Can an anxiolytic (anxiety-reducing medication) be administered to a 9-year-old patient prior to a dental procedure to alleviate severe anxiety related to medical procedures, specifically procedure-related anxiety?

From the Guidelines

Yes, an anxiolytic can be given to a 9-year-old child before a dental procedure to help reduce severe anxiety related to medical procedures. The most recent and highest quality study, 1, provides guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. According to these guidelines, the goals of sedation in pediatric patients include minimizing physical discomfort and pain, controlling anxiety, and modifying behavior to allow for the safe completion of the procedure. Some key points to consider when administering anxiolytics to children include:

• Selecting the lowest dose of drug with the highest therapeutic index for the procedure
• Matching drug selection to the type and goals of the procedure
• Considering the potential for adverse outcomes when administering multiple sedating medications
• Monitoring the child during and after the procedure for potential side effects such as respiratory depression, prolonged sedation, or paradoxical reactions
• Arranging for transportation home after the procedure as these medications can cause drowsiness Commonly prescribed options for anxiolytics in children include midazolam and nitrous oxide, which can be administered orally or intranasally, or via inhalation, respectively. For example, midazolam can be given orally at a dose of 0.25-0.5 mg/kg, with a maximum dose of 20 mg, or intranasally at a dose of 0.2-0.3 mg/kg, given 20-30 minutes before the procedure. Nitrous oxide can be administered during the appointment at concentrations of 30-50% mixed with oxygen. It's essential to have a thorough pre-procedure assessment, including the child's medical history, current medications, and any allergies, before administering any medication. Additionally, the child should be monitored during and after the procedure by an individual with the skills needed to rescue a patient from an adverse response. Overall, the use of anxiolytics in children can be effective in reducing anxiety related to medical procedures, but it's crucial to follow established guidelines and protocols to ensure the child's safety and well-being.

From the FDA Drug Label

Midazolam Injection, USP is indicated: intramuscularly or intravenously for preoperative sedation/anxiolysis/amnesia; The initial pediatric dose of midazolam for sedation/anxiolysis/amnesia is age, procedure, and route dependent

Anxiolytic Use in Pediatric Patients:

• Midazolam can be used for sedation/anxiolysis/amnesia in pediatric patients, including those undergoing dental procedures.
• The dose must be calculated on a mg/kg basis and titrated slowly.
• Key Considerations:
  • Dedicated monitoring by a trained individual is required for deeply sedated pediatric patients.
  • Risks of respiratory depression and sedation are increased with concomitant use of opioids.
  • Personnel and equipment for monitoring and resuscitation must be available. 2 2

From the Research

Anxiolytic Administration to Children

• Anxiolytics can be used to reduce anxiety in children undergoing dental procedures, as seen in studies 3, 4.
• The use of oral midazolam has been shown to be effective in reducing anxiety in children, with moderate-certainty evidence from six small clinically heterogeneous studies 4.
• The dosage of oral midazolam used in these studies ranged from 0.25 mg/kg to 1 mg/kg, and was associated with more co-operative behavior compared to placebo 4.

Sedation Techniques for Pediatric Dentistry

• Procedural sedation and analgesia are considered standard care for managing pain and anxiety in pediatric dental patients 3.
• Non-pharmacologic interventions, such as Behavior Management Technology, can help reduce preprocedural agitation and ease the transition to sedation 3.
• Combination therapy of nitrous oxide with oxygen and oral sedation may be an option to increase the efficacy of both routes of sedation 5.

Safety and Efficacy of Anxiolytics in Children

• The safety and efficacy of anxiolytics in children must be carefully considered, with special considerations applying to sedation of pediatric patients 5, 4.
• Studies have shown that anxiolytics such as midazolam and diazepam can be effective in reducing anxiety in children, with minimal effects on vital signs and retrograde amnesia 6.
• However, the risk of bias in many studies is high, and further well-designed and well-reported clinical trials are needed to evaluate the efficacy and safety of anxiolytics in children 4.