour, based on current evidence we cannot confirm whether melatonin is non-inferior to current “usual care” pre-medications. Further consideration of melatonin as an anxiolytic pre-medication in paediatric surgery is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03149-w.

Knowledge, Attitude, and Performance of Pregnant Women Regarding General Anesthesia Neurotoxicity in Children under Three: A Report from an Academic Hospital

Background: Recently, concerns about general anesthesia (GA)-related neurotoxicity has been growing in societies. Parents’ information obviously plays an important role to make right decision for elective surgeries on children aged under three years old. Objectives: The aim of this survey was to evaluate the knowledge, attitude, and performance of pregnant women about the GA-related neurotoxicity in children aged under three years old. Methods: This descriptive study was conducted at Alzahra Teaching Hospital in Guilan, Iran, during 2020. The eligible pregnant women admitted to this center were interviewed, and a questionnaire containing 10 items was filled out by the responsible resident of anesthesiology. Results: In this research, a total of 361 pregnant women were enrolled and underwent a face-to-face interview. The mean age of the participants was 31.4 ± 7 years, 64.5% were living in urban areas, 82.5% were housewives, and 65.7% were multipara. Moreover, 83.7% of participants believed that receiving information in this regard was crucial, and 81.7% preferred physicians as the source of information. Only 8% of mothers had received information regarding the issue. A significant correlation was observed between the habitat, employment, the level of education, knowledge, and attitude status, and the source of receiving information. Conclusions: According to our results, the knowledge, attitude, and performance of pregnant women were not optimal and needed to be improved through practical strategies.

As part of multimodal anxiolysis oral melatonin but not midazolam decreases emergence delirium in children: A randomised, double-blind, placebo-controlled study

BACKGROUND

Pre-operative anxiety is a risk factor for emergence delirium in children and a multimodal approach including sedatives and nonpharmacological measures is the current strategy to tackle this anxiety. The efficacy of oral melatonin as a component of multimodal anxiolytic strategy to decrease emergence delirium is not well studied.

OBJECTIVE

The aim of this study was to evaluate the efficacy of a multimodal anxiolytic strategy including oral melatonin or midazolam to decrease emergence delirium after sevoflurane anaesthesia.

DESIGN

A randomised, double-blind, parallel arm, placebo-controlled trial.

SETTING

Tertiary care teaching hospital from July 2019 till January 2020.

PARTICIPANTS

Children in the age group of 3 to 8 years who received sevoflurane anaesthesia for elective ambulatory procedures.

INTERVENTIONS

Children were randomised to receive oral premedication with either melatonin 0.3 mg kg-1, midazolam 0.3 mg kg-1 or honey as placebo. All the children received standardised nonpharmacological measures involving multiple techniques to allay anxiety. The anaesthetic plan was also standardised.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of emergence delirium as assessed by the Watcha scale in the postanaesthesia care unit. The secondary outcomes were pre-operative anxiety assessed using a modified Yale Preoperative Anxiety scale, patient compliance with mask induction using the Induction Compliance Checklist and postoperative sedation.

RESULTS

Data from 132 children were analysed. Melatonin significantly reduced the incidence of emergence delirium compared to placebo: 27 vs. 50%, respectively, an absolute risk reduction of 23.3 [95% confidence interval 3.7 to 42.9), P = 0.03]. Melatonin also significantly reduced the risk of emergence delirium compared with midazolam: 27 vs. 56%, respectively, an absolute risk reduction of 29.2 (95% CI 9.5 to 48.8). The midazolam group had a similar incidence of emergence delirium as placebo. Sedation scores were similar in the three groups postoperatively. The incidence and score of pre-operative anxiety as well as the compliance with mask induction were similar in the three groups.

CONCLUSIONS

A multimodal anxiolytic approach including oral melatonin, as opposed to oral midazolam, significantly reduced emergence delirium after sevoflurane anaesthesia.

TRIAL REGISTRATION

CTRI/2019/06/019850 in Clinical Trial Registry of India (www.ctri.nic.in).

Melatonin as an adjunctive treatment on dental procedures: A systematic review

The systematic review tried to answer the following question: Does the melatonin administered systemically or topically ameliorate patients involved with oral health conditions or dental procedures? The systematic review has been registered in the PROSPERO (2021CRD42021095959). Eligibility criteria included only randomized controlled clinical trials (RCTs) with at least 10 participants that compared patients that received melatonin as a treatment before and/or after their oral intervention topically or systemically, with control patients. A search was performed in PubMed/MEDLINE, Web of Science, Cochrane Library, and Academic Google databases for articles up to February 2021. The Cochrane risk-of-bias tool for randomized clinical trials was used and revealed that the studies included presented low risk of bias for the majority of criteria assessed. It was selected 25 articles, of which only six did not demonstrate positive effects and three presented null effects with the use of melatonin. Melatonin has improved the inflammatory response in periodontal disease, dental surgeries, and mucositis of head and neck oncologic irradiated patients. In addition, it showed anxiolytic potential in patients that were submitted to dental procedures. In conclusion, melatonin favored the treatment of oral changes when used topically and systemically.

Comparison the Oral Premedication of Midazolam, Dexmedetomidine, and Melatonin for Children's Sedation and Ease of Separation from Parents before Anesthesia

Background:

Children’s fear of surgery and preoperative separation from parents can contribute to anxiety and distress in children undergoing surgery. The study addressed the comparable efficacy of oral premedication of midazolam, dexmedetomidine, and melatonin to alleviate preoperative anxiety and easing the children’s separation from parents.

Materials and Methods:

A double-blinded trial enrolled three equal-sized groups of children (n = 153, aged 2–10 years) undergoing elective surgery who received oral midazolam, melatonin, and dexmedetomidine 30 min before induction. The observation sedation score, and ease of separation, acceptance of drug both preceding and following premedication administration were assessed and recorded every 5min till anesthesia induction.

Results:

A significant difference was observed in the mean scores of sedation before premedication and after separation from parents, as well as in the degree of the separation when comparing between the midazolam and melatonin groups and the dexmedetomidine and melatonin groups (P < 0.001). The scores were significantly lower in the melatonin group than the other two groups, whereas no significant difference was found in those between the midazolam and dexmedetomidine groups, as well as in the acceptance of anesthesia induction between the midazolam and melatonin groups (P = 0.250). The differences were significant between the midazolam and dexmedetomidine groups (P = 0.002) and melatonin and dexmedetomidine groups (P < 0.001) and anesthesia induction was effective in the dexmedetomidine group than that in the other two groups.

Conclusion:

Dexmedetomidine is more effective in acceptance of anesthesia induction. Furthermore, the midazolam and dexmedetomidine groups indicated better ease of separation and sedation scores than melatonin.

Melatonin for anaesthetic indications in paediatric patients: a systematic review

The favourable safety profile and ubiquitous nature of melatonin has led to an increase in its use in various clinical settings in adults and children. We performed a systematic review of published studies on the use of melatonin for anaesthetic indications in paediatric patients. To identify relevant articles, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Scopus databases were searched. Study title and abstract screening, and full text review were performed by two reviewers. Twenty-seven eligible studies investigating melatonin use for anaesthetic indications were identified. Due to significant heterogeneity in study methodology, a quantitative synthesis of the published findings was not possible. The identified studies were therefore categorised by the indication for melatonin: analgesia, diagnostic sedation and as an anaesthetic adjunct. Melatonin use for anaesthetic-related indications is safe; may provide analgesia for inflammatory-associated pain in neonates and children before venepuncture; may decrease the need for, or replace, general anaesthesia for diagnostic procedures; and may serve as an anaesthesia adjunct before induction in paediatric patients.

Should Melatonin Be Used as an Alternative Sedative and Anxiolytic Agent in Mandibular Third Molar Surgery?

PURPOSE

Melatonin is a natural hormone that regulates circadian rhythms. The aim of this study was to compare the anxiolytic effects of oral melatonin and oral midazolam in patients undergoing third molar surgery. The study also sought to investigate the effects of these drugs on cognitive and psychomotor functions.

MATERIALS AND METHODS

This was a double-blinded, prospective, randomized clinical study. Patients scheduled for impacted third molar surgery were included in the study. Anxiety was evaluated with the visual analog scale (VAS). To measure psychomotor and cognitive functions before the procedure, all patients were asked to complete the digit symbol substitution test (DSST) and the trail making test (TMT parts A and B). Then, all patients were allocated to 1 of 3 groups to receive oral midazolam 0.2 mg/kg (group MD), oral melatonin 0.4 mg/kg (group M), or an oral multivitamin tablet as placebo (group P). After 60 minutes, patients were reassessed using the same 3 tests. The difference between the pre- and post-drug VAS values was calculated and the anxiolytic effects of the drugs were evaluated.

RESULTS

Ninety patients participated in the study. No relevant differences were observed among groups for age, gender, or duration of operation. The results suggested that anxiety decreased most in group MD (P < .001), but anxiety in group M also decreased significantly compared with group P (P = .016). Similarly, the greatest increase in TMT-A and -B score differences was in group MD compared with the other groups (P < .001), whereas there was no significant difference between groups M and P for TMT-A and -B scores (P = .913 and P = .964, respectively).

CONCLUSION

Melatonin showed sufficient anxiolytic effect in third molar surgery without affecting cognitive and psychomotor functions.

Premedication and Induction of Anaesthesia in paediatric patients

Perioperative anxiety has been associated with adverse clinical outcomes such as emergence delirium, increased analgesic requirements and negative postoperative behavioural changes such as sleep disturbance, separation anxiety, eating problems and new-onset enuresis. Predictors of preoperative anxiety have been identified, and these include, among other factors, the age and temperament of the child. Any plan for anaesthetic induction in a child must take into account these factors. The anaesthetic plan must be individualised for special situations, for example, the child with behavioural disorder or at risk of aspiration. This article details the pharmacological and nonpharmacological methods to minimise preoperative anxiety and the techniques of anaesthetic induction in infants and children undergoing surgery. The benefits and limitations of inhalational and intravenous induction and the current status of rapid sequence induction in children are discussed. MEDLINE database was searched for this narrative review using the keywords including preoperative anxiety, child, premedication, paediatric and anaesthetic induction. Search was restricted to articles in English, but without any publication date restrictions.