Sleep-related risk factors for sedation-related behavioral dysregulation in children: a nested case-control study

Sedation-related agitation and behavioral dysregulation may occur during pediatric procedural sedation, but clinically accessible pre-sedation vulnerability factors remain insufficiently characterized. We examined whether pre-existing sleep disturbance and peri-sedation sleep-related factors were associated with sedation-related behavioral dysregulation in children receiving intranasal dexmedetomidine combined with oral midazolam. This single-center nested case-control study with matched sampling was conducted from April to December 2024 using prospectively collected pediatric sedation data. Children aged 6-72 months who received oral midazolam 0.25 mg/kg plus intranasal dexmedetomidine 2 µg/kg constituted the source population. Cases were children who developed sedation-related agitation and behavioral dysregulation, assessed using the Pediatric Anesthesia Emergence Delirium scale during the sedation-unit observation period. For each case, two controls were selected from the same source population and matched by age, weight, gender, patient category, and examination type. Sleep disturbance was assessed before sedation using the parent-reported Sleep Disturbance Scale for Children. Conditional logistic regression was used to account for the matched sampling structure. The analysis included 118 cases and 236 matched controls. Sleep disturbance was more frequent in cases than controls (47.5% vs. 13.6%, P < 0.001). Daytime nap within 2 h before sedation was also more common in cases (60.2% vs. 38.1%, P < 0.001), and fasting duration was longer [3.00 (2.00-7.12) vs. 2.50 (2.00-3.30) h, P < 0.001]. In adjusted conditional logistic regression, sleep disturbance (adjusted odds ratio [AOR] = 5.36, 95% CI 3.02-9.51), daytime nap within 2 h before sedation (AOR = 2.26, 95% CI 1.32-3.85), and fasting duration ≥ 4 h (AOR = 2.75, 95% CI 1.40-5.39) were independently associated with the outcome. DIMS and SWTD were the most relevant SDSC domains. Pre-existing sleep disturbance, recent daytime nap, and prolonged fasting were associated with sedation-related behavioral dysregulation in children receiving dexmedetomidine-midazolam sedation. These findings should be interpreted as associative and require prospective validation in larger, independent cohorts before clinical implementation.