What are the recommended dosages of benzodiazepines (benzos) for pediatric patients?

Pediatric Benzodiazepine Dosing Guidelines

The recommended dosages of benzodiazepines for pediatric patients vary by indication, with specific weight-based calculations required to ensure both safety and efficacy. Proper dosing is critical as benzodiazepines can cause respiratory depression, particularly when administered rapidly or combined with other sedative agents.

Status Epilepticus

Diazepam

• IV/IO: 0.1-0.3 mg/kg (maximum: 10 mg per dose)
  • Administer slowly over 1-2 minutes
  • May repeat every 5-10 minutes if needed 1
• Rectal: 0.5 mg/kg (maximum: 20 mg) 1

Lorazepam

• IV/IM: 0.05-0.10 mg/kg (maximum: 4 mg per dose)
  • May repeat every 10-15 minutes for continued seizures 2

Midazolam

• IM: 0.2 mg/kg (maximum: 6 mg per dose)
  • May repeat every 10-15 minutes 2
• For refractory status epilepticus:
  • IV: Loading dose 0.15-0.20 mg/kg, followed by continuous infusion of 1 mg/kg per minute
  • Increase by increments of 1 mg/kg per minute (maximum: 5 mg/kg per minute) every 15 minutes until seizures stop 2

Sedation/Anxiolysis

Midazolam

• IV: 0.05-0.10 mg/kg over 2-3 minutes (maximum: 5 mg)
  • Peak effect occurs at 3-5 minutes
  • Dose/observe and redose/observe every 3-5 minutes to avoid oversedation 2
• PO: 0.25-0.50 mg/kg (maximum: 20 mg)
  • Children <6 years may require up to 1 mg/kg 2

For Rapid Sequence Intubation

• Midazolam IV: 0.2 mg/kg 2
• Lorazepam IV/IO: 0.05-0.15 mg/kg (maximum: 4 mg) 2

Seizure Disorders (Maintenance Therapy)

Clonazepam (Oral)

• Initial dose: 0.01-0.03 mg/kg/day (not to exceed 0.05 mg/kg/day)
  • Divided into two or three doses
• Titration: Increase by no more than 0.25-0.5 mg every third day
• Maintenance dose: 0.1-0.2 mg/kg/day
  • Divided into three equal doses (largest dose before bedtime) 3

Acute Agitation/Psychosis

Lorazepam

• IV/IM: 0.05-0.15 mg/kg (maximum: 5 mg per dose)
  • May repeat hourly as necessary 2

Important Safety Considerations

1. Respiratory Monitoring:

   • Monitor oxygen saturation and respiratory effort during administration
   • Be prepared to provide respiratory support if respiratory depression occurs 1
   • Risk of apnea increases when combined with other sedative agents, particularly opioids 2

2. Reversal Agent:

   • Flumazenil: 0.01-0.02 mg/kg IV (maximum: 0.2 mg)
   • May repeat at 1-minute intervals to maximum cumulative dose of 0.05 mg/kg or 1 mg (whichever is lower)
   • Note: Will also counteract anticonvulsant effects and may precipitate seizures in patients with underlying seizure disorders 2

3. Paradoxical Reactions:

   • Paradoxical agitation may occur, especially in younger children 2
   • More common in children with developmental disabilities 2

Administration Routes

• IV administration: Preferred for emergency situations requiring rapid onset
• IM administration: Alternative when IV access unavailable, but absorption can be erratic for some benzodiazepines
• Rectal administration: Useful alternative for seizure management when IV access is unavailable 1
• Oral administration: Appropriate for scheduled dosing in seizure disorders and anxiety disorders

Contraindications

Benzodiazepines are contraindicated in:

• Severe respiratory insufficiency
• Sleep apnea syndrome
• Severe hepatic impairment
• Myasthenia gravis
• Acute narrow-angle glaucoma 1

Clinical Pearls

1. For status epilepticus, a long-acting anticonvulsant should be administered immediately after diazepam due to its rapid redistribution and potential for seizure recurrence within 15-20 minutes 1

2. Lorazepam may be preferred over diazepam for status epilepticus due to its longer duration of anticonvulsant activity 1

3. When using benzodiazepines for sedation, always have resuscitation equipment immediately available and ensure continuous monitoring of vital signs 2, 1

4. Benzodiazepines should generally be used for the shortest duration possible to minimize risks of tolerance and dependence 4