Can oral midazolam provide relief of discomfort oranalgesia?

To the Editor:We read with interest the study by McErlean et al,1

‘‘The use of midazolam syrup as a premedication to reduce thediscomfort associated with pediatric intravenous catheterinsertion,’’ and the editorial by Drs Berde and Wolfe.2

Respectfully, we have concerns regarding that report.We think the title and the substance of the study gives

readers a misconception in regard to midazolam, which hasbeen represented in the article as reducing discomfort associ-ated with intravenous catheter insertion in the emergency de-partment. We want to emphasize that anxiolysis and analgesiaare two different modalities. Although discomfort is behav-iorally indistinguishable from pain and anxiety, discomfortassociated with venipuncture is, in fact, pain associated with aninvasive procedure. Pediatric patients are understandably ap-prehensive when undergoing painful procedures. Fear of theprocedure, anticipation of an injection, and the strangeness ofthe hospital environment can all create a significant levelof anxiety, which may render simple procedures challengingand unfeasible. Benzodiazepines are the most widely usedmedications for the relief of anxiety. Traditionally, oral or in-travenous diazepam has been used as a perioperative anxiolytic.Short-acting midazolam offers hypnotic, anxiolytic, sedative,and anterograde amnestic properties.3 Its mechanism of actionismediated by binding withGABA receptors in the subcorticallimbic system and preventing neuronal depolarization. Becausemidazolam is lipophylic at PH above 4, it is rapidly absorbedand has rapid onset. It is also rapidly metabolized and elimi-nated.4 It is our practice at Arkansas Children’s Hospital to usemidazolam for anxiolysis supplemented by a topical local an-esthetic to minimize the pain associated with intravenouscatheter insertion. Although our effort is to maximize patientcomfort associated with intravenous catheter insertion, thereis no such thing as ‘‘pain-free’’ or ‘‘ouchless’’ venipuncture.Products available for topical application include EMLAand ELA-Max creams.5-9 Other modalities available includecognitive and behavioral interventions deemed appropriatefor the patient’s age, tolerance, and previous experiencewith pain management, psychosocial support, and otherfactors.10-14

The editorial2 is an excellent overview on this subject,but we believe a clear distinction between anxiolysis andanalgesia is needed.

288 Letters

Shahid Hussain, MD, FAAPM. Saif Siddiqui, MD

James F. Mayhew, MD, FAAPDepartment of AnesthesiologyArkansas Children’s Hospital

University of Arkansas for Medical SciencesLittle Rock, AR 72202

YMPD63910.1016/j.jpeds.2003.11.016

REFERENCES1. McErlean M, Bartfield JM, Karunakar TA, Whitman MCW,

TurleyDM.Midazolamsyrupas apremedication to reduce thediscomfort asso-

ciatedwith pediatric intravenous catheter insertion. J Pediatr 2003;142:429-30.

2. Berde Charles, Wolfe Joanne. Pain, anxiety, distress and suffering:

interrelated but not interchangeable. J Pediatr 2003;142:361-3.

3. Smith BM, Cutilli BJ, Saunders W. Oral midazolam: pediatric

conscious sedation. Compend Contin Educ Dent 1998;19:586-8, 590, 592.

4. Marshall J, Rodarte A, Blumer J, Khoo KC, Akbari B, Kearns G.

Pediatric pharmacodynamics of midazolam oral syrup: Pediatric Pharmacol-

ogy Research Unit Network. J Clin Pharmacol 2000;40:578-89.

5. Kleiber C, SorensonM,Whiteside K, Gronstal BA, Tannous R. Topical

anesthetics for intravenous insertion in children: a randomized equivalency

study. Pediatrics 2002;110:758-61.

6. Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB. A

clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as

compared with eutectic mixture of local anesthetics cream for pain reduction

of venipuncture in children. Pediatrics 2002;109:1093-9.

7. Carceles MD, Alsonso JM, Garciaj-Munoz M, Najera MD, Castano I,

Vila N. Amethocaine-lidocaine cream, a new topical formulation for pre-

venting venopuncture-induced pain in children. Reg Anesth Pain Med 2002;

27:289-95.

8. Fetzer SJ. Reducing venipuncture and intravenous insertion painwith eu-

tectic mixture of local anesthetic: a meta-analysis. Nurs Res 2002;51:119-24.

9. Galinkin JL, Rose JB, Harris K, Watcha MF. Lidocaine iontophoresis

versus eutectic mixture of local anesthetics (EMLA) for IV placement in

children. Anesth Analg 2002;94:1484-8.

10. Jay SM, Elliott CH, Fitzgibbons I, Woody P, Siegel SE. A

comparative study of cognitive behavior therapy versus general anesthesia

for painful medical procedures in children. Pain 1995;62:3-9.

11. Jay SM, Elliott CH, Katz E, Siegel SE. Cognitive-behavioral and

pharmacologic interventions for children’s distress during painful medical

procedures. J Consult Clin Psychol 1987;55:860-5.

12. French GM, Painter EC, Coury DL. Blowing away shot pain: a tech-

nique for pain management during immunization. Pediatrics 1994;93:384-8.

13. Krauss B. Managing acute pain and anxiety in children undergoing

procedures in the emergency department. Emerg Med (Fremantle) 2001;

13:293-304.

14. Kohen DP, Olness KN, Colwell SO, Heimel A. The use of relaxation-

mental imagery (self-hypnosis) in the management of 505 pediatric behavioral

encounters. J Dev Behav Pediatr 1984;5:21-5.

The Journal of Pediatrics � February 2004