Background: Pre-anesthetic anxiety and emergence agitation are major challenge for anesthesiologists in pediatric anesthesia . Sevoflurane is a volatile anesthetics agent with low pungency, non-irritating odor, and low blood/gas partition coefficient that makes it an attractive alternative to halothane . However, a high incidence of emergence agitation (EA) or has been reported in pediatric patients after sevoflurane anesthesia . Pre-anesthetic anxiety and rapid recovery of consciousness from sevoflurane anesthesia has been propsed as possible mechanisms. It was, therefore , hypothesized that sedatives such as midazolam may reduce pre-anesthetic anxiety and counteract sevoflurane's rapid emergence and thus reduce the incidence and the severity of sevoflurane –inducee EA. The present study evaluate the effect of oral and rectal midazolam on pre-operative anxiety and the emergence behavior after sevoflurane anesthesia in children. METHODS: This randomized , controlled double – blinded study include 80 ASA class 1&2 pediatric patients, aged between 3 and 8 yr, scheduled for elective outpatient surgery. Patients were assigned to receive either oral midazolam (0.2mg kg-1) or rectal midazolam (0.3 mg kg-1) as premedication before the conduct of anesthesia Thirty minutes after administration of the premedication, the children were separated from their parents to assess the effectiveness of the premedicant in minimizing emotional responses at this time using sedative and anxiolysis scores. Induction and maintenance of anesthesia were uniform in both groups. Induction of anesthesia was made with 8% sevoflurane in 100% oxygen. Intubation was performed without the aid of muscle relaxant,and the ventilator was set to maintain normocapnia. Anesthesia was maintained with sevoflurane and N2O in 50% 02 until the end of surgery. All matters of relevant time periods were recorded ( induction, surgical procedure, extubation and transportation). IN the post-anesthesia care unit (PACU), adverse events, the incidence and the severity of EA using modified objective pain scale , duration of PACU stay, and parental as well as PACU nurses' satisfaction were evaluated. RESULTS: Patients premedicated with midazolam rectally were more sedated (85%) compared to patient premedicated with midazolam orally (75%). Also 80% of rectal –treated children had excellent anxiolysis vs., 70% of oral treated children at the time of separation from their parents. Both sedation and anxiety scores were not statistically significant in both groups (P>0.05) . However, the incidence of EA was 50% vs 60% for oral and rectal midazolam respectively (P >0.05) . The EA incidence in patients aged 3-5 years groups were significantly higher than that in patients 7-8 years group in both rectal ang oral midazolam groups (P<0.o1). Although these patients remained sedated after sevoflurane anesthesia, the duration of the PACU stay was not signiflcantly different between both – treated group. Both parents and PACU nurses were more satisfied with oral midazolam as premedication (P < 0.001). Conclusion: We concluded that premedication with low doses of either oral or rectal midazolam is safe, convenient and effective in decreasing the occurrence of anxiety pre-operatively and sevoflurane-induced emergence agitation post operatively without delaying discharge from PACU and both are suitable for outpatient surgery.