Intranasal Midazolam Dosing for Pediatric Sedation
For intranasal midazolam spray in children, administer 0.2 mg/kg for procedural sedation, with 0.3 mg/kg providing faster onset and better sedation quality when more rapid effect is needed. 1
Recommended Dosing by Route
Intranasal Administration (Spray/Atomized)
- Standard dose: 0.2 mg/kg for adequate sedation in most pediatric patients 2, 1
- Higher dose: 0.3 mg/kg achieves faster sedation (adequate sedation in 70% at 10 minutes vs 40% with 0.2 mg/kg) and better parent separation scores 1
- Onset of action: 17.94 ± 8.99 minutes with intranasal route, significantly faster than oral administration 2
- Acceptance: 89.8% of children accept intranasal administration more readily than oral 2
Intravenous Administration (for comparison)
- Initial dose: 0.05-0.10 mg/kg with maximum single dose of 5 mg 3
- Age-specific titration:
- Titration approach: Wait 3-5 minutes between doses to assess peak effect using "dose/observe/redose/observe" strategy 3
Oral Administration (alternative route)
- Dose range: 0.25-0.5 mg/kg (maximum 20 mg) for anxiolysis 3
- Onset: Significantly slower (34.50 ± 11.45 minutes) compared to intranasal 2
- Efficacy: Response rates 36.7-97.8% depending on dose and procedure 5
Critical Safety Considerations
Respiratory depression is the primary concern with midazolam, particularly when combined with opioids. 3, 6
- Monitoring: Continuous pulse oximetry is mandatory for all routes of administration 3
- Oxygen desaturation: Occurs in 26% of children, especially when combined with opioids (used in 84% of cases), with saturations dropping as low as 65% 6
- Airway complications: Include airway obstruction, hypoventilation, and apnea 3, 4
- Reversal agent: Have flumazenil immediately available for life-threatening respiratory depression 3
- Combination therapy risk: Risk of adverse outcomes increases significantly when midazolam is combined with opioids or other sedating medications 7, 6
Route Selection Algorithm
Choose intranasal over oral when:
- Faster onset is needed (emergency department or time-sensitive procedures) 2
- Child cooperation with oral medication is poor 2
- More predictable absorption is desired 1
Choose IV over intranasal when:
- Immediate sedation is required 3
- Precise titration to effect is necessary 3
- Deeper sedation levels are needed 4
Age-Related Dosing Considerations
Younger children require higher mg/kg doses than older children and adolescents. 6
- Toddlers: Mean dose 0.26 ± 0.13 mg/kg 6
- Adolescents: Mean dose 0.09 ± 0.06 mg/kg 6
- This inverse relationship with age reflects differences in pharmacokinetics and metabolism 4, 6
Common Pitfalls to Avoid
- Inadequate waiting time: Not allowing 3-5 minutes for peak effect before redosing leads to oversedation 3
- Underestimating respiratory risk: The combination of midazolam with opioids dramatically increases respiratory depression risk—84% of sedated children receive both 6
- Choosing oral route in emergencies: Oral midazolam has significantly slower onset (34 minutes vs 18 minutes intranasal) 2
- Excessive dosing: Doses above 0.5 mg/kg increase risk of oversedation and adverse events without proportional benefit 5