Dealing with a crying and moving child who needs sedation for a laceration repair? Intranasal midazolam is a good sedative option but what dose do you choose? Learn more in this journal club episode where we talk about a recent study that evaluated the most effective dosing of intranasal midazolam.

This episode was written by pediatricians Tammy Yau and Lidia Park with content support from Julia Marlow (pediatric hospitalist). Pediatricians Tammy and Lidia take full responsibility for any errors or misinformation.

Follow us on Twitter/X @Pediagogypod, Instagram/Threads @pediagogy, Bluesky @pediagogypodcast.bluesky.social, and connect with us at pediagogypod@gmail.comKey Points:

• Intranasal midazolam is a good non-invasive sedative option. It has similar plasma concentrations as intravenous administration because it bypasses first pass metabolism unlike oral administration. Onset of action is 20-30 minutes and can last 30-60 minutes.
• Dosing of intranasal midazalam for children is 0.2 - 0.5 mg/kg
• Based on the results of this study, 0.4 - 0.5 mg/kg of midazolam was found to provide more effective sedation without increased adverse events for the studied patient population (6 months - 7 years old with simple laceration)
• Always critically think through studies! This study had limitations including the narrow patient population (did not include children with autism or developmental delay, did not include children less than 6 months old, and had a small study sample size with n = 101)

Sources:

• Tsze DS, Woodward HA, McLaren SH, et al. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. Published online July 28, 2025. doi:10.1001/jamapediatrics.2025.2181
• UpToDate “Pediatric procedural sedation: pharmacological agents”

Sometimes kids are FOS - full of stool! In today's episode, we talk about how to diagnose and treat functional constipation which is a common cause of abdominal pain in pediatrics and can be a pain in the butt, literally!

This episode was written by pediatricians Tammy Yau and Lidia Park with content support from Kelly Haas (pediatric gastroenterology). Pediatricians Tammy and Lidia take full responsibility for any errors or misinformation.

Follow us on Twitter/X @Pediagogypod, Instagram/Threads @pediagogy, Bluesky @pediagogypodcast.bluesky.social, and connect with us at pediagogypod@gmail.com

Key Points:

• Functional constipation is constipation not due to any other underlying conditions such as Hirschsprungs, spinal cord dysphraphism, or other disease.
• Functional constipation is defined as having at least 1 month of symptoms in kids younger than 4 years old (or) symptoms at least once per week for at least 2 months in kids older than 4 years old who do not meet IBS criteria. Symptoms include 2 or fewer stools per week, at least 1 episode of incontinence per week after toilet training is established, a history of excessive stool retention/retentive posturing/excessive volitional stool retention, a history of hard or painful bowel movements, the presence of large fecal mass in rectum, or a history of large diameter stools that may obstruct the toilet
• Encopresis is liquid stool that goes around large stool balls and is indicative of constipation rather than diarrhea
• Polyethylene glycol (PEG, miralax), lactulose, and enemas are all good treatment options for constipation

Sources:

• Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Tabbers MM, et al. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. doi:10.1097/MPG.0000000000000266
• Constipation. Neal S. LeLeiko, et al. Pediatr Rev (2020) 41 (8): 379–392. https://doi.org/10.1542/pir.2018-033

Tripoding and a thumb print sign on X-ray are your buzz words for epiglottitis that you don't want to miss as it can cause very rapid respiratory compromise requiring ICU care. We'll go over what to look out for and how to treat epiglottitis in this week's episode

This episode was written by pediatricians Tammy Yau and Lidia Park with content support from Zachary Chaffin (pediatric critical care). Pediatricians Tammy and Lidia take full responsibility for any errors or misinformation.

Follow us on Twitter/X @Pediagogypod, Instagram/Threads @pediagogy, Bluesky @pediagogypodcast.bluesky.social, and connect with us at pediagogypod@gmail.com

Key Points:

• Epiglottitis can present with rapid onset fever, sore throat, difficulty breathing, and drooling. On exam, you might see stridor, retractions, and tripoding which is when the patient is leaning forward with their head tilted upward.
• Epiglottitis can lead to respiratory failure and may require intubation
• The most common causes of epiglottitis are Staph aureus, Streptococcus pneumonoiae, and Haemophilus influenzae though the latter has decreased due to vaccination with the Hib vaccine
• Treatment for epiglottitis includes antibiotics like ceftriaxone and vancomycin for 7-10 days. Steroids and racemic epinephrine have not been shown to improve outcomes for epiglottitis.

Sources:

• Croup and Epiglottitis. Mark Shlomovich, et al. Pediatr Rev (2025) 46 (7): 366–372. https://doi.org/10.1542/pir.2024-006420
• Epiglottitis Associated With Intermittent E-cigarette Use: The Vagaries of Vaping Toxicity. Pediatrics (2020) 145 (3): e20192399. https://doi.org/10.1542/peds.2019-2399
• Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 8th edition, Tovar Padua LJ, Cherry JD, Harrison GJ, Kaplan SL, Steinbach WJ, Hotez PJ (Eds), Elsevier, Philadelphia 2019. Vol 1, p.175.
• Up to Date: Epiglottitis: Management, Clinical Features and Diagnosis