Oral and intravenous caffeine for treatment of children with post-sedation paradoxical hyperactivity

Abstract

Background

Paradoxical hyperactivity (PH) is a known complication of sedation in children, especially with barbiturates such as pentobarbital. The accompanying inconsolable irritability and agitation, similar to behaviors reported in children with attention deficit hyperactivity disorder (ADHD), is uncomfortable for the child and anxiety-provoking for parents and health-care workers. Our objective was to describe our experience with oral (PO) and intravenous (IV) caffeine as a treatment for sedation-induced PH.

Materials and methods

From January 2000 to April 2003, 19,894 children were sedated in our institution for radiology procedures. Of these, 360 children were diagnosed with PH. A total of 229 children exhibiting symptoms of PH after sedative administration were treated with PO caffeine (n=88; 43 boys, 45 girls; mean age 4.5 years, mean weight 18.7 kg) or IV caffeine (n=131; 73 boys, 58 girls; mean age 4.8 years, mean weight 20.1 kg) or both (n=10; 8 boys, 2 girls; mean age 5.0 years, mean weight 19.9 kg). A positive effect was defined as a decrease in agitation, crying, or hyperactivity within 40 min of caffeine administration. A control group (n=45) was obtained from those 141 children who experienced post-sedation PH but were not treated with caffeine, and matched for age and sex with samples of children treated with IV caffeine (n=45) and PO caffeine (n=45).

Results

Children treated intravenously received the equivalent of 20 mg/kg caffeine citrate (to a maximum of 200 mg). Of those treated with IV caffeine, 82/131 (63%) showed a positive effect, and returned to baseline behavioral status after an average of 33 min (SD=23 min). The untreated control group required a significantly longer time to recover (P<0.01) than those treated with IV caffeine. Children treated orally received approximately 1.0–2.5 mg/kg caffeine in Mountain Dew (Pepsi-Cola Company), and 36/88 (41%) showed a positive effect and returned to baseline behavioral status after an average of 42 min (SD=27 min). Of the 10 children treated with both PO and IV caffeine, 6 showed a positive effect. There was no significant difference in recovery time between the untreated control group and either the matched orally treated group or the group treated with both IV and PO caffeine. No complications occurred after caffeine administration.

Conclusion

IV caffeine appears to be an effective treatment for PH in children with sedation-induced PH. Further controlled prospective study is needed to determine the optimum dose and route of administration and to compare efficacy with other potential drug classes.