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Intranasal Midazolam Uncooperative Child — FRCA Final MCQ

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ModeratePaediatric AnaesthesiaIntranasal Midazolam Uncooperative ChildFRCA Final

A 5-year-old boy (20 kg) with autism spectrum disorder requires dental extractions. He is extremely distressed and will not allow IV cannulation, mask application, or oral premedication. He is accompanied by his parents. What is the most appropriate initial approach?

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Correct answer: A — Intranasal midazolam 0.2-0.5 mg/kg as premedication

Intranasal midazolam (0.2-0.5 mg/kg, maximum 10 mg) is an effective non-invasive premedication for uncooperative children who will not accept oral, IV, or inhalational routes. It provides anxiolysis and sedation within 10-15 minutes via nasal mucosal absorption, often enabling cooperative induction (IV or inhalational). Intranasal dexmedetomidine (2-4 mcg/kg) is an alternative. If intranasal premedication fails, IM ketamine may be used as a rescue technique. Physical restraint for IV cannulation should be avoided unless medically essential and all alternatives have been exhausted. ASD-specific considerations include: minimal sensory stimulation, familiar objects, and parental presence.

Reference: APA – 2019 – Premedication in children; RCOA – 2023 – Paediatric anaesthesia for children with ASD