Daily Sedation Interruption Versus Continuous Sedation in Mechanically Ventilated Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Sedation management in critically ill children is challenging, with continuous infusions often leading to oversedation, prolonged mechanical ventilation, and iatrogenic withdrawal syndrome. Daily sedation interruption (DSI) is a strategy to mitigate these risks, but evidence regarding its efficacy and safety in the pediatric population is conflicting. This systematic review and meta-analysis aimed to evaluate the impact of DSI versus continuous sedation on clinical outcomes in mechanically ventilated pediatric patients. A systematic search of PubMed, Embase, and CENTRAL was conducted to identify randomized controlled trials (RCTs) comparing DSI with continuous sedation in children (0-18 years). The primary outcome was the duration of mechanical ventilation. Secondary outcomes included length of stay (LOS) in the pediatric ICU (PICU), total drug exposure, sedation depth, and adverse events. Data were pooled using a random-effects model. Trial sequential analysis (TSA) was performed to assess the sufficiency of the evidence, and the certainty of evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Six RCTs comprising 2,810 patients were included. In the pooled analysis, DSI was associated with a reduction in the duration of mechanical ventilation (mean difference (MD) -1.01 days; 95% CI -2.07 to 0.05; p = 0.06) and PICU LOS (MD -0.85 days; p = 0.31), though neither reached statistical significance. Significant heterogeneity was observed (I²= 51.8%). Subgroup analysis revealed that DSI reduced ventilation time in studies with a nonstandardized control group (MD -1.85 days) but offered no benefit over protocolized sedation (MD -0.41 days). No significant differences were found in mortality (risk ratio (RR) 1.08), accidental extubation (RR 0.89), or re-intubation rates (RR 0.85). TSA indicated that the current evidence is inconclusive, having not met the required information size to detect a 1.5-day reduction in ventilation. DSI is safe in critically ill children but does not consistently reduce the duration of mechanical ventilation compared to modern protocolized sedation care. Its utility may be greatest in resource-limited settings lacking robust sedation titration protocols. Given the low certainty of current evidence, DSI should be considered a component of multimodal sedation management rather than a standalone standard of care.