What is the dosage and administration protocol for buccal midazolam in pediatric patients with acute seizures?

Buccal Midazolam for Pediatric Acute Seizures

For pediatric patients with acute seizures, buccal midazolam should be administered at a dose of 0.3 mg/kg (maximum doses based on age), with seizure cessation typically occurring within 3-4 minutes of administration.

Dosage Protocol

The recommended dosing for buccal midazolam in pediatric patients with acute seizures follows an age-based approach:

Age	Dose
3 months to <1 year	2.5 mg
1 year to <5 years	5 mg
5 years to <10 years	7.5 mg
10 years to <18 years	10 mg

Administration Technique

1. Draw up the appropriate dose of midazolam solution
2. Place the liquid between the gum and cheek (buccal cavity)
3. Administer half the dose on one side of the mouth and half on the other side
4. Do not administer during active chewing as this may lead to swallowing and reduced absorption
5. Monitor the patient continuously after administration

Efficacy and Timing

Buccal midazolam has demonstrated high efficacy in terminating seizures:

• 84-94% of seizures stop within 10 minutes of administration 1, 2
• Median time to seizure cessation is approximately 3-4 minutes 1
• Most effective when administered for seizures lasting less than 30 minutes (100% efficacy) 1
• Efficacy decreases with longer seizure duration (50% for status epilepticus) 1

Advantages Over Alternative Routes

Buccal midazolam offers several advantages compared to other administration routes:

• More socially acceptable than rectal diazepam 3, 4
• Easier to administer than intravenous medications, especially in community settings
• Similar efficacy to intranasal and intramuscular routes (91% vs 93.3% vs 94.2% in home settings) 2
• High caregiver satisfaction, though intranasal route showed highest satisfaction among caregivers 2

Safety Profile

Buccal midazolam has a favorable safety profile:

• No clinically significant cardiorespiratory events reported in multiple studies 1, 3, 2
• Respiratory depression requiring intervention is rare
• In comparative studies with rectal diazepam, the rate of respiratory depression did not differ between groups 5

Important Considerations

• Monitoring: All patients should be monitored for respiratory depression and oxygen desaturation
• Rescue equipment: Ensure availability of airway management equipment and flumazenil (benzodiazepine antagonist)
• Caution: Be prepared to provide respiratory support regardless of administration route 6
• Contraindications: Use with caution in patients with respiratory compromise or when combined with other sedative agents

Common Pitfalls to Avoid

1. Delayed administration: Seizures lasting >5 minutes should be treated promptly
2. Improper technique: Ensure the medication is placed between cheek and gum, not swallowed
3. Inadequate monitoring: Continue monitoring for at least 30 minutes after administration
4. Failure to prepare for complications: Always have airway management equipment readily available
5. Not adjusting for prolonged seizures: For seizures lasting >30 minutes, be prepared for potential treatment failure and have backup anticonvulsants ready

Buccal midazolam represents an effective, safe, and socially acceptable first-line treatment for acute seizures in children, with high efficacy rates and minimal adverse effects when administered properly.