Incidence and predictors of nonresponse to intranasal midazolam in children undergoing laceration repair.

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Pediatric laceration repairs are common in the emergency department (ED) and often associated with significant procedural anxiety. Despite the increased use of intranasal midazolam (INM) prior to pediatric ED procedures, there is limited, real-world data on the effects of INM on anxiety. This study aimed to describe the proportion of children who were nonresponsive to INM (i.e., exhibited extreme anxiety) and identify factors associated with INM nonresponse. This cross-sectional study included a sample of 102 children (ages 2-10 years) who received 0.2 mg/kg INM prior to laceration repair in the ED. Procedural anxiety was assessed using the modified Yale Preoperative Anxiety Scale (mYPAS). Children exhibiting extreme procedural anxiety (mYPAS score ≥72.91) when procedure started were labeled as INM nonresponders. Bivariate and multivariable logistic regression analyses explored associations between child age, temperament, laceration location, time from INM administration, and likelihood of INM nonresponse. In this sample, 45.1% of the children were classified as INM nonresponders, exhibiting extreme procedural anxiety. Bivariate analyses indicated that nonresponders were younger, had lower sociability temperament, longer delay between INM administration and the procedure, and were more likely to have extremity lacerations. In the logistic regression, younger age (odds ratio [OR] 0.79, p = 0.034), lower sociability temperament (OR 0.28, p = 0.002), and extremity lacerations (OR 8.04, p = 0.009) were significantly associated with likelihood of INM nonresponse. Nearly half of the children in our sample exhibited extreme procedural anxiety despite receiving INM. The high incidence of nonresponse to INM has important clinical practice implications and suggests that 0.2 mg/kg INM alone may not be sufficient to manage all pediatric procedural anxiety in the ED. Findings highlight a need for further research examining multimodal strategies to manage procedural anxiety in the pediatric ED, particularly for younger children with low sociability temperament or extremity lacerations.