Intranasal Midazolam Dosing for Pediatric Patients
The recommended intranasal dosing of midazolam (Versed) for pediatric patients is 0.2-0.3 mg/kg, with a maximum single dose of 10 mg. 1, 2
Dosing Recommendations by Route
Intranasal Administration
- Intranasal midazolam at 0.2 mg/kg is effective for procedural sedation, though 0.3 mg/kg achieves faster sedation and better separation scores 1, 2
- Maximum single intranasal dose should not exceed 10 mg 3
- Onset of action is typically 10-20 minutes, significantly faster than oral administration (17.9 ± 9.0 minutes vs. 34.5 ± 11.5 minutes for oral) 1
- For seizure management, standard intranasal dosing of 0.1 mg/kg may be subtherapeutic and require redosing compared to IV or IM routes 4
Other Routes for Comparison
- Intravenous: 0.05-0.10 mg/kg given over 2-3 minutes, with maximum single dose of 5 mg 3
- Oral: 0.25-0.50 mg/kg with maximum of 20 mg (children under 6 years may require up to 1 mg/kg) 3
- For intubation: 0.2 mg/kg IV, allowing 2-3 minutes for effect before muscle relaxant 3
Monitoring and Safety Considerations
- Continuous monitoring of oxygen saturation is essential as midazolam carries significant risk of respiratory depression, especially in infants 5, 3
- The most serious adverse events associated with midazolam in children include hypoventilation, decreased oxygen saturation, apnea, and hypotension 6
- There is an increased risk of respiratory depression when midazolam is combined with other sedative agents, particularly opioids 5, 3
- Always have respiratory support equipment immediately available when administering midazolam by any route 7
- Practitioners must be able to rescue patients from a deeper level of sedation than intended 7
Advantages of Intranasal Administration
- Noninvasive with good bioavailability 2
- Better patient acceptability compared to oral administration (89.8% vs. 36.9%) 1
- Atomized spray ensures more accurate dosing and virtually complete absorption 2
- Convenient administration and rapid onset are significant advantages over intravenous and oral agents 8
Clinical Pearls and Pitfalls
- Intranasal midazolam is most effective for short procedures due to its shorter duration of action 8
- For longer procedures, it may be used as an adjunct to other sedative agents 8
- Paradoxical agitation may occur, especially in younger pediatric patients 3
- Have flumazenil readily available as an antidote for life-threatening respiratory depression 5, 3
- Be aware that flumazenil will also reverse the anticonvulsant effects of midazolam and may precipitate seizures if midazolam was used for seizure control 3