Author:
Kai Knudsen
Updated:
8 September, 2025
Premedication in pediatric patients prior to anesthesia and surgery – a comprehensive guide addressing indications, pharmacological choices, routes of administration, and nursing considerations. The chapter emphasizes patient safety, perioperative security, and individualized management tailored to the specific needs of the child
Premedication Children
There are many different medications used in premedication for children to achieve analgesia and anxiolysis. The main principle is that these medications should be analgesic and relaxing. The general preoperative care of children with parents is essential to gain trust from the patient and parents, ensuring a good and safe anesthesia induction. Anxious and worried parents can easily spread their anxiety to the child, so preoperative information is crucial. During anesthesia induction, it is advisable that only the calmest parent is present.
Clonidine
Dosage: 2-5 µg/kg orally, provides good sedation in premedication. The downside is that it has a long onset time and must be given well in advance, 60-90 minutes beforehand. Premedication with Mixture Clonidine Hydrochloride 20 µg/ml or Tablet Clonidine 75 µg.
Dosage interval: 2-4-(6) μg/kg. Dose: We recommend 3 μg/kg. Children < 3 years and all ENT children 2-3 μg/kg. Example; child’s weight 15 kg x 3 μg/kg = 45 μg and 2.2 ml (20 μg/ml) clonidine hydrochloride.
Dexmedetomidine and Clonidine for children
| Dexmedetomidine 100 µg/ml | Clonidine 150 µg/ml | |||
|---|---|---|---|---|
| Intravenously | Intranasally | Intravenously | Orally | Epidurally (Epi) |
| 1 µg/kg (max. 200 µg) by infusion or slow injection | 1,5-2 µg/kg (MR 4 µg/kg) Max 200 µg | 1-4 µg/kg x 3 | 1-4 µg/kg x 3 | 0,1-0,3 µg/kg/tim |
Dexmedetomidine
Provides good premedication for young children coming for ear, nose, and throat procedures. Injection fluid dexmedetomidine (Dexdor®) 100 µg/ml can be given both nasally and buccally. Nasal administration is preferred as it gives better absorption and faster effect. The solution has no taste and does not sting in the nose. Dexmedetomidine is a specific alpha2 receptor agonist and its effect is similar to clonidine, but with a more pronounced effect. The main effects are sedation and some analgesia. Dexmedetomidine has a shorter half-life, approximately 2 hours compared to clonidine 5-10 hours. The onset time is significantly longer compared to orally administered midazolam, approximately 20-40 minutes.
Dosage
Children 1-3 years old are given 1 µg/kg. Children 3-10 years old are given 1-2 µg/kg. Children over 10 years old are given 1-3 µg/kg. The dose can be increased with age to a maximum of 3 µg/kg. Nasal administration is easiest with MAD (Mucosal Atomization Device) or MADdy (pediatric variant) connected to an injection syringe. The prescribed dose of the drug is diluted to the desired volume (usually 0.3-0.5 ml) with physiological saline solution.
Reasonable dose for dexmedetomidine nasal 100 microg/ml
| 1 kg | 5 kg | 10 kg | 50 kg | |
|---|---|---|---|---|
| 1 mikrog/kg | - | - | 0,1 mL | 0,5 mL |
| 2 mikrog/kg | - | 0,1 mL | 0,2 mL | 1 mL |
| 3 mikrog/kg | - | 0,15 mL | 0,3 mL | 1,5 mL |
Monitoring
Patients must have the presence of parents or staff during the waiting time after application. Perioperative monitoring with blood pressure and ECG. The child may need a slightly extended wake-up time compared to patients without premedication.
Paracetamol
Paracetamol is administered alone or in combination with other drugs.
Common combinations of pharmacological premedication for children often include paracetamol (30 mg/kg x 1) in combination with benzodiazepines or benzodiazepine-like drugs, sometimes with the addition of an NSAID preparation. Paracetamol is given either as a tablet, mixture, or suppository (Table 6). Children under 6 months are generally not premedicated. Several different drug combinations are common. Various variants of sedative sympathomimetic drugs have become more common in recent times, such as clonidine and dexmedetomidine. These are usually given as an oral solution but can also be given intravenously.
Routinely, a loading dose of paracetamol (max orally 30 mg/kg) is given in the premedication. Practically, it is given as a mixture of paracetamol 24 mg/ml, 1 ml/kg in the ward before most operations. Before more painful procedures, children > 6 months are also given an NSAID preparation. The youngest children, <6 months, are usually not premedicated.
Premedication and maintenance with paracetamol
Children 6-25 kg. Administered as a Mixture, Suppository or Tablet.
| Premedication | Maintenance for the first 2 days 20 mg/kg body weight |
|||||
|---|---|---|---|---|---|---|
| The child's weight (kg) | Mixture Paracetamol 24 mg/ml | Supp Paracetamol (mg) | Tablet Paracetamol (mg) | Mixture Paracetamol 24 mg/ml | Tablet Paracetamol (mg) | Supp Paracetamol (mg) |
| 6-8 kg | 8,5 ml | 250 mg | - | 2,5 ml x 4 | - | 60 mg x 4 |
| 8-10 kg | 12 ml | 310 mg | - | 3,5 ml x 4 | - | 125 mg x 3 |
| 10-12 kg | 14 ml | 375 mg | - | 5 ml x 3 | - | 125 mg x 4 |
| 12-15 kg | 17,5 ml | 500 mg | - | 5 ml x 4 | - | 185 mg x 4 |
| 15-20 kg | 22 ml | 625 mg | - | 7,5 ml x 4 | - | 250 mg x 3 |
| 20-25 kg | 28 ml | 750 mg | 500 mg | 10 ml x 4 | 500 mg x 3 | 250 mg x 4 |
Benzodiazepines
Bensodiazepines are administered alone or in combination as a premedication.
A common standard mixture for children is midazolam + atropine in a mixture. This mixture is dosed according to a schedule based on weight. Midazolam often provides trouble-free needle placement if EMLA has been used. Rectally, 0.3 mg/kg (max 10 mg) is given, as nasal spray 0.2 mg/kg (max 5 mg), and orally 0.5 mg/kg (max 15 mg) can be given.
Some children, e.g., those who are very anxious or who have previously experienced major problems with anesthesia, may be offered a heavier premedication. Flunitrazepam in tablet form 0.05 mg/kg, gives heavy sedation after about 20 minutes that lasts at least 1 hour. This premedication can be given on the ward and the timing must be coordinated with the operating room. In some cases, midazolam can be given by anesthesia staff to facilitate a difficult induction. The child must not be left alone after flunitrazepam or midazolam has been given. An alternative to midazolam is triazolam (Halcion). Dosage T. Halcion 0.125 mg, ½ tablet for children weighing 20-30 kg and 0.125 mg, 1 tablet for children weighing 30-40 kg. Older children may find the waiting on the ward before surgery long and anxious. Diazepam (Stesolid), tablet or suppository, 0.5 mg/kg rounded down, max 25 mg rectally, can provide relief.
Atropine is given after a doctor’s order in the operating room, either intravenously, orally, subcutaneously, rectally, or sublingually.
Premedication with midazolam (children 10-25 kg)
A common standard mixture for children is midazolam + atropine in a mixture given orally. In addition, paracetamol 30 mg/kg x 1 is usually given.
Pharmacy mixture Midazolam 1 mg/ml + Atropine 0.05 mg/ml. Dosage: 0.4
Midazolam 1 mg/ml + Atropine 0,05 mg/ml in a mixture
| Weight (kg) | Quantity in ml |
|---|---|
| 10 | 4,0 |
| 11 | 4,5 |
| 12 | 5,0 |
| 13 | 5,0 |
| 14 | 5,5 |
| 15 | 6,0 |
| 16 | 6,5 |
| 17 | 7,0 |
| 18 | 7,0 |
| 19 | 7,5 |
| 20 | 8,0 |
| 21 | 8,0 |
| 22 | 8,5 |
| 23 | 9,0 |
| 24 | 9,5 |
| 25 | 10,0 |
Premedication with midazolam (children 10-25 kg)
Midazolam + atropine in a mixture prepared in the operating room. Midazolam 1 mg/ml is mixed with Atropine 0.5 mg/ml and strong juice is added to a solution of 5–12 ml. Dosage: Midazolam 0.4 mg/kg + Atropine 0.02 mg/kg orally according to the list below. In addition, paracetamol 30 mg/kg x 1 is usually given.
Midazolam 1 mg/ml + Atropine 0,05 mg/ml
Mixed at op. dept. for children 10-25 kg. The dose is given orally in a mixture.
| Weight (kg) | Volume in ml. of the mixture | Amount of medicine midazolam/atropine (mg) |
|---|---|---|
| 10 | 4,4 | 4,0/0,20 |
| 11 | 4,9 | 4,5/0,225 |
| 12 | 5,5 | 5,0/0,25 |
| 13 | 5,5 | 5,0/0,25 |
| 14 | 5,55 | 5,5/0,275 |
| 15 | 6,6 | 6,0/0,30 |
| 16 | 7,15 | 6,5/0,325 |
| 17 | 7,7 | 7,0/0,35 |
| 18 | 7,7 | 7,0/0,35 |
| 19 | 8,25 | 7,5/0,375 |
| 20 | 8,8 | 8,0/0,40 |
| 21 | 8,8 | 8,0/0,40 |
| 22 | 9,35 | 8,5/0,425 |
| 23 | 9,9 | 9,0/0,45 |
| 24 | 10,45 | 9,5/0,475 |
| 25 | 11 | 10,0/0,50 |
Premedication for rectal administration of midazolam (children 5-20 kg)
Midazolam + atropine in a mixture prepared in the operating room for rectal administration. Midazolam 5 mg/ml is mixed with 2 ml NaCl to a strength of 3 mg/ml. Dosage 0.3 mg/kg = 0.1 ml/kg. + Atropine 0.5 mg/ml is mixed undiluted in the midazolam mixture.
Rectal administration of Midazolam/Atropine to children 5-20 kg
| Weight (kg) | Midazolam 3 mg/ml Amount (mg) | Midazolam 3 mg/ml Volume (ml) | Atropine 0,5 mg/ml Amount (mg) | Atropine 0,5 mg/ml Volume (ml) |
|---|---|---|---|---|
| 5 | 1,5 | 0,5 | 0,15 | 0,3 |
| 7,5 | 2,25 | 0,75 | 0,15 | 0,3 |
| 10 | 3 | 1 | 0,15 | 0,3 |
| 12,5 | 3,75 | 1,25 | 0,25 | 0,5 |
| 15 | 4,5 | 1,5 | 0,25 | 0,5 |
| 20 | 6,0 | 2 | 0,25 | 0,5 |
Ketamine
Another option, primarily for children with heart disease aged 1-4 years, is ketamine 7 mg/kg mixed with midazolam 0.3 mg/kg. In cases where the child does not cooperate at all, ketamine can be given intramuscularly. 3-5 mg/kg is given, in some cases up to 10 mg/kg, preferably in m. deltoideus. If no injection is desired and the child does not cooperate, ketamine can be given orally in exceptional cases. This induction method is time-consuming, about 20 minutes, until needle placement can occur. 6 mg/kg is given mixed in a little liquid, e.g., Coca-Cola.
Thiopentone – Pentothal
Rectal induction with thiopental (Pentocur – “Pentorect/Sleep tail”) can be given to young children 1-4 years (10-20 kg) if needle placement is not desired while the child is awake. This is an older form of anesthesia that is hardly used anymore. Pentothal can be given rectally at a dose of 30 mg/kg from a solution of 100 mg/ml. This premedication acts as anesthesia induction and is given in the operating room. The weight limits are not strict; this induction often works well for sensitive children weighing 5-30 kg. The maximum rectal dose is 600 mg of Pentothal. Pentorect can be used as the sole form of anesthesia for minor surgical procedures or when the child only needs to lie still, such as during X-ray examinations and certain radiological interventions.
NSAIDs approved preparations that can be used for young children are mixture Ibuprofen (Brufen) and supp Diclofenac (Voltaren)
Premedication with mixture Ibuprofen (Brufen®) 20 mg/ml
Children 6-10 kg (> 6 months)
| Weight (kg) | Dosage (ml) |
|---|---|
| 7 kg | 2,5 ml x 3 |
| 8 kg | 3,0 ml x 3 |
| 9 kg | 3,5 ml x 3 |
| 10 kg | 4,0 ml x 3 |
Premedication with suppositories of diclofenac 25 mg
Children >1 year and >10 kg
| Weight (kg) | Number of suppositories |
|---|---|
| 10 kg | ½ supp x 2 |
| 12,5 kg | ½ supp x 2 |
| 15 kg | ½ supp x 3 |
| 20 kg | 1 supp x 2 |
| 25 kg | 1 supp x 3 |
| 30-40 kg | 1½ supp x 3 |
Premedication with Intranasal Sufentanil for Children
Indication
Children who are to receive anesthesia where sedation is deemed appropriate before induction.
Contraindication
Ongoing nosebleed or other nasal obstruction.
Administration of intranasal sufentanil requires the presence of anesthesia personnel, the ability for continuous monitoring, and potential ventilation support.
Effect
Sedation is usually achieved within 10 – 15 minutes and the maximal analgesic effect occurs after 20 – 25 minutes. In some patients, the effect may occur within a few minutes.
Dosage/Administration
- Sufentanil 1 microgram/kg (50 micrograms/ml) is given with a 2 ml syringe-attached Mucosal Aerosol Device (MAD). Use a Luer Lock syringe to prevent the MAD from coming off during injection.
- Total dose 1 – 2 micrograms/kg: Half of the dose is administered in each nostril.
- Administer one syringe with 0.1 – 0.2 ml at a time. When applying, aim upward inside the nostril in the direction of the eyes (cranial direction).
- Apply in both nostrils as quickly as possible. It is important to use force on the plunger to achieve aerosol.
- Uncertain effect with larger volume, as part of the dose passes the nasal mucosa and is swallowed.
Dosage Table
Sufentanil administered nasally for children
| Weight (kilo) | Dose (microgram) | Volume (ml) |
|---|---|---|
| 10 | 20 | 0.4 |
| 13 | 26 | 0.5 |
| 15 | 30 | 0.6 |
| 18 | 36 | 0.7 |
| 20 | 40 | 0.8 |
| 23 | 46 | 0.9 |
| 25 | 50 | 1 |
| 28 | 56 | 1.1 |
| 30 | 60 | 1.2 |
| 35 | 70 | 1.4 |
| 40 | 80 | 1.6 |
| 45 | 90 | 1.8 |
| 50 | 100 | 2 |
| 55 | 110 | 2.2 |
| 60 | 120 | 2.4 |
References
- Bayrak F, Gunday I, Memis D, Turan A. A comparison of oral midazolam, oral tramadol, and intranasal sufentanil premedication in pediatric patients. J Opioid Manag. 2007 Mar-Apr;3(2):74-8.
- Zedie N, Amory DW, Wagner BK, O’Hara DA. Comparison of intranasal midazolam
Disclaimer:
The content on AnesthGuide.com is intended for use by medical professionals and is based on practices and guidelines within the Swedish healthcare context.
While all articles are reviewed by experienced professionals, the information provided may not be error-free or universally applicable.
Users are advised to always apply their professional judgment and consult relevant local guidelines.
By using this site, you agree to our Terms of Use.
