Lacerations are among the most frequently treated injuries in pediatric emergency care. The process of repairing these injuries can provoke considerable anxiety in children, which may lead to heightened pain, difficulty completing the procedure, and negative psychological and clinical effects (1-6). Midazolam is widely used to manage procedural anxiety in children, with intranasal administration gaining popularity in recent years. A recent study by Martin et al. explored both clinical and child-specific factors that may influence the effectiveness of intranasal midazolam (7).
The Data
In Martin et al., a cross-sectional study was conducted at a Level 1 pediatric trauma center and included 102 children, aged 2 to 10 years, who received 0.2 mg/kg of intranasal midazolam prior to laceration repair in the emergency department. Procedural anxiety was measured using the Modified Yale Preoperative Anxiety Scale (MYPAS), while child temperament was assessed using the Emotionality Activity Sociability Temperament Survey (EASTS) (8,9). Children with procedural anxiety scores above 72.91 per MYPAS were classified as non-responders to intranasal midazolam. The study found that 45.1% of participants met this criterion and were considered non-responders. These children tended to be younger, demonstrated lower sociability per EASTS, and were more likely to present with lacerations of their extremities. Additionally, the interval between midazolam administration and the start of the procedure was significantly longer in non-responders. Notably, children whose procedures began 10 to 20 minutes after midazolam administration experienced significantly lower anxiety levels compared to those whose procedures started more than 25 minutes afterwards.
Discussion
Overall, in the Martin et al. study, nearly half of the children who received intranasal midazolam for laceration repair were classified as non-responders, exhibiting high levels of anxiety during the procedure. This rate is substantially higher than what has been reported in preoperative settings, where non-response rates have been found to be as low as 14.9% (10). The discrepancy may be attributed to differences in environment, with the emergency department generally considered to be a louder and more unpredictable environment compared to the typically controlled and calmer atmosphere of a preoperative setting. Consistent with prior research, this study also found that younger age and temperaments marked by greater emotionality and lower sociability were associated with increased procedural anxiety. The emergency department's fast pace, loud noise, frequent staff transitions, and overall unpredictability may further heighten anxiety levels. Additionally, extremity lacerations may contribute to greater distress, as these injuries are more easily visible to children - unlike facial or scalp lacerations, which patients are less likely to see - potentially amplifying their fear and anxiety.
Take Away Points
The Martin et al. study utilized a 0.2 mg/kg dose of intranasal midazolam, which aligns with the dosing guidelines (0.2-0.3 mg/kg) approved at our institution, Cook County Health (CCH). However, this dosage represents the lower end of the range recommended by the American Academy of Pediatrics (0.2-0.5 mg/kg), which may partly explain the higher rate of non-response observed in this study compared to previous research. The study’s findings suggest that allowing 10-15 minutes for the medication to reach its peak effect may be beneficial, especially in children displaying signs of significant procedural anxiety. The variability in children’s anxiety responses to intranasal midazolam is striking and underscores the need for further research into the safety and efficacy of higher doses. Ultimately, this study reinforces the importance of a multimodal strategy for managing pediatric procedural anxiety - combining pharmacologic interventions with supportive services such as child life specialists.
Authored by Taylor Wahrenbrock, MD; Samson Frendo, MD; Eric Leser, MD; and Joanne Routsolias, PharmD.
References:
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