It is not routine practice to administer oral sedatives for surgical procedures. Children’s behavior patterns vary and it is essential to do a behavioral assessment prior to the procedure. It is good practice to discuss this with the parent or guardian before sedation, as they usually can give the sedation practitioner guidance as to whether the child needs an oral sedative before surgery. Some children are, however, just too frightened due to previous traumatic experiences, and may thus need a sedative. An oral sedative must never be given to the child at home but in the facility where the procedure will be done.

Chloral hydrate is a sedative hypnotic still being used in some hospitals for sedation for children under the age of 3 years, especially for painless imaging [20]. The drug has no analgesic activities and the usual dose is 20–75 mg/kg, given orally.

Midazolam is a short-acting, water-soluble benzodiazepine with no analgesic properties. It is the most commonly used benzodiazepine for pediatric sedation and can be administered via various routes. The oral dose is 0.35 mg/kg, 20–30 min before surgery [21]. To make it easier to remember, we advise sedation providers to administer 7.5 mg orally to those children above 8 years of age, and 5 mg to those less than 8 years of age. The child must be constantly supervised and monitored after administration of the oral sedative. Midazolam is not available in a syrup formulation in Africa, so instead the tablet is crushed and diluted with paracetamol syrup. Alternatively, the aqueous formulation for intravenous midazolam is administered orally. Midazolam is a useful sedative in combination with other oral drugs.

Oral ketamine provides excellent sedation, analgesia, and amnesia and can also be used for painful procedures. In the developing world, it is usually combined with midazolam. Oral ketamine is useful for burn debridement in children at a dose of 10 mg/kg because of its excellent safety profile [22]. Acceptable sedation for dental procedures was achieved in children, 2–7 years of age, by the use of 12.5 mg/kg oral ketamine. The incidence of hallucinations was 16.6 % [23].

Ketamine administered orally is used extensively for analgesia and sedation during dressing changes in children suffering from burn injuries at the Red Cross War Memorial Children’s hospital in South Africa [24]. A recent study from this institution in children between 1 and 8 years of age suggests that oral ketamine 5–10 mg/kg via a nasogastric tube with intravenous supplementation of 0.5–1 mg/kg provides reasonable sedation and analgesia for short dressing changes. Furthermore, oral ketamine administration results in high norketamine concentrations due to first-pass metabolism in turn contributing to good long-lasting post-procedural analgesia. Oral ketamine may serve as a valuable premedicant, sedative, and analgesic for children suffering from burn injuries.

Intranasal midazolam may be uncomfortable for children as it may cause a burning sensation. It is, however, useful in children who refuse to take medication by mouth, are vomiting, or are developmentally delayed. Although a tuberculin syringe can be used to administer 0.2 mg/kg midazolam intranasally, a Mucosal Atomization Device (MAD®, LMA North America, San Diego, CA) is available and makes nasal administration easier and more acceptable.

Rectal administration of midazolam is useful for providing sedation for younger children (Table 25.3). Acceptance is high, particularly in small children. In some of the countries in Sub-Saharan Africa some parents prefer the rectal route for administration of sedative drugs. The administration of midazolam by this route may be indicated where children refuse to take oral drugs, are nauseous, vomiting, or very anxious. It can be used on its own for painless procedures or in combination with other drugs when analgesia is required. In a study, rectal midazolam administered at 1 mg/kg to children 30 min before dental surgery achieved satisfactory sedation and recovery whilst maintaining hemodynamic stability.

Rectal diazepam is a useful and cost-effective alternative sedative for midazolam, especially in rural areas, where the latter drug is often not available. Rectal diazepam, at a dose of 0.70 mg/kg, provides acceptable levels of sedation, and patient acceptance, when administered 30 min before a procedure [25]. Rectal ketamine at a dose of 5 mg/kg has also successfully been used in dental surgery and may be a useful alternative for pediatric sedation [26].

Any sedation administered by the intravenous route, using bolus or infusion techniques should be considered an advanced sedation technique [15], and should be administered by suitably trained and equipped personnel. Intravenous agents can be used as small boluses titrated to effect or as a continuous infusion. Unadjusted continuous infusion techniques may result in gradually rising plasma concentrations of sedative and necessitate constant intensive monitoring and airway vigilance.

Propofol is a short-acting phenol derivative. Its use as a sedative hypnotic agent outside the operating room remains contentious. Propofol has a narrow therapeutic index and the sedation practitioner should anticipate that deep sedation, airway obstruction, and apnea may occur rapidly and unpredictably. Although it is an effective sedative, it should be used only for brief procedures, as repeated doses or infusions are more likely to be associated with adverse events. The usual sedative dose in children is 0.3–0.5 mg/kg titrated to effect with a titration interval of at least 1 min. Target Controlled Infusion (TCI) of propofol may overcome some of the limitations of continuous infusions [27, 28]. TCI is an infusion controlled by a real-time pharmacokinetic model that employs algorithms to construct a variable rate infusion. (Refer to Chap. 31.) Two algorithms are available in South Africa: the Kataria and Paedfusor models. The Kataria model caters to children over the age of 3, whereas the Paedfusor model may be used in children over a year of age [29, 30]. As the effect site equilibration constant is not known in children, both models only allow use as plasma targeting. Usual plasma targets for sedation are between 0.5 and 2 mcg/mL, but like bolus dosing should be titrated to effect.

Ketamine is probably the most widely used single intravenous sedative in the developing world. Ketamine induces a state of cortical dissociation with profound analgesia, sedation, and amnesia. At typical sedative doses, there is relative preservation of airway reflexes and tone. Emergence delirium is less common in children, and of a much smaller magnitude than adults and it correlates significantly with the degree of pre-procedural agitation. See Table 25.4 for dosing recommendations.

Midazolam is a short-acting benzodiazepine with potent amnestic, sedative, and anxiolytic properties. Paradoxical agitation may occur in up to 1.4 % of children and may necessitate treatment with flumazenil and use of an alternative agent. When given intravenously, most children should require no more than 1 mg [15]. See Table 25.3 for dosing recommendations.

Dexmedetomidine is an alpha 2-receptor agonist that has the ability to provide sedation without causing respiratory depression. A biphasic dose–response effect on hemodynamics has been described, characterized by decreases in arterial blood pressure and heart rate at low plasma concentrations and an increase in arterial blood pressure with further reductions in heart rate at higher plasma concentrations [31]. To minimize the hemodynamic effects of dexmedetomidine, the loading dose of 1 mcg/kg should be given as a slow intravenous injection over at least 10 min. This can be followed by a constant infusion of 0.2–0.7 mcg/kg/h.

No single drug is available that meets all the requirements of an ideal sedative. Drug combinations may therefore be necessary, particularly in the management of uncooperative children. Drug combinations do, however, increase the risk of complications and the sedation practitioner involved should be trained in advanced sedation techniques, and preferably have experience in general anesthesia. A combination of midazolam and ketamine is useful for sedation in short, painful procedures. Oral midazolam (0.35 mg/kg) combined with oral ketamine (5 mg/kg), in children has been shown to provide safe, effective, and practical sedation for minor oral surgical procedures under local anesthesia [32]. When oral ketamine and midazolam are used, in conjunction with an intravenous technique, the dose of oral ketamine should be reduced to 2 mg/kg. This dose of ketamine is also suitable for children under the age of 2 years [33] but they need to be monitored carefully for over sedation.

The safe and effective management of children for painful procedures outside the operating room remains a challenge. Dental procedures are common pediatric day-cases and are one of the commonly used research models used for studying the efficacy of minor analgesic agents [34]. Severity of postoperative pain is related to the number of teeth extracted, and an effective clinical research model has been established by studying children who have undergone six or more extractions [35]. This study gives valuable information regarding pain after pediatric dental procedures. Children aged 4–7 years, undergoing six or more dental extractions, received tramadol (1.5 mg/kg) or placebo 30 min before surgery. Both groups furthermore received oral midazolam (0.5 mg/kg) up to a maximum of 7.5 mg 30 min before surgery. Postoperative rescue analgesia was required by 19.4 % of the tramadol group, compared with 82.8 % of the placebo group [35]. This showed that the use of effective analgesic drugs, before sedation, minimized postoperative pain in children. Other studies have confirmed tramadol’s analgesic efficacy, lack of significant respiratory depression and preservation of time to recovery when used in combination with other sedative agents [36, 37]. The combination of oral tramadol 1.5–3 mg/kg with midazolam is a useful combination for sedation and analgesia for children undergoing painful procedures outside the operating room. Another useful oral combination is trimeprazine (6 mg/mL) and methadone linctus (0.4 mg/mL) in a syrup base [23, 32]. The usual oral dose is 0.5 mL/kg of the mixture up to a maximum of 10 mL. This can be used as sedation for small, painful surgical procedures where local anesthesia is to be used. It is also a useful sedative combination for painless procedures as profound sedation is achieved. Unfortunately methadone, an opioid and trimeprazine a phenothiazine derivative have long elimination half-lives resulting in prolonged recovery. However, despite these limitations, the low cost of this combination makes it useful for oral pediatric sedation in the developing world. Deeper levels of sedation can be obtained by adding droperidol (0.1 mg/kg) to the mixture.