Recommended Midazolam Dosing for Neonates and Pediatric Patients
The recommended dose of midazolam for sedation in pediatric patients varies by age group, with neonates requiring 0.05-0.1 mg/kg IV initially, infants and young children (6 months to 5 years) requiring 0.05-0.1 mg/kg IV initially (up to 0.6 mg/kg total), and older children (6-12 years) requiring 0.025-0.05 mg/kg IV initially (up to 0.4 mg/kg total).
Age-Specific Dosing Guidelines
Neonates and Infants <6 months
- IV administration: 0.05-0.1 mg/kg initially 1
- Limited data available for non-intubated neonates
- Particularly vulnerable to airway obstruction and hypoventilation
- Titrate with small increments to clinical effect
- For mechanically ventilated neonates: 200 μg/kg loading dose followed by 37.5-100 μg/kg/hour infusion 2
Infants and Young Children (6 months to 5 years)
- IV administration: 0.05-0.1 mg/kg initially 1, 3
- Total dose up to 0.6 mg/kg may be necessary (not exceeding 6 mg total) 1
- IM administration: 0.1-0.15 mg/kg (anxious patients up to 0.5 mg/kg, not exceeding 10 mg total) 1
- Oral administration: 0.25-0.5 mg/kg (effective dose range) 4
Children (6-12 years)
- IV administration: 0.025-0.05 mg/kg initially 1, 3
- Total dose up to 0.4 mg/kg may be necessary (not exceeding 10 mg total) 1
- IM administration: 0.1-0.15 mg/kg (anxious patients up to 0.5 mg/kg, not exceeding 10 mg total) 1
- Oral administration: 0.5-0.75 mg/kg for preoperative sedation 5
Adolescents (12-16 years)
- Should be dosed as adults, though some may require higher than recommended adult doses 1
- Total dose usually does not exceed 10 mg 1
Route-Specific Administration
Intravenous Administration
- Administer initial dose over 2-3 minutes 1
- Wait additional 2-3 minutes to evaluate sedative effect before repeating dose 1
- For seizure management: 0.15-0.20 mg/kg loading dose, followed by continuous infusion of 1 μg/kg/min, increasing by increments of 1 μg/kg/min (maximum: 5 μg/kg/min) every 15 minutes until seizures stop 6
Intramuscular Administration
- For pre-procedure sedation: 0.1-0.15 mg/kg (up to 0.5 mg/kg for anxious patients) 1
- For acute seizure management: 0.2 mg/kg (maximum: 6 mg per dose), may repeat every 10-15 minutes if needed 6
Oral Administration
- Effective dose range: 0.25-0.75 mg/kg 4, 5
- Onset of action is slower than parenteral routes
- Higher doses increase risk of adverse events and over-sedation 4
Important Considerations
Dose Adjustments
- Reduce dose by 20% or more when used with opioids or other CNS depressants 6, 1
- Calculate dose based on ideal body weight in obese pediatric patients 1
Monitoring Requirements
- Continuous monitoring of respiratory function and oxygen saturation 6
- Be prepared for respiratory support, especially when combined with other sedatives 6
- Apnea can occur up to 30 minutes after the last dose 6
Adverse Effects
- Most serious: respiratory depression, decreased oxygen saturation, apnea, and hypotension 3
- Other common effects: tachycardia (27.9%), increased secretions (17.6%), agitation (13.6%), nausea/vomiting (9.2%) 7
- Caution with midazolam doses above 0.3 mg/kg due to increased risk of desaturation 7
Special Considerations
- Midazolam is 1.5-3.5 times more potent than diazepam, with faster onset and shorter duration 6
- Half-life in children over 12 months is 0.8-1.8 hours 3
- Flumazenil may be used to reverse life-threatening respiratory depression, but with caution as it may precipitate seizures 6
Remember that careful titration to effect is vital for safe sedation in pediatric patients, and the total dose will depend on patient response, procedure type/duration, and concomitant medications 1.