Midazolam Infusion Guidelines for Neonates and Pediatric Patients
For refractory status epilepticus in pediatric patients, a continuous infusion of midazolam may be used with a loading dose of 0.15-0.20 mg/kg, followed by an infusion of 1 μg/kg per minute, increasing by increments of 1 μg/kg per minute (maximum: 5 μg/kg per minute) every 15 minutes until seizures stop. 1
Age-Specific Dosing Recommendations
Neonates
- Use with extreme caution in neonates
- Severe hypotension and seizures have been reported following rapid IV administration, particularly with concomitant use of fentanyl 2
- Midazolam should not be administered by rapid injection in neonatal populations 2
- Pharmacokinetics in neonates are less predictable, with potential for adverse effects that could worsen treatment outcomes 3
Infants (< 6 months)
- Limited information available in non-intubated infants less than 6 months 2
- These patients are particularly vulnerable to airway obstruction and hypoventilation
- Titration with small increments to clinical effect and careful monitoring are essential 2
Children (6 months to 5 years)
- Initial IV dose: 0.05 to 0.1 mg/kg 2, 4
- Maximum total dose: Up to 0.6 mg/kg may be necessary (usually does not exceed 6 mg) 2, 4
- Higher doses associated with prolonged sedation and risk of hypoventilation 2
Children (6 to 12 years)
- Initial IV dose: 0.025 to 0.05 mg/kg 2, 4
- Maximum total dose: Up to 0.4 mg/kg may be needed (usually does not exceed 10 mg) 2, 4
- Higher doses associated with prolonged sedation and risk of hypoventilation 2
Adolescents (12 to 16 years)
Administration Guidelines
- Initial dose should be administered over 2-3 minutes 2
- Wait an additional 2-3 minutes to fully evaluate the sedative effect before initiating a procedure or repeating a dose 2
- Titrate with small increments until appropriate level of sedation is achieved 2
- For IM administration: 0.1 to 0.15 mg/kg is usually effective; for more anxious patients, doses up to 0.5 mg/kg have been used (total dose usually does not exceed 10 mg) 2
Monitoring Requirements
- Continuous monitoring of respiratory and cardiac function (e.g., pulse oximetry) is mandatory 2
- For deeply sedated pediatric patients, a dedicated individual, other than the practitioner performing the procedure, should monitor the patient throughout the procedure 2
- Monitor for:
- Respiratory depression
- Oxygen desaturation
- Apnea
- Hypotension 4
Safety Considerations
- Midazolam has been associated with respiratory depression and respiratory arrest, especially when used for sedation in non-critical care settings 2
- Should only be used in settings that provide for continuous monitoring of respiratory and cardiac function 2
- Immediate availability of resuscitative drugs and age-appropriate equipment for ventilation and intubation is essential 2
- Dose reduction is necessary when combined with opioids or other CNS depressants 2
- Adverse effects include:
Common Pitfalls and Caveats
- Dosing errors: Calculate doses on a mg/kg basis, not adult doses 2
- Rapid administration: Administer slowly over at least 2 minutes to avoid severe hypotension 2
- Inadequate monitoring: Ensure continuous cardiorespiratory monitoring 2
- Concomitant medications: Reduce dose when used with opioids or other sedatives 2
- Dose escalation: Midazolam above 0.3 mg/kg should be used with caution due to increased risk of desaturation 5
- Neonatal use: Exercise extreme caution in neonates due to unpredictable pharmacokinetics 3
- Recovery monitoring: Median recovery time is approximately 87 minutes but can be longer with hallucinations 5
Midazolam is an effective and relatively safe sedative for pediatric patients when used appropriately, but patients should be observed closely and monitored for psychological and hemodynamic side effects 6, 7.