Can lorazepam (Ativan) be given to an infant?

Lorazepam Use in Infants

Lorazepam should generally be avoided in infants, particularly in premature and newborn infants, due to significant risks of adverse effects including respiratory depression, seizures, and hypotension. If absolutely necessary for seizure management, it should only be used with extreme caution under close monitoring.

Safety Concerns in Infants

The use of lorazepam in infants carries substantial risks:

• Adverse events: A retrospective study found that 16% of infants receiving benzodiazepines experienced adverse events including seizures (n=6), hypotension (n=5), and respiratory depression (n=3) 1

• Premature infants: Particularly high risk due to:

  • Immature glucuronidation pathways needed for metabolism 2
  • Reports of toxic serum concentrations even days after administration 2
  • Cases of myoclonus in very-low-birth-weight infants following administration 3

• FDA labeling: The FDA does not establish safety in children under 12 years of age 4

Limited Indications in Infants

The American Academy of Pediatrics mentions lorazepam use in infants only in very specific circumstances:

1. Status epilepticus: When used, the recommended dosage is 0.1 mg/kg intravenously/intraosseously over >10 minutes 5

2. Neonatal drug withdrawal: Only as part of a carefully monitored conversion from intravenous midazolam, not as primary therapy 5

Precautions if Use is Unavoidable

If lorazepam must be used in an infant for status epilepticus:

• Ensure respiratory support is immediately available
• Continuously monitor vital signs, especially respiratory effort and blood pressure
• Watch for seizure activity as paradoxical reactions including myoclonus have been reported 3, 6
• Be aware of tachyphylaxis (decreasing effectiveness) with sequential doses 7
• Consider alternatives when possible, especially in premature infants

Alternative Approaches for Seizure Management

For seizure management in infants, the recommended algorithm is:

1. Ensure airway patency and provide high-flow oxygen
2. Check glucose levels
3. Establish vascular or intraosseous access
4. If lorazepam is absolutely necessary: 0.1 mg/kg IV/IO over >10 minutes
5. If seizures continue: Consider paraldehyde 0.4 mg/kg rectally
6. For ongoing seizures: Consider phenytoin (loading dose 18 mg/kg IV/IO over 20 min) or phenobarbital (15-20 mg/kg IV/IO over 10 min) 5

Conclusion

The risks of lorazepam in infants generally outweigh the benefits except in specific emergency situations like status epilepticus. Even then, it should be used with extreme caution, appropriate monitoring, and awareness of the high risk of adverse effects in this vulnerable population.