A large-scale retrospective study of 3.7 million children found an association between radiation exposure from medical imaging and a small but significantly increased risk of developing hematologic cancers (primarily leukemia).

• Finding: Cancer risk increased with cumulative radiation dose

• Dose-Response: For the highest exposure group (50 to <100 mGy), the Relative Risk (RR) for hematologic cancer was 3.59 compared to no exposure.

  • Note: 13.7 mGy is roughly one head CT
     

• Attributable Risk: An estimated 10.1% of hematologic cancers in the cohort may have been attributable to medical imaging radiation, with CT scans being a major contributor.

• Vulnerability: Children are more susceptible to radiation-induced cancer due to their heightened radiosensitivity and longer life expectancy for the cancer to manifest.

Take Away:  Providers should critically assess the necessity of high-dose imaging like CT scans and use the lowest effective dose or possible alternative imaging (e.g. US, MRI, etc.) to prevent unnecessary cumulative exposure.

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In the pediatric ED, intranasal midazolam is a common choice among providers for procedural sedation. However, with widely varying recommendations, the ideal dose remains a topic of debate.

A recent randomized clinical trial published in JAMA Pediatrics involving 101 children, ages 6 months to 7 years, sought to determine the best dose of intranasal (IN) midazolam for sedation during laceration repair. Researchers compared four different doses: 0.2, 0.3, 0.4, and 0.5 mg/kg.

The primary outcome was achieving adequate sedation for at least 95% of the procedure. Secondary outcomes included the level of sedation, how quickly it took effect, recovery time, satisfaction of clinicians and caregivers, and any negative side effects.

What did they find?

The lower doses (0.2 and 0.3 mg/kg) were found to be less effective and were removed from the study early.

The two higher doses (0.4 and 0.5 mg/kg) both provided similar, adequate sedation for about two-thirds of the children.

Sedation took effect quickly, within a few minutes, and children recovered fast.

Adverse events were rare and not serious.

Satisfaction among both clinicians and caregivers was high across the board.

Bottom line: Consider reaching for higher doses of intranasal midazolam (0.4 to 0.5 mg/kg) for pediatric patients requiring procedural sedation.

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