BNF for Children 2011-2012

638 15.1.4 Sedative and analgesic peri-operative drugs BNFC 2011–201215 Anaesthesialytic and sedative effects last about 90 minutes, althoughthere may be residual drowsiness. Temazepam is rarelyused for dental procedures in children.Lorazepam produces more prolonged sedation thantemazepam and it has marked amnesic effects.Peri-operative use of diazepam is not recommended inchildren; onset and magnitude of response are unreliable,and paradoxical effects may occur. Diazepam isnot used for dental procedures in children.LORAZEPAMCautions see notes above and section 4.8.2; interactions:Appendix 1 (anxiolytics and hypnotics)Contra-indications see Diazepam, section 4.8.2Hepatic impairment see Benzodiazepines, section4.8.1Renal impairment see Benzodiazepines, section 4.8.1Pregnancy see Benzodiazepines, section 4.8.1Breast-feeding see Benzodiazepines, section 4.8.1Side-effects see notes above and Diazepam, section4.8.2Licensed use not licensed for use in children under 5years by mouth; not licensed for use in childrenunder 12 years by intravenous injectionIndication and dosePremedication. By mouthChild 1 month–12 years 50–100 micrograms/kg(max. 4 mg) at least 1 hour before procedureChild 12–18 years 1–4 mg at least 1 hour beforeprocedureNote Same dose may be given the night before procedurein addition to, or to replace, dose before procedure. By intravenous injectionChild 1 month–18 years 50–100 micrograms/kg(max. 4 mg)Note Give intravenous injection 30–45 minutes beforeprocedureStatus epilepticus section 4.8.2Administration for intravenous injection, diluteinjection solution with an equal volume of SodiumChloride 0.9%; give over 3–5 minutes; max. rate50 micrograms/kg over 3 minutesLorazepam (Non-proprietary) KTablets, lorazepam 1 mg, net price 28-tab pack =£5.42; 2.5 mg, 28-tab pack = £7.11. Label: 2 or 19Injection, lorazepam 4 mg/mL, net price 1-mL amp =35pExcipients include benzyl alcohol (avoid in neonates unless there is nosafer alternative available, see Excipients, p. 2), propylene glycolBrands include Ativan cExtemporaneous formulations available seeExtemporaneous Preparations, p. 6MIDAZOLAMCautions see notes above; cardiac disease; respiratorydisease; myasthenia gravis; neonates; history of drugor alcohol abuse; reduce dose if debilitated; risk ofsevere hypotension in children with hypovolaemia,vasoconstriction, hypothermia; avoid prolongeduse (and abrupt withdrawal thereafter); interactions:Appendix 1 (anxiolytics and hypnotics)Contra-indications marked neuromuscular respiratoryweakness including unstable myasthenia gravis;severe respiratory depression; acute pulmonaryinsufficiencyHepatic impairment use with caution; can precipitatecomaRenal impairment start with small doses in severeimpairment; increased cerebral sensitivityPregnancy avoid regular use (risk of neonatal withdrawalsymptoms); use only if clear indication such asseizure control (high doses during late pregnancy orlabour may cause neonatal hypothermia, hypotonia,and respiratory depression)Breast-feeding present in milk—avoid breast-feedingfor 24 hours after administrationSide-effects see notes above; gastro-intestinal disturbances,increased appetite, jaundice; hypotension,cardiac arrest, heart rate changes, anaphylaxis,thrombosis; laryngospasm, bronchospasm, respiratorydepression and respiratory arrest (particularlywith high doses or on rapid injection); drowsiness,confusion, ataxia, amnesia, headache, euphoria, hallucinations,convulsions (more common in neonates),fatigue, dizziness, vertigo, involuntary movements,paradoxical excitement and aggression, dysarthria;urinary retention, incontinence; blood disorders;muscle weakness; visual disturbances; salivationchanges; skin reactions; injection-site reactions; withintranasal administration burning sensation, lacrimation,and severe irritation of nasal mucosaLicensed use not licensed for use in children under 6months for premedication and conscious sedation;not licensed for use by mouth, or by buccaladministrationIndication and doseConscious sedation for procedures (but see notesabove). By mouthChild 1 month–18 years 500 micrograms/kg(max. 20 mg) 30–60 minutes before procedure. By buccal administrationChild 6 months–10 years 200–300 micrograms/kg (max. 5 mg)Child 10–18 years 6–7 mg (max. 8 mg if 70 kg orover). By rectumChild 6 months–12 years 300–500 micrograms/kg 15–30 minutes before procedure. By intravenous injection over 2–3 minutes 5–10 minutes before procedureChild 1 month–6 years initially 25–50 micrograms/kg,increased if necessary in small steps(max. total dose 6 mg)Child 6–12 years initially 25–50 micrograms/kg,increased if necessary in small steps (max. totaldose 10 mg)Child 12–18 years initially 25–50 micrograms/kg, increased if necessary in small steps (max. totaldose 7.5 mg)