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In a cohort of 102 children receiving intranasal midazolam in the ED for a laceration repair, nearly half exhibited extreme procedural anxiety.
IN midazolam isn’t a silver bullet for procedural anxiety
This cross-sectional study examined the incidence of extreme procedural anxiety despite intranasal midazolam (INM) administration in children undergoing laceration repair and identified predictors of nonresponse. While midazolam is widely used for pediatric procedural anxiety, prior studies have shown variability in its effectiveness, particularly in emergency settings. Researchers assessed 102 children (ages 2–10) who received 0.2 mg/kg (max 6mg) INM in a pediatric ED, measuring anxiety with the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Results showed that 45.1% exhibited extreme anxiety (mYPAS ≥72.91). Nonresponders were younger (OR 0.79, p=0.034), had lower sociability temperament (OR 0.28, p=0.002), and were more likely to have extremity lacerations (OR 8.04, p=0.009). The study’s observational design, single-center setting, and use of a lower-end INM dose (0.2 mg/kg) may limit generalizability, and unmeasured confounders, such as provider discretion in administration timing, could have influenced results.
How will this change my practice?
As a pediatric emergency medicine physician, I tend to reach for midazolam for most of the lacerations I see in younger children. Given that this study shows nearly half of children who receive IN midazolam still experience extreme anxiety – especially younger children and those with extremity lacerations – it makes me rethink how I will approach procedural anxiety for these patients. For these types of lacerations, I will be more proactive about involving our excellent child life specialists or even considering alternative sedation strategies. This study also helps me set expectations for families; for lacerations needing only one or two stitches, there’s always a balance between managing anxiety and moving efficiently. In some cases, especially when the procedure is brief, a calm but direct approach with reassurance and swift execution may be the least distressing option overall.
JF Editor’s note: Here are my pro tips. 1) Use 0.5mg/kg, max 10mg IN. 2) Wait 10 min for peak effect. 3) Use a distraction… Bluey videos are like a drug… seriously. ~Clay Smith
Source
Incidence and predictors of nonresponse to intranasal midazolam in children undergoing laceration repair. Acad Emerg Med. 2025 Feb 3. doi: 10.1111/acem.15106. Epub ahead of print. PMID: 39901057
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Dr. Joshua Belfer, MD, is a Pediatric Emergency Medicine physician at the Children’s Hospital of Philadelphia, and is the Founder and Editor-in-Chief of HipPEMcrates. He can be reached at HipPEMcrates@gmail.com.
Thoughts on IN Fentanyl vs. IN Midazolam? Personally, 2-4mcg IN fentanyl works well for my practice; even used it on my own son with an eyebrow laceration some years ago.
I am curious to know what the indication of IN fentanyl is in this instance? Ae you aiming for mild sedation/anxiolysis? Are you aiming for analgesia? Or are you aiming for procedural sedation (moderate or deep)?
I am not sure I would directly compare the anxiolytic effects of a benzodiazepine like midazolam with an opioid like fentanyl. Midazolam, with its potentiation of the inhibitory neurotransmitter GABA, causes anxiolysis, amnesia, and muscle relaxation. While an opioid like fentanyl increases pain threshold, changes perception of pain, and inhibits ascending pain pathways. It’s certainly true that you can sedate a patient (or even induce general anesthesia) with a big enough dose of an opioid, however you would also very likely get respiratory depression (hypopnea, bradypnea, apnea).
4 mcg/kg of IN fentanyl is a very large dose. Are you also monitoring these patients like a procedural sedation? At these doses, monitoring would be recommended.
For the goal of mild sedation/anxiolysis, benzodiazepines are frequently used in pediatric EDs. Other options are dexmedetomidine, and nitrous oxide.
I also want to call out Josh’s comments about the dose in this study. The dose used in this study, 0.2 mg/kg, is much smaller that what most providers would use. Maybe the small dose is why it didn’t work!