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Meta-Analysis
. 2017 Jan 31;1(1):CD002052.
doi: 10.1002/14651858.CD002052.pub3.

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit

Eugene Ng  1 , Anna Taddio  2 , Arne Ohlsson  3
Affiliations
Meta-Analysis

Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit

Eugene Ng et al. Cochrane Database Syst Rev. .

Abstract

Background: Proper sedation for neonates undergoing uncomfortable procedures may reduce stress and avoid complications. Midazolam is a short-acting benzodiazepine that is used increasingly in neonatal intensive care units (NICUs). However, its effectiveness as a sedative in neonates has not been systematically evaluated.

Objectives: Primary objeciveTo assess the effectiveness of intravenous midazolam infusion for sedation, as evaluated by behavioural and/or physiological measurements of sedation levels, in critically ill neonates in the NICU. Secondary objectivesTo assess effects of intravenous midazolam infusion for sedation on complications including the following.1. Incidence of intraventricular haemorrhage (IVH)/periventricular leukomalacia (PVL).2. Mortality.3. Occurrence of adverse effects associated with the use of midazolam (hypotension, neurological abnormalities).4. Days of ventilation.5. Days of supplemental oxygen.6. Incidence of pneumothorax.7. Length of NICU stay (days).8. Long-term neurodevelopmental outcomes.

Selection criteria: We selected for review randomised and quasi-randomised controlled trials of intravenous midazolam infusion for sedation in infants aged 28 days or younger.

Data collection and analysis: We abstracted data regarding the primary outcome of level of sedation. We assessed secondary outcomes such as intraventricular haemorrhage, periventricular leukomalacia, death, length of NICU stay and adverse effects associated with midazolam. When appropriate, we performed meta-analyses using risk ratios (RRs) and risk differences (RDs), and if the RD was statistically significant, we calculated the number needed to treat for an additional beneficial outcome (NNTB) or an additional harmful outcome (NNTH), along with their 95% confidence intervals (95% CIs) for categorical variables, and weighted mean differences (WMDs) for continuous variables. We assessed heterogeneity by performing the I-squared (I2) test.

Main results: We included in the review three trials enrolling 148 neonates. We identified no new trials for this update. Using different sedation scales, each study showed a statistically significantly higher sedation level in the midazolam group compared with the placebo group. However, none of the sedation scales used have been validated in preterm infants; therefore, we could not ascertain the effectiveness of midazolam in this population. Duration of NICU stay was significantly longer in the midazolam group than in the placebo group (WMD 5.4 days, 95% CI 0.40 to 10.5; I2 = 0%; two studies, 89 infants). One study (43 infants) reported significantly lower Premature Infant Pain Profile (PIPP) scores during midazolam infusion than during dextrose (placebo) infusion (MD -3.80, 95% CI -5.93 to -1.67). Another study (46 infants) observed a higher incidence of adverse neurological events at 28 days' postnatal age (death, grade III or IV IVH or PVL) in the midazolam group compared with the morphine group (RR 7.64, 95% CI 1.02 to 57.21; RD 0.28, 95% CI 0.07 to 0.49; NNTH 4, 95% CI 2 to 14) (tests for heterogeneity not applicable). We considered these trials to be of moderate quality according to GRADE assessment based on the following outcomes: mortality during hospital stay, length of NICU stay, adequacy of analgesia according to PIPP scores and poor neurological outcomes by 28 days' postnatal age.

Authors' conclusions: Data are insufficient to promote the use of intravenous midazolam infusion as a sedative for neonates undergoing intensive care. This review raises concerns about the safety of midazolam in neonates. Further research on the effectiveness and safety of midazolam in neonates is needed.

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Conflict of interest statement

E Ng ‐ no conflicts of interest to declare.

A Taddio ‐ no conflicts of interest to declare.

A Ohlsson ‐ no conflicts of interest to declare.

Figures

1
1
Study flow diagram: review update.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Midazolam versus placebo, outcome: 1.6 Length of NICU stay (days).
5
5
Forest plot of comparison: 1 Midazolam versus placebo, outcome: 1.9 PIPP score during drug infusion.
6
6
Forest plot of comparison: 2 Midazolam versus morphine, outcome: 2.2 Poor neurological outcome up to 28 days' postnatal age.
1.1
1.1. Analysis
Comparison 1 Midazolam versus placebo, Outcome 1 Intraventricular haemorrhage (any grade).
1.2
1.2. Analysis
Comparison 1 Midazolam versus placebo, Outcome 2 Mortality.
1.3
1.3. Analysis
Comparison 1 Midazolam versus placebo, Outcome 3 Days of ventilation.
1.4
1.4. Analysis
Comparison 1 Midazolam versus placebo, Outcome 4 Days of supplemental oxygen use.
1.5
1.5. Analysis
Comparison 1 Midazolam versus placebo, Outcome 5 Pneumothorax.
1.6
1.6. Analysis
Comparison 1 Midazolam versus placebo, Outcome 6 Length of NICU stay (days).
1.7
1.7. Analysis
Comparison 1 Midazolam versus placebo, Outcome 7 Average NAPI scores at 36 weeks' PMA.
1.8
1.8. Analysis
Comparison 1 Midazolam versus placebo, Outcome 8 Poor neurological outcome by 28 days' postnatal age.
1.9
1.9. Analysis
Comparison 1 Midazolam versus placebo, Outcome 9 PIPP score during drug infusion.
2.1
2.1. Analysis
Comparison 2 Midazolam versus morphine, Outcome 1 PIPP score during drug infusion.
2.2
2.2. Analysis
Comparison 2 Midazolam versus morphine, Outcome 2 Poor neurological outcome up to 28 days' postnatal age.
See this image and copyright information in PMC

Update of

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