Pediatric Sedation

Pediatric Sedation

What is pediatric sedation?

Pediatric sedation is a method of using different sedatives, anxiolytics, and/or anesthetics to induce a level of sedation/comfort based on the requested test, scan or procedure.

Pediatric sedation IS NOT anesthesia; it is a separate division from general anesthesia. The CHOP pediatric sedation team utilizes medications and one of three levels of sedation for your child based on age, developmental stage, and/or type (and duration) of scan, test or procedure.

There are several levels of sedation:

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

Sedation medications may be given:

  • Orally, by mouth (your child takes a pill or drinks liquid)
  • Intranasally (spray into your child’s nostrils)
  • Intramuscularly (an injection into your child’s muscle)
  • Intravenously (an injection into your child’s vein)

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 orally, intranasally or intravenously.
  • Fentanyl (Brand name: Sublimaze®): A pain medication used to supplement sedation and/or relieve pain. It’s 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: An aesthetic used for sedation and pain relief; it is administered intramuscularly, intravenously or orally.
  • Propofol: A short acting medication with a quick onset that causes deep sedation; it is given intravenously.
  • Dexmedetomidine (Brand name: PrecedexTM): A short acting medication used as a sedative, anxiolytic and analgesic; in sedation, it is given intranasally.

Who gets pediatric sedation?

If your child needs a test or procedure that requires them to sit or lay still for a few minutes or several hours, they 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.

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 for your child during expected wait times. In addition, please remember to bring any communication systems your child may use. 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:

  • A favorite book or 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, iTouch)
  • Activities to keep your child busy independently (e.g., word finds, Sudoku, portable game system, iPod/music, 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

Tips to help prepare your child before pediatric sedation

  • Know your child’s disposition! Are they anxious the more they know, or do they want to know the details?
  • Encourage your child to discuss their feelings and ask questions about the upcoming experience, but be careful not to force a discussion if your child does not seem ready.
  • Use simple words your child will understand.
  • 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 for parents and guardians

  • BE POSITIVE! Don’t relay your fears and negative experiences to your child.
  • LISTEN to all voice messages, READ all text messages or emails that arrive the day prior to your child’s scheduled test, scan or procedure.
  • Remain calm and take care of yourself. You will be able to provide better support to 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, friend or a family member with you, 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 or radiology scheduler so we can connect you with any additional resources that may be helpful and plan the best ways to work with your child. A typical visit to CHOP’s Pediatric Sedation Unit lasts a minimum of three to four hours. This includes registration, the procedure and recovery.

Preparing for pediatric sedation

Sedation requires fasting before the procedure. Based on the type of scan, test or procedure your child is receiving, you may receive text or voice messages about your arrival times and your child’s fasting times.

The following are some general guidelines:

  • Food (solids): Your child should eat no solid foods, including applesauce, pudding, gum or candy, after 11 p.m. the evening before the procedure. Fasting is needed for eight (8) hours prior to your instructed arrival time.
  • Liquids: Your child can drink clear liquids, including water, apple juice or ginger ale, until two (2) hours before your arrival time.
  • Breast milk:
    • Children, regardless of age, may have unfortified breast milk until three (3) hours before your arrival time.
  • Formula for babies less than 6 months old: Healthy babies less than 6 months old on the day of the procedure may have formula (with no additives) until four (4) hours before your 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 (6) hours before your arrival time. Do not add cereal. Do not use formula that has cereal already added.
  • NO 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.

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

After registration, one of CHOP’s sedation team members will guide you and your child to an assigned Sedation Unit room and obtain your child’s weight, height/length, head circumference, if needed, and vital signs (heart rate, blood pressure, oxygen saturation and temperature).

A registered nurse, nurse practitioner or sedation pediatrician will join you and will go over the sedation process with you. A nurse practitioner and/or physician sedation pediatrician will review your child’s medical history and examine your child; the sedation pediatrician will obtain written consent prior to sedation.

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

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(s).

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

During pediatric sedation

Sedation is a process where the child is awake with the placement of the intravenous (IV) catheter. To assist with the IV placement, most children are given an oral or intranasal (IN) anxiolytic (Versed®) medication that should make them forget any negative experiences associated with the IV placement and/or sedation.

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. Once your child is asleep, you will be directed to the waiting room/registration area or back to the patient’s hospital room.

Most procedures, scans and tests last approximately 30-60 minutes, however your child’s nurse will provide a timeframe and obtain a cell phone number to give you updates or tell you when you can return to the sedation unit.

After pediatric sedation

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

If your child has significant challenges in the hospital setting or other similar settings, we encourage you to let the nurse know when they call to complete your child’s intake process or when they call 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.

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 in 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 these triggers if possible.

Does your child have difficulty with unpredictability or change?

  • Ask staff if a picture schedule is available to help show each step 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 your child’s room when possible.
  • Provide familiar objects or toys for your child to play with during wait time. If you did not bring any, ask the staff for help. The Pediatric Sedation Unit is equipped with some toys and games for patient use.
  • If your child tends to have a rigid schedule, such as a child diagnosed with autism, early appointments may make it easier to manage their fasting time.