Premedication in children: does taste matter?

Abstract

Sedative premedication is commonly prescribed for anxious, non-compliant children, those who have been distressed previously, and those with learning disabilities or behavioural issues. In addition, the type of procedure and its likely duration may influence the choice of sedative. The aims of premedication in children include: allaying their anxiety; allowing easy separation from their parent or carer; facilitation of a smooth anaesthetic induction; and a reduction in postoperative psychological problems. The ideal sedative premedication should be safe and easy to administer, have a predictable onset time, a high success rate and minimal side-effects.Administration of an oral formulation is usually preferred because it is most likely to be tolerated, yet there is currently no ideal sedative premedicant available. Most drugs are developed and marketed for adults, but their pharmacokinetic and pharmacodynamic information are not directly translatable to the paediatric population. Children form a heterogeneous group that requires special attention when developing a new drug [1]. In developing such formulations the intended recipients include children of different ages and at different developmental stages, as well as those with special needs and neurodevelopmental disorders. Factors to consider in the development of an oral paediatric drug formulation include smaller and variable dose requirements depending on the patient's age and size, a formulation that allows accurate dosing, is palatable and acceptable to young children, easy to swallow and relatively cheap to manufacture. Midazolam Midazolam is the most commonly prescribed preoperative sedative in paediatric anaesthesia practice [2, 3]. It is usually prescribed in an oral dose of 0.5 mg.kg À1 and has been shown to be an effective anxiolytic [4], whereby patients usually appear relaxed and quiet, allowing easy separation from parents. This should allow smooth induction of anaesthesia and alleviate stress for children and parents as well as the anaesthesia team.However, less than 20% of children appear adequately sedated at this dose [5] and although increasing the dose to 0.75 mg.kg À1 or even 1 mg.kg À1 provides sedation in more children [6], this is at the expense of increased side-effects, including loss of balance and head control, blurred vision, dysphoric reactions [7] and delayed emergence from anaesthesia. Although the anterograde amnesic property of midazolam is promoted as an important advantage compared with other sedatives, there is concern regarding its association with implicit memory in children [8]. Implicit memory is defined as the preservation of unpleasant emotions or anxiety associated with an event, although this cannot be recalled consciously. The association between midazolam and implicit memory is thought to be a cause of distress at subsequent medical encounters in children who have previously been treated with midazolam [8] and could lead to paradoxical anxiety which in turn results in an increase in the incidence of emergence agitati...

Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine

“…This contrasts with our findings that both drugs had a similar rejection rate 8,14 . Flavored preparations of the drugs might be used to increase compliance for the oral premedications 31 …”

Added Syrup as a Flavoring to Oral Midazolam Intravenous Solution Premedication Improves Tolerability in Pediatric Patients

“…Flavored preparation of midazolam—such as the midazolam hydrochloride syrup used in the United Kingdom 8 and chocolate-flavored midazolam tablet in Australia—helps increase compliance with its oral premedication. 13 Unfortunately, only the IV midazolam formulation is currently available in China.…”

“…5–7 In the United Kingdom, midazolam hydrochloride syrup is dispensed at a 2 mg/mL concentration. 8 This oral formula is not available in China, and the midazolam intravenous (IV) formulation—a bitter-tasting drug—is used for oral administration in our institution. Because children are naturally fond of sugar, and because syrup is commercially available in China, we aimed to assess whether syrup added as a flavoring to oral IV midazolam could improve its tolerability in clinical administration.…”

Parents’ Perspectives Towards Novel Paediatric Medication Formulations: A Qualitative Study

“…6 However, the bitter taste of this medication often results in poor tolerance in young children and adolescents. 7 Therefore, attempts to mask this medication have been made, such as the formulation of oral midazolam syrups, albeit to no avail. 8 However, a clinical trial involving paediatric patients and their carers 8 , have demonstrated the e cacy of the novel chocolate delivery platform to mask the bitter taste of midazolam.…”