Effect of Intranasal Sedation Using Ketamine and Midazolam on Behavior of 3-6 Year-Old Uncooperative Children in Dental Office: A Clinical Trial
Objectives: The aim of the present study was to compare the effects of intranasal ketamine and midazolam on behavior of 3-6 year-old children during dental treatments.
Materials and Methods: In this randomized cross-over clinical trial, 17 uncooperative children requiring at least two dental treatments were selected and randomly received ketamine (0.5mg/kg) or midazolam (0.2mg/kg) prior to treatment. The other medication was used in the next visit. The children’s behavioral pattern was determined according to the Houpt's scale regarding sleep, movement, crying and overall behavior. Physiological parameters were also measured at different time intervals. The data were subjected to Wilcoxon Signed Rank test and two-way repeated measures ANOVA.
Results: The frequency of crying decreased significantly following ketamine administration compared to midazolam (P=0.002); movement of children decreased with fewer incidence of treatment interruption (P=0.001) while their sleepiness increased (P=0.003). Despite higher success of sedation with ketamine compared to midazolam, no significant differences were found between the two regarding patients’ overall behavior (P>0.05). The patients had higher heart rate and blood pressure with ketamine; however, no significant difference was found regarding respiratory rate and oxygen saturation (P>0.05).
Conclusions: Ketamine (0.5mg/kg) led to fewer movements, less crying and more sleepiness compared to midazolam (0.2mg/kg). No significant differences were found between the two drugs regarding children’s overall behavior and sedation efficiency. Both drugs demonstrated positive efficacy for sedation of children during dental treatments.
- Kazemi AP, Kamalaipour H, Seddighi M. Comparison of intranasal midazolam versus ketamine as premedication in 2-5 years old pediatric surgery patients. Pak J Med Sci 2005;21(4):460-4.
- Weissman C. The metabolic response to stress: an overview and update. Anesthesiology. 1990 Aug;73 (2):308-27.
- Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: Assessment and nonpharmacological management. Int J Pediatr. 2010;2010. pii: 474838.
- Wong C, Lau E, Palozzi L, Campbell F. Pain management in children: Part 1 – Pain assessment tools and a brief review of nonpharmacological and pharmacological treatment options. Can Pharm J (Ott). 2012 Sep;145(5):222-5.
- Kogan A, Katz J, Efrat R, Eidelman LA. Premedication with midazolam in young children: a comparison of four routes of administration. Paediatr Anaesth. 2002 Oct;12(8):685-9.
- Louon A, Reddy VG. Nasal midazolam and ketamine for pediatric sedation during computerized tomography. Acta Anaesthesiol Scand. 1994 Apr;38 (3):259-61.
- Warrington SE, Kuhn RJ. Use of intranasal medications in pediatric patients. Orthopedics. 2011 Jun;34(6):456.
- Tyagi P, Tyagi S, Jain A. Sedative effects of oral midazolam, intravenous midazolam and oral diazepam in the dental treatment of children. J Clin Pediatr Dent. 2013 Spring;37(3):301-5.
- Lokken P, Backstad OJ, Fonnelop E, Skogedal N, Hellsten K, Bjerkelund CE, et al. Conscious sedation by rectal administration of midazolam or midazolam plus ketamine as alternative to general anesthesia for dental treatment of uncooperative children. Scand J Dent Res. 1994 Oct;102(5):274-80.
- Mathai A, Nazareth M, Raju RS. Preanesthetic sedation of preschool children: comparison of intranasal midazolam versus oral promethazine. Anesth Essays Res. 2011 Jan-Jun;5(1):67-71.
- Damle SG, Gandhi M, Laheri V. Comparison of oral ketamine and oral midazolam as sedative agents in pediatric dentistry. J Indian Soc Pedod Prev Dent. 2008 Sep;26(3):97-101.
- Alfonzo-Echeverri EC, Berg JH, Wild TW, Glass NL. Oral ketamine for pediatric outpatient dental surgery sedation. Pediatr Dent. 1993 May-Jun;15(3): 182-5.
- Rita L, Cox JM, Seleny FL, Tolentino RL. Ketamine hydrochloride for pediatric premedication. I. Comparison to pentazocine. Anesth Analg. 1974 May-Jun;53(3):375-9.
- Abrams R, Morrison JE, Villasenor A, Hencmann D, Da Fonseca M, Mueller W. Safety and effectiveness of intranasal administration of sedative medications (ketamine, midazolam, or sufentanil) for urgent brief pediatric dental procedures. Anesth Prog. 1993;40(3):63-6.
- Fukuta O, Bahram RL, Yanase H, Atsumi N, Kurosu K. The sedative effect of intranasal midazolam administration in the dental treatment of patients with mental disabilities. Part1. The effect of a 0.2 mg/kg dose. J Clin Pediatr Dent. 1993;17(4): 231-7.
- Fukuta O, Braham RL, Yanase H, Kurosu K. Intranasal administration of midazolam: pharmacokinetic and pharmacodynamic properties and sedative potential. ASDC J Dent Child. 1997 Mar-Apr;64(2):89-98.
- Frankl SL, Shiere FR, Fogels HR. Should the parents remain with the child in the dental operatory? J Dent Child. 1962 Apr;29(2):150-62.
- Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006 Dec;118(6):2587-602.
- Houpt MI, Weiss NJ, Koenigsberg SR, Desjardins PJ. Comparison of chloral hydrate with and without promethazine in the sedation of young children. Pediatr Dent. 1985 Mar;7(1):41-6.
- Savage GH. Insanity following the use of anesthetics in operations. BMJ 1887 Dec;2(1405): 1199.
- Lam C, Udin RD, Malamed SF, Good DL, Forrest JL. Midazolam premedication in children: A pilot study comparing intramuscular and intranasal administration. Anesth Prog. 2005 Summer;52(2):56-61.
- Cote CJ. Preoperative preparation and premedication. Br J Anaesth. 1999 Jul;83(1):16-28.
- Malinovsky JM, Populaire C, Cozian A, Lepage JY, Lejus C, Pinaud M. Midazolam for premedication in children. Effect of intranasal, rectal and oral routes on plasma concentration. Anaesthesia. 1995 Apr;50 (4):351-4.
- Chakoshi AA, Patel VR, Chauhan PR, Patel DJ, Chandha IA, Ramani MN. Evaluation of intranasal midazolam spary as a sedative in pediatric patients for radiological imaging procedures. Anesth Essays Res. 2013 May-Aug;7(2):189-93.
- Hosseini Jahromi SA, Hosseini Valami SM, Adeli N, Yazdi Z. Comparison of the effects of intranasal midazolam versus different doses of intranasal ketamine on reducing preoperative pediatric anxiety: a prospective randomized clinical trial. J Anesth 2012 Dec;26(6):878-82.
- Ozen B, Malamed SF, Cetiner S, Ozalp N, Ozer L, Altun C. Outcomes of moderate sedation in pediatric dental patients. Aust Dent J. 2012 Jun;57(2): 144-50.
- Lightdale JR, Mitchell PD, Fredette ME, Mahoney LB, Zgleszewski SE, Scharff L, et al. A pilot study of ketamine versus midazolam/fentanyl sedation in children undergoing GI endoscopy. Int J Pediatr. 2011;2011:623710.
- Singh N, Pandey RK, Saksena AK, Jaiswal JN. A comparative evaluation of oral midazolam with other sedatives as premedication in pediatric dentistry. J Clin Pediatr Dent. 2002 Winter;26(2):161-4.
- Bahetwar SK, Pandey RK, Saksena AK, Chandra G. A comparative evaluation of intranasal midazolam, ketamine and their combination for sedation of young uncooperative pediatric dental patients: a triple blind randomized crossover trial. J Clin Pediatr Dent. 2011 Summer;35(4):415-20.
- Ljungman G, Kreuger A, Andreasson S, Gordh T, Sorensen S. Midazolam nasal spray reduces procedural anxiety in children. Pediatrics. 2000 Jan;105(1 Pt 1):73-8.
- Holloway VJ, Husain HM, Saetta JP, Gautam V. Accident and emergency department led implementation of ketamine sedation in pediatric practice and parental response. J Accid Emerg Med. 2000 Jan;17(1):25-8.
- Reinemer HC, Wilson CF, Webb MD.A comparison of two oral ketamine-diazepam regimens for sedating anxious pediatric dental patients. Pediatr Dent. 1996 Jul-Aug;18(4):294-300.
- Tanaka M, Sato M, Saito A, Nishikawa T. Reevaluation of rectal ketamine premedication in children, comparison with rectal midazolam. Anesthesiology. 2000 Nov;93(5):1217-24.