Remembering the classics: midazolam v parental presence in the OR

Robert H. Friesen MD

I’ve asked my good friend Rob Friesen to join us a regular contributor to the PAAD.  For those unfortunate few of you who don’t know him, Rob played a pivotal and pioneering role in the development of pediatric and congenital cardiac anesthesiology. His transformative research included the study of the hemodynamic effects of inhalational and intravenous anesthetic agents in the newborn and the effects of anesthetic agents on pulmonary vascular resistance in patients with pulmonary hypertension. And all of us owe him thanks…He pioneered the use of automated non-invasive blood pressure devices in pediatric anesthetic practice! Without his efforts, we  might still be using manual sphygmomanometry! A Robert M. Smith award winner, a profile of Rob’s career and many contributions was published in Pediatric Anesthesiology.1

Myron Yaster MD

Managing Preoperative Anxiety in Children

Robert H. Friesen MD

Original article:

Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication. Anesthesiology 1998;89:1147-56  PMID: 9822003

It is well known that aspects of the perioperative period—especially the preoperative events of separation from parents and anesthetic induction--are associated with significant anxiety for young children. Pediatric anesthesiologists through the decades have attempted to allay this anxiety by various means, often with success.

Some methods involve distraction techniques, such as storytelling or magic tricks. The late great Chris Abajian was a master magician who perfected his art to great acclaim and enjoyment.

Mostly we have relied on pharmacologic interventions to achieve sedation, thus decreasing the child’s awareness of preoperative events. For several decades, this was achieved with intramuscular injections of a variety of sedatives (e,g, morphine/scopolamine and others). While often effective, treating anxiety by giving the child a jab with a needle seemed somehow to be counter-productive!

A needle-less alternative used for a while was rectal administration of sedatives (e.g barbiturates, chloral hydrate, and later midazolam).2-4 These generally worked, but due to the slow uptake and distribution of drugs through the rectal mucosa, large doses and a lot of time were required to achieve inconsistent results.

The development of midazolam provided an attractive drug for pharmacologic premedication. While it can be administered rectally (slower onset)4 and intranasally (unpleasant)5,6, midazolam given orally provides effective, predictable, and reasonably rapid anxiolytic sedation.7,8 This method has superseded all others for preoperative sedation of children.

Alternatively, parental presence during induction of anesthesia is an appealing non-pharmacologic approach to the problem. It eliminates one of the major sources (separation from parents) of anxiety to the child. During the past couple of decades, parental presence has been incorporated into the preoperative routine of many, if not most, pediatric anesthesia centers and seems to be very popular with parents of children undergoing anesthesia and surgery.

Enter SARS-CoV-2. The pandemic has forced a reappraisal of the presence and movement of non-essential personnel in hospitals, resulting in widespread suspension of protocols for parental presence during anesthetic induction. Does this mean that we have returned to the bad old days of frightened children in the operating room?

Fortunately, this 23-year-old article by Zeev Kain provides some guidance. In this study, children were randomly assigned to one of three groups: 1) oral midazolam premedication, 2) parental presence during induction, or 3) control (neither premedication nor parental presence). At several times during the perioperative period, anxiety in both children and parents was assessed with multiple behavioral measures. It turned out that children in the midazolam group experienced significantly less anxiety and greater compliance during induction than children in the other groups. Furthermore, parental anxiety was significantly less in the midazolam group than in the others. Oral midazolam was superior to parental presence during induction of anesthesia. The lesson here is that when we are forced to suspend a popular program designed to reduce the anxiety surrounding induction of anesthesia in children, we can look back a couple of decades to find something that works even better.


1.          Twite MD, Ing RJ, Nichols CS, Yaster M: Outstanding contribution to pediatric anesthesiology: An interview with Dr. Robert H. Friesen. Paediatr Anaesth 2017; 27: 991-996

2.          Liu LM, Goudsouzian NG, Liu PL: Rectal methohexital premedication in children, a dose-comparison study. Anesthesiology 1980; 53: 343-345

3.          Liu LM, Gaudreault P, Friedman PA, Goudsouzian NG, Liu PL: Methohexital plasma concentrations in children following rectal administration. Anesthesiology 1985; 62: 567-570

4.          Spear RM, Yaster M, Berkowitz ID, Maxwell LG, Bender KS, Naclerio R, Manolio TA, Nichols DG: Preinduction of anesthesia in children with rectally administered midazolam. Anesthesiology 1991; 74: 670-674

5.          Davis PJ, Tome JA, McGowan FX, Jr., Cohen IT, Latta K, Felder H: Preanesthetic medication with intranasal midazolam for brief pediatric surgical procedures. Effect on recovery and hospital discharge times [see comments]. Anesthesiology 1995; 82: 2-5

6.          Malinovsky JM, Populaire C, Cozian A, Lepage JY, Lejus C, Pinaud M: Premedication with midazolam in children. Effect of intranasal, rectal and oral routes on plasma midazolam concentrations. Anaesthesia 1995; 50: 351-354

7.          Vetter TR: A comparison of midazolam, diazepam, and placebo as oral anesthetic premedicants in younger children. J Clin Anesth 1993; 5: 58-61

8.          Brosius KK, Bannister CF: Midazolam premedication in children: a comparison of two oral dosage formulations on sedation score and plasma midazolam levels. Anesth Analg 2003; 96: 392-5, table of contents