Pediatric Sedation

  • What is pediatric sedation?

    Many tests and procedures require that children hold still in a particular position for anywhere from a few minutes to several hours. Sedation is the use of a sedative or tranquilizing drug to help children relax. It can help minimize your child’s fears and anxiety during a test or procedure.

    Sedation, in combination with pain medication, is also used to help children remain comfortable during painful procedures.

    There are several levels of sedation:

    • Minimal sedation: Child is in a relaxed state in which he is awake and able to respond normally to questions.
    • Moderate sedation: Child is in and out of consciousness and can be woken by sound or touch.
    • Deep sedation: Child is unconscious and does not respond to sound or touch.

    Sedation medications can be given:

    • Orally (your child takes a pill)
    • Intranasally (spray injected into your child’s nostrils)
    • Intramuscularly (an injection into your child’s muscle)
    • Intravenously (an injection into your child’s vein)

    At The Children’s Hospital of Philadelphia, we provide inpatient and outpatient sedation for infants, children and adolescents in the Pediatric Sedation Unit.

    Our staff of highly trained pediatricians, nurse practitioners, nurses and child life specialists works very closely with your child and family to determine the most appropriate sedation plan.

    We use multiple methods to help children tolerate their procedures, including distraction, preparation, and teaching techniques followed by sedating medications. Medications and levels of sedation are chosen based on your child’s needs and developmental level, duration of the test or procedure and invasiveness of the procedure.

    Sedation medications

    Some of the medications used for pediatric sedation include:

    • Midazolam (Brand name: Versed®): A medication used to help ease anxiety and help the child relax. It may be given in combination with other medications to help the child sleep through a test or procedure. Midazolam is administered by mouth, intranasally or intravenously.
    • Fentanyl (Brand name: Sublimaze®): A pain medication used to supplement sedation and/or relieve pain. It’s usually given to help ease children to sleep during sedation with Pentobarbital, and used as needed to maintain comfort during painful procedures. Fentanyl is administered intranasally or intravenously.
    • Pentobarbital (Brand name: Nembutal®): Long-acting medication that causes deep sedation. Children usually fall asleep within a few minutes of receiving this medication. Pentobarbital is administered orally or intravenously.
    • Ketamine: A medication used for sedation and pain relief. It’s administered intramuscularly or intravenously.
  • Who gets pediatric sedation?

    If your child needs a test or procedure that requires her to sit or lay still for a few minutes or several hours, she may need pediatric sedation. Sedation helps your child remain calm and relaxed, and can assist us in getting the most accurate results possible.

    Procedures that may require sedation

  • Evaluation and planning

    Preparing your child for sedation depends on what works best for your child and family. For some children, telling them too far in advance of the procedure or test may actually increase their anxiety. In this case, the best way to help prepare them is brief, factual information the morning of the procedure, or the day before the procedure.

    Other children may need more time — a few days to a week — to process information, ask questions and get help working through coping strategies.

    Tips to help prepare your child

    • Use simple words your child will understand.
    • Encourage your child to discuss feelings and ask questions about the upcoming experience, but be careful not to force a discussion if your child does not seem ready.
    • Be honest. If you do not know the answer to your child's question, tell your child that you do not know, but that you will find out.
    • Be aware that your visit may take a minimum of three to four hours. It is helpful to bring items to distract, entertain and comfort your child before and after sedation.

    Tips to help prepare yourself

    • Remain calm and take care of yourself. You will be able to provide better support for your child if you are rested and comfortable. The sedation process will be discussed during your entire visit, so there should be no surprises.
    • Bring a spouse, a friend or a family member with you, but try to leave younger children at home and keep your party small to decrease stimulation in your child’s room. A second person will be very helpful during your journey home when your child is still groggy.

    If your child has special needs, please tell the Sedation Unit scheduler so we can connect you with any additional resources that may be helpful and plan the best ways to work with your child. 

  • Before pediatric sedation

    Sedation requires fasting before the procedure. Our triage nurse will call you the evening before your child's test or procedure to give you specific information about fasting.

    The following are some general guidelines:

    • Food: Your child should eat no solid foods, including applesauce, pudding, gum or candy, after 11 p.m. the evening before the procedure.
    • Liquids: Your child can drink clear liquids, including water, apple juice or ginger ale, until two hours before your arrival time.
    • Breast milk:
      • Children younger than 12 months may have breast milk until three hours before your arrival time.
      • Children 12 months and older may have breast milk until 11 pm the night before the procedure.
    • Formula for babies less than 6 months old: Healthy babies less than 6 months old on the day of the procedure may have formula until four hours before your child’s arrival time.
    • Formula for babies 6-12 months old: Healthy babies 6-12 months old on the day of the procedure may have formula until six hours before your child’s arrival time. Do not add cereal. Do not use formula that has cereal already added.
    • Avoid brushing teeth or chewing gum as either will stimulate your child’s stomach secretions. Please be sure there are no snacks left in or around your child’s car seat.
  • What to bring to your child’s sedation appointment

    To make sedation as easy as possible for you and your child, please bring anything you think will be comforting or entertaining during expected wait times. In addition, please remember to bring any communication systems your child may have. Our staff also wants to know of any ways we can support you and your child, so please tell us about your child’s likes and dislikes, concerns and needs.

    Some suggestions that have worked for other patients and families:

    • Favorite book
    • Favorite toy
    • Favorite “snuggly” item (blanket, binky/pacifier, doll or stuffed animal)
    • Favorite cup (if your child has a preferred cup)
    • Communication device, if your child uses one (PECS book, iPad, Dynavox, iTouch)
    • Activities to keep your child busy independently (word finds, Sudoku, Nintendo DS, iPod/music, and coloring books)
    • Sensory objects that are soothing for your child like (squishy balls, teething/biting toys, and sound minimizing headphones)
    • A drink for after the procedure is complete if your child has specific preferences
  • On appointment day

    A typical visit to CHOP’s Pediatric Sedation Unit lasts a minimum of three to four hours. This includes registration, the procedure and recovery.

    Please arrive 1½ hours (90 minutes) before your child’s scheduled procedure. Our team needs this time to:

    • Complete the insurance registration
    • Provide time for your child to be examined by a nurse practitioner or pediatrician
    • Have medications ordered and double checked by the pharmacy
    • Have the sedation pre-medication take effect
    • Allow for the IV catheter to be placed

    Most procedures last approximately 30 to 60 minutes. Interventional radiology procedures average one hour, and MRIs last approximately one hour per study ordered. Your nurse will be able to provide a time frame for you depending on your child's procedure.

    Recovery will also last approximately one hour. However, each child is different, and some children wake earlier while others require longer recovery times.

    We suggest siblings stay at home to minimize distraction. If this is not possible, please bring toys, coloring books and favorite snacks to keep children entertained. There is a cafeteria available; however, fragrant foods are discouraged on the unit as patients are fasting.

    After registration, one of CHOP’s medical assistants will guide you and your child to an assigned Sedation Unit room. This staff member will measure your child’s weight and vital signs (heart rate, blood pressure, oxygen saturation and temperature).

    A registered nurse (RN) will join you and will go over the sedation process with you. A nurse practitioner and/or physician will examine your child before sedation begins. They will also ask for your written consent for the procedure.

    Sometimes, a Child Life Specialist will help prepare your child for his medical procedure by using age-appropriate education and supportive activities. A Child Life Specialist is a professional trained to speak with children about the procedure from CHOP’s Child Life, Education, and Creative Arts Therapy department.

  • During pediatric sedation

    Your child may receive an oral medication, which begins the sedation process. Then, an intravenous catheter (IV) will be placed and secured in your child’s arm to give her fluids and the rest of the sedation medicine.

    As your child is going to sleep, a calm approach on your part is best. Less stimulation in the room usually results in the need for less medication.
    While your child’s study or procedure is underway, you may stay in the Sedation Unit or leave the unit to use the restroom, visit the cafeteria or check in with a clinic.

    Most procedures last approximately 30 to 60 minutes. Your nurse will be able to provide a time frame for you. The nurse will also ask for your cell phone number, if you have one, so that you may be updated with times as needed.

  • After pediatric sedation

    Once the procedure or diagnostic study is completed, your child will recover in his original Sedation Unit room. Recovery time is variable, but averages about 45 minutes to one hour. Your child will receive fluids through his IV to help with recovery.

    Children who wake prematurely are at risk for “emergence delirium,” where they appear awake but are extremely upset and can injure themselves. This may last for several hours. For this reason, you may be asked to minimize interacting with your child to allow him to awaken slowly.

    Some children can become sick to their stomach after sedation and may require medication through the IV to prevent nausea and vomiting. The IV will be removed before your child goes home.

    Tips for comforting your child during recovery

    • Ask to be present before your child wakes from sedation, if allowed.
    • When medically cleared, offer a preferred snack (approved by staff). Bring this item from home.
  • What to expect after sedation

    Once your child is ready to leave, the nurse will give you instructions on how to care for your child at home. The nurse will also give you a number to call for any questions or concerns that arise after you go home.

    • Many children can have side effects from the sedation medication for up to 24 hours after their procedure. Be aware that they may be sleepy for several hours, they may have vomiting, and they may have some difficulty with balance.
    • Some children also have challenging behaviors for a few hours after sedation.
    • Some children may need to stay home from school the next day, so a plan should be in place just in case.
    • Wheelchairs are available to get your child back to your car once you are discharged. Feel free to bring a stroller if your child is small.
    • We discourage public transportation (bus or train) for your ride home for the following reasons: your child may vomit, and your child may require mild confinement to maintain her safety. A car seat or seatbelt would be ideal.
  • Sedation for children with special needs

    If your child with special needs has a very rigid daily routine and needs pediatric sedation for a procedure or test, please tell the Sedation Unit scheduler.

    We may be able to provide:

    • An early appointment to make it easier to manage fasting
    • A later appointment to lessen the disruption to your child’s daily routine.

    Sedation is the use of a sedative or tranquilizing drug to help your child relax. It can help minimize your child’s fears and anxiety. Sedation, in combination with pain medication, is also used to help children remain comfortable during painful procedures.

    If your child has significant challenges in the hospital setting or other similar settings, we encourage you to let the nurse know when she calls to complete your child’s intake process or when she calls with final instructions the day before your child’s procedure. Our team can use this information to better prepare for your visit and to connect your family with a Child Life Specialist prior to the hospital visit if you are interested.

    We also encourage you to share your child’s strengths and challenges with care providers during the visit, as well as the best ways to approach and work with your child.

    Items to bring to your child's visit

    Here are a few ideas about items you may bring from home to help your child with his hospital experience:

    • Distracting items (toys, books, DVD players, video game players)
    • Comforting items (stuffed animals, blanket, binky/pacifier, music, noise-blocking headphones, sensory stimulation items)
    • Any communication aids your child uses (iPad, Picture Exchange Communication System [PECS], Dynavox, etc.)
    • Reinforcers your family uses with your child
    • Special items your child may need, such as a specific cup to drink from or specific drinks for after the procedure

    Environmental modifications

    If you're the parent or guardian of a child with special needs, please let us know what will help your child feel most comfortable during your time at CHOP.

    Please take a moment to review the following questions and we will do our best to accommodate your child’s needs.

    Is your child sensitive to noise?

    • Ask hospital staff to speak with quiet/calm voices when addressing your child.
    • Ask hospital staff to limit the number of people in the room when possible.
    • Playing classical music quietly may help to organize and calm your child’s senses. You may ask a team member if music is available.

    Is your child sensitive to touch?

    • Inform hospital staff if your child is bothered by light touch, deep pressure, certain fabrics or textures. We may be able to avoid or postpone some of this if possible.

    Does your child have difficulty with unpredictability or change?

    • Ask staff if a picture schedule is available to help show steps of the encounter to your child.
    • Ask staff to limit the number of transitions when possible.
    • Ask staff to limit the number of new people entering the room when possible.
    • Provide familiar objects/ toys for your child to play with during wait time. If you did not bring any, ask the staff, as the Pediatric Sedation Unit is equipped with some toys and games.
    • If your child tends to have a rigid schedule, such as a child diagnosed with autism, early appointments may make it easier to manage the fasting time.