Background <p>Perioperative anxiety is common in pediatric patients, contributing to increased morbidity and postoperative dissatisfaction. While behavioral management techniques (BMT) are preferred, midazolam is often used when BMT is not feasible. Language barriers and racial disparities may influence healthcare delivery. This study examines the impact of English fluency and race on midazolam administration in pediatric patients,</p> Methods <p>This retrospective study analyzed pediatric anesthesia cases from a single medical center between January 1, 2014, and December 31, 2021. It included patients aged 1 to 12 years undergoing outpatient procedures. Demographic variables such as age, sex, weight, race, ASA physical status, and preferred language were collected. Patients were classified as English-Proficient (EP) or Limited English Proficiency (LEP) speakers. The primary outcome was oral midazolam administration. Oral midazolam was selected because it reflects the pre-induction anxiolysis decision made prior to IV placement and parental separation, which is the clinical context most relevant to behavioral management strategies and communication barriers. Although intravenous midazolam administration is available and captured in the electronic medical record, it is typically administered after IV access has been established or intraoperatively and does not represent the same preoperative decision-making process.</p>