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Evidence-based clinical update: Does premedication with oral midazolam lead to improved behavioural outcomes in children?

[Mise à jour basée sur des données probantes : Améliore-t-on le comportement des enfants par une prémédication au midazolam par la bouche ?]

Robin G. Cox, MB BS MRCP(UK) FRCA FRCPC^*, Ulyana Nemish, BSc MSc^*, Alastair Ewen, MB ChB FRCA FRCPC^* and Marie-Josée Crowe, MD FRCPC

^* From the Division of Pediatric Anesthesia, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta; and the
Department of Anesthesiology, University of Montréal, Montréal, Québec, Canada.

Address correspondence to: Dr. Robin G. Cox, Division of Pediatric Anesthesia, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta T3B 6A8, Canada. Phone: 403-955-7260; Fax: 403-955-7606; E-mail: robin.cox{at}calgaryhealthregion.ca

Purpose: The purpose of this evidence-based clinical update was to identify the best evidence to determine if behavioural outcomes are improved in children after oral midazolam premedication.

Methods: A literature search was conducted using both PubMed and OVID programs, utilizing the terms "midazolam", and either "premedication" or "preoperative treatment". Search limits that were employed included randomized controlled trials (RCTs), English language, human studies, children aged 0–18 yr, and publication dates 1990 – present (January 2006). A review of the 171 abstracts obtained was undertaken and, of these, 30 papers were identified that concerned oral midazolam in children prior to general anesthesia, and that involved a RCT with a placebo or control arm. These studies were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria.

Results: Oral midazolam premedication in children was found to reduce the anxiety associated with separation from parents/guardians, and with induction of anesthesia. Recovery times are not significantly delayed. There is no consistent evidence to suggest a reduction in the phenomenon of emergence agitation. Evidence suggesting an improvement in behavioural outcomes at home is also inconsistent.

Conclusion: Premedication with midazolam 0.5 mg·kg^–1 po administered 20–30 min preoperatively, is effective in reducing both separation and induction anxiety in children (grade A recommendation), with minimal effect on recovery times. However improved postoperative behavioural outcomes in the postanesthesia care unit, or at home cannot be predicted on a consistent basis.

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