Weight-Based Intravenous Midazolam Dosing in Pediatric Patients
For intravenous midazolam in children, administer 0.05-0.10 mg/kg over 2-3 minutes for sedation/anxiolysis (maximum single dose: 5 mg), with younger children requiring higher mg/kg doses than older children and adolescents. 1, 2
Age-Stratified Dosing Recommendations
Infants <6 Months
- Initial dose: 0.05-0.1 mg/kg IV over 2-3 minutes 2
- This age group is particularly vulnerable to airway obstruction and hypoventilation 2
- Titrate with small increments and monitor continuously 2
- Limited safety data exists for this population 2
Children 6 Months to 5 Years
- Initial dose: 0.05-0.1 mg/kg IV over 2-3 minutes 1, 2, 3
- Total dose may reach up to 0.6 mg/kg to achieve desired effect (usually not exceeding 6 mg) 2, 3
- This age group typically requires the highest mg/kg doses compared to older children 1, 4
- Mean doses in toddlers have been documented at 0.26 ± 0.13 mg/kg 4
Children 6 to 12 Years
- Initial dose: 0.025-0.05 mg/kg IV over 2-3 minutes 2, 3
- Total dose up to 0.4 mg/kg may be needed (usually not exceeding 10 mg) 2, 3
- Higher doses are associated with prolonged sedation and increased hypoventilation risk 2
Adolescents 12-16 Years
- Dose as adults: 1-2 mg IV initially 2
- Some patients may require higher than adult doses, but total usually does not exceed 10 mg 2
- Mean doses in adolescents documented at 0.09 ± 0.06 mg/kg 4
Critical Titration Protocol
Wait 3-5 minutes between doses to assess peak effect before redosing 1, 2. Midazolam takes approximately three times longer than diazepam to achieve peak EEG effects due to its water solubility 2. Failure to wait adequate time between doses is a common cause of oversedation 1.
Redosing Strategy
- After initial dose, observe for 3-5 minutes 1
- If additional sedation needed, give incremental doses of 1 mg (or 0.2-0.3 mg/kg in smaller children) 1
- Continue titrating at 2-minute intervals until desired effect achieved 1, 2
Special Clinical Situations
Rapid Sequence Intubation
- Dose: 0.2 mg/kg IV 1
- Allow 2-3 minutes for effect before administering muscle relaxant 1
- Lower doses are ineffective for RSI 1
Refractory Status Epilepticus
- Loading dose: 0.15-0.20 mg/kg IV 1
- Follow with continuous infusion starting at 1 μg/kg/min, titrating up to maximum 5 μg/kg/min 1
When Combined with Opioids
- Reduce midazolam dose by 50% or more 1, 2
- Synergistic respiratory depression occurs when combined with fentanyl or other opioids 1, 4
- In one study, 26% of children with normal lungs developed oxygen desaturation (as low as 65%) when midazolam was combined with opioids 4
Mandatory Safety Monitoring
Continuous pulse oximetry is non-negotiable 1, 5. Oxygen desaturation occurred in 11.6% of pediatric patients receiving midazolam for procedural sedation 5.
Required Equipment and Personnel
- Resuscitation equipment including bag-valve-mask and supplemental oxygen 6
- Flumazenil (0.01 mg/kg) immediately available to reverse life-threatening respiratory depression 1, 5
- Personnel trained in pediatric airway management present throughout sedation 5
- Suction equipment readily accessible 6
Warning Signs Requiring Intervention
- Respiratory rate <10 breaths/minute or irregular pattern 4
- Oxygen saturation <90% 4
- Airway obstruction (occurred in 3% of cases in one series) 4
- Paradoxical agitation, particularly in children <6 years 1, 2
Critical Pitfalls to Avoid
Never administer midazolam as a rapid IV bolus - always give over 2-3 minutes to prevent respiratory depression and hypotension 1, 2.
Do not combine with other sedatives without appropriate monitoring capabilities - the American Academy of Pediatrics specifically warns of significantly increased apnea risk when midazolam is combined with opioids 5.
In obese children, calculate dose based on ideal body weight, not actual weight 2.
Flumazenil reverses both sedation AND anticonvulsant effects - if midazolam was used for seizure control, flumazenil may precipitate seizure recurrence 1, 5.