Keywords

Introduction

Intrathecal chemotherapy is an integral part of the treatment in many pediatric cancers. The success story of pediatric acute lymphoblastic leukemia has been possible also because of the central nervous system protective actions of intrathecal chemotherapy. However, the long-term side effects of intrathecal methotrexate with or without cranial radiotherapy are known, and there are attempts to decrease the toxicity without altering the efficacy by de-escalation strategies.

Along with the cognitive, academic, and psychosocial effects of the intrathecal chemotherapy, the other areas of concern are the fear and distress caused by the repeated invasive procedures such as intrathecal methotrexate. As per the treatment protocol, it is given at least 15–20 times to these children. This concern has been discussed earlier in the pediatric community.[1] Earlier in 1990, the American Academy of Pediatrics proposed the guidelines for preprocedural sedation or anesthesia for children undergoing invasive procedures in an emergency room.[2] This article noted that although more research and innovation are needed, every opportunity should be taken to use available methods of pain control. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can have a positive effect on providing comfort to children.

Thereafter, there have been multiple studies to find out the optimum agent to give adequate sedation and to decrease the pain associated with procedures in children. The current drugs that are used for preprocedural sedation in children include ketamine, midazolam, propofol, etomidate, or their combinations. Oral route is always the preferred route in children as the injection anxiety counteracts the purpose. Although there are studies on oral ketamine,[3] the preferred agent for sedation in children remains intravenous (IV) ketamine in combination with propofol.[4] Various institutional protocols have been developed based on the ACEP guidelines which consider IV ketamine as Level A recommendation. Midazolam with or without fentanyl is given as Level B recommendation. Midazolam can be given via IV, oral, intramuscular, intranasal, or per rectal routes.

Midazolam

In 1998, Davies and Waters[5] published a study on oral midazolam for conscious sedation in children undergoing minor procedures. They concluded that at 0.5 mg/kg, oral midazolam appears safe and is effective in sedating most children for minor procedures. Thereafter, multiple studies have been conducted on oral midazolam, and it remains the preferred medication for pediatric dentistry and also for other minor invasive procedures.[6] A recent review of safety of oral midazolam in pediatric dentistry noted that significant side effects are rare with oral midazolam.[7] Midazolam is the most common drug used for premedication in the preoperative period to alleviate the separation anxiety before being shifted to the operation theater.

A study from India by Deshmukh et al.[8] compared oral and intranasal midazolam in a randomized way and concluded that oral midazolam and intranasal midazolam spray produce similar anxiolysis and sedation, but acceptance of drug and response to drug administration is better with oral route. The sedation and satisfactory separation was 80%–90%. No significant side effects were noted.