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Midazolam for Anesthetic Premedication in Children: Considerations and Alternatives
Michael Lethin1, Matthew R Paluska2, Timothy R Petersen3
1Department of Internal Medicine, Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Northwest, Lebanon, USA.
Insights
Oral midazolam is a common pediatric premedication for anesthesia, effectively reducing anxiety and delirium. However, emerging evidence and FDA warnings raise concerns about its long-term neurodevelopmental effects in young children.
Area of Science:
- Anesthesiology
- Pediatric Anesthesia
- Pharmacology
Background:
- Premedication with oral midazolam is widely used in pediatric anesthesia for its anxiolytic, amnestic, and anti-delirium effects.
- Midazolam offers ease of administration and a generally favorable side effect profile in the perioperative setting.
- Concerns exist regarding potential neurodevelopmental effects of prolonged benzodiazepine exposure in infants.
Purpose of the Study:
- To review the historical use of midazolam as a pediatric premedication.
- To examine the evidence supporting and challenging its continued use in this population.
- To inform the ongoing debate within the anesthetic community.
Main Methods:
- Literature review of studies on midazolam's efficacy and safety in pediatric premedication.
- Analysis of evidence regarding neurodevelopmental concerns associated with benzodiazepine exposure.
- Consideration of regulatory warnings, such as the 2017 FDA label changes.
Main Results:
- Midazolam has a long-standing record of efficacy in reducing pediatric anxiety and emergence delirium.
- Recent research suggests potential risks of neurodevelopmental changes with prolonged midazolam exposure in young children.
- FDA warnings highlight the need for caution in administering midazolam to children under three years old.
Conclusions:
- The established benefits of midazolam for pediatric premedication are being weighed against emerging safety concerns.
- Further research is needed to fully understand the long-term neurodevelopmental impact of midazolam in pediatric patients.
- The anesthetic community is re-evaluating the use of midazolam in light of new evidence and regulatory guidance.
Abstract:
Premedication in anesthesia has long been used to reduce patient anxiety, increase patient compliance, and supplement the overall anesthetic. In pediatric populations, premedication also has the indirect benefits of reducing parental anxiety as well as both the incidence and severity of emergence delirium. Oral midazolam, selected for its ease of administration, short duration of action, and reliable anxiolytic and amnestic effects, has been a favorite choice in this role for decades. The side effect profile of midazolam is also relatively benign, heavily dose-dependent, and easily managed in the perioperative setting. While midazolam appears to be an ideal adjunct in the anesthetic care of pediatric patients, there is a growing body of evidence suggesting prolonged benzodiazepine exposure causes neurodevelopmental changes in infants. This evidence, along with the 2017 Food and Drug Administration (FDA) warning labels for the use of select anesthetic medications, including midazolam in children under the age of three, has led to some debate in the anesthetic community over the continued use of this anesthetic for premedication in pediatric populations. This article aims to educate the reader on the history of midazolam as a premedication agent in pediatric populations and examine the evidence supporting and against its continued use in this role.
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