From the Guidelines
Versed (midazolam) sedation drips in neonates should be avoided due to significant risks of respiratory depression, cardiovascular instability, and neuroapoptosis, which can negatively impact morbidity, mortality, and quality of life. The primary concerns with midazolam use in neonates include:
- Respiratory depression, which can lead to apnea and require ventilatory support 1
- Cardiovascular instability, including hypotension, especially in preterm or critically ill infants
- Paradoxical agitation, which can worsen the clinical situation
- Neuroapoptosis, a serious concern with prolonged benzodiazepine exposure in neonates, potentially affecting neurodevelopmental outcomes 1
- Accumulation of midazolam in neonatal tissues due to immature hepatic metabolism and renal clearance, leading to prolonged sedation and withdrawal symptoms after discontinuation
When sedation is necessary, alternative strategies like dexmedetomidine, low-dose opioids, or non-pharmacological comfort measures should be considered first, as they may have a more favorable risk-benefit profile in neonates 1. If midazolam is used, careful dosing (typically starting at 0.05-0.1 mg/kg/hr), continuous cardiorespiratory monitoring, and frequent reassessment are essential to minimize the risks associated with its use. According to the most recent and highest quality study, sedation with benzodiazepines in neonates is advised against due to unfavorable patient outcomes 1.
From the FDA Drug Label
When midazolam is given in conjunction with opioids or other sedatives, the potential for respiratory depression, airway obstruction, or hypoventilation is increased. Midazolam should not be administered by rapid injection in the neonatal population. Severe hypotension and seizures have been reported following rapid intravenous administration, particularly with concomitant use of fentanyl Pediatric patients less than 6 months of age are particularly vulnerable to airway obstruction and hypoventilation; therefore, titration with small increments to clinical effect and careful monitoring are essential. Published animal studies demonstrate that the administration of anesthetic and sedation drugs that block NMDA receptors and/or potentiate GABA activity increase neuronal apoptosis in the developing brain and result in long-term cognitive deficits when used for longer than 3 hours.
The downsides to a versed sedation drip for a neonate include:
- Respiratory depression
- Airway obstruction
- Hypoventilation
- Severe hypotension
- Seizures (particularly with rapid intravenous administration or concomitant use of fentanyl)
- Potential long-term cognitive deficits due to neuronal apoptosis in the developing brain 2, 2, 2
From the Research
Downsides to Versed Sedation Drip for a Neonate
- The use of midazolam (Versed) in neonates can lead to significant respiratory depression, including hypoxemia and apnea, especially when combined with opioids such as fentanyl 3.
- Midazolam has been associated with a high risk of adverse reactions, including respiratory problems, and has been linked to several deaths, particularly when used in combination with opioids 3.
- The pharmacokinetics of midazolam in neonates may be unpredictable, with a potential for increased volumes of distribution and elimination half-lives, leading to prolonged sedation and increased risk of side effects 4.
- Midazolam can also cause pharyngeal dysfunction and increase the risk of aspiration, particularly when used in combination with morphine 5.
- Additionally, the use of midazolam in neonates may be associated with neurotoxicity and long-term effects on neurocognitive development, although more research is needed to fully understand these risks 6.
Key Considerations
- The potential for drug interactions and cumulative effects when using midazolam in combination with other sedatives or analgesics 4, 3.
- The importance of close monitoring and careful titration of midazolam doses in neonates to minimize the risk of adverse effects 4, 3.
- The need for alternative sedation options, such as dexmedetomidine, which may have a more favorable safety profile in certain situations 7.