Comparative acceptability and immediate behavioral response to different pediatric premedications: A systematic review and network meta-analysis - 10/12/25
Abstract |
Study objective |
To compare the acceptability and immediate behavioral response of different premedications, considering routes and formulations.
Design |
Systematic review and Bayesian network meta-analysis of randomized controlled trials
Setting |
Elective procedures involving pediatric patients undergoing general anesthesia or sedation
Patients |
Children aged 1–12 years, classified as ASA physical status I–III, receiving premedication with midazolam, dexmedetomidine, clonidine, ketamine, or related agents.
Measurements |
Two separate Bayesian network meta-analyses were performed. The first evaluated premedication acceptability (the child's willingness to take the drug), and the second assessed the immediate behavioral response after administration. Each intervention was classified by drug, formulation, and route of administration. Outcomes were ranked using SUCRA values. Risk of bias, node-splitting, and model diagnostics were assessed to evaluate robustness and consistency
Main results |
Twenty-four trials comprising 1858 patients were included in the quantitative synthesis. Both oral midazolam in commercial syrup and oral midazolam using the intravenous formulation mixed with syrup showed the highest acceptability. Interventions with low acceptability included nebulized ketamine, midazolam, and dexmedetomidine. For immediate behavioral response, the most favorable responses were observed with oral or intranasal clonidine, followed by oral midazolam mixed with syrup. Intranasal midazolam consistently showed the poorest behavioral response among all interventions. Commercial midazolam syrup could not be analyzed.
Conclusions |
Syrup-based oral midazolam offers a favorable balance between acceptability and behavioral response, making it a practical option for pediatric premedication. Intranasal clonidine and dexmedetomidine demonstrated moderate behavioral performance, with dexmedetomidine also showing moderate acceptability. In contrast, nebulized formulations were poorly accepted, and intranasal midazolam, despite good acceptability, was poorly tolerated. These findings provide comparative evidence on acceptability and tolerability, which should be integrated with existing evidence on efficacy and safety when selecting premedication strategies in pediatric anesthesia.
Registration |
PROSPERO ID: CRD420251048872.
Le texte complet de cet article est disponible en PDF.Highlights |
• | Syrup-based oral midazolam showed the best acceptability and good behavior. |
• | Intranasal midazolam had good acceptance but poor behavioral tolerability. |
• | Clonidine yielded the most favorable behavioral responses across all agents. |
• | Nebulized premedications showed the lowest levels of acceptability. |
• | Flavoring and formulation significantly influenced premedication outcomes. |
Keywords : Pediatric anesthesia, Premedication, Midazolam, Clonidine, Dexmedetomidine, Network meta-analysis, Behavioral response, Acceptability
Plan
Vol 108
Article 112077- janvier 2026 Retour au numéro
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