AIM:　To investigate the impact of oral midazolam solution and dexmedetomidine nasal spray on preoperative anxiety in pediatric patients.  METHODS: A total of 90 children who planned to receive elective surgery in our hospital from June to December 2022 were selected and divided into midazolam oral solution group, dexmedetomidine nasal spray group and normal saline nasal drops group by random number table method. Thirty minutes before anesthesia, midazolam oral solution 0.5 mg/kg was administered to midazolam oral solution group. Dexmedetomidine nasal spray group received 2 μg/kg dexmedetomidine nasal spray and normal saline nasal drops group received 2 mL normal saline nasal drip. Drug acceptance was recorded in the three groups. modified Yale preoperative anxiety scale-short form (m-YPAS-SF) score of the three groups of children were analyzed before administration (T1), while separated from their parents (T2), while during anesthesia induction (T3), while 24 hours after surgery (T4). The scores of induction Cooperation Scale (ICC) in induction of anesthesia were recorded in the three groups. The recovery time and PACU residence time of the three groups were recorded. RESULTS: Compared with dexmedetomidine nasal spray group and normal saline nasal drops group, midazolam oral solution group exhibited a lower drug acceptance score (P<0.05), as well as lower m-YPAS-SF scores at T2, T3, and T4 (P<0.05). Additionally, midazolam oral solution group had a lower ICC score (P<0.05) and longer recovery time (P<0.05), but no significant difference in the length of PACU stay was observed (P>0.05). CONCLUSION: Oral midazolam solution is more readily accepted by pediatric patients compared to dexmedetomidine nasal spray, and it exhibits superior efficacy in alleviating preoperative anxiety, however, its recovery time is prolonged.