What is the recommended dosing for pediatric seizure treatment?

Pediatric Seizure Treatment Dosing Guidelines

For pediatric seizure treatment, the recommended first-line medication is lorazepam at 0.05-0.10 mg/kg IV/IM (maximum 4 mg per dose), which may be repeated every 10-15 minutes for continued seizures. 1

First-Line Treatment Options

Lorazepam (Preferred)

• IV/IM: 0.05-0.10 mg/kg (maximum: 4 mg per dose), may repeat every 10-15 minutes if needed for continued seizures 1
• Monitor for increased incidence of apnea, especially when combined with other sedative agents 1
• Always monitor oxygen saturation and be prepared to provide respiratory support 1

Diazepam (Alternative)

• IV: 0.1-0.3 mg/kg every 5-10 minutes (maximum: 10 mg per dose) 2
• Rectal: 0.5 mg/kg up to 20 mg when IV access is unavailable 2
• Should be administered over approximately 2 minutes to avoid pain at the IV site 2

Midazolam (Alternative)

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

Second-Line Treatment Options

Phenobarbital

• IV: 20 mg/kg (maximum dose: 1000 mg), infused over 10 minutes 1
• Repeat dose once if necessary after 15 minutes (maximum total dose: 40 mg/kg) 1
• Be prepared to provide respiratory support and monitor oxygen saturation 1

Phenytoin

• Neonates IV: 10 mg/kg 1
• Children IV: 20 mg/kg (maximum initial dose: 1000 mg) 1
• Recommended infusion time is 10-20 minutes; drug-delivery rate not to exceed 1 mg/kg per minute 1
• Must be diluted in normal saline to avoid precipitation; incompatible with glucose-containing solutions 1
• May cause hypotension and arrhythmias, especially with rapid infusion 1
• Monitor heart rate and reduce infusion rate if heart rate decreases by 10 beats per minute 1

Seizure Management Algorithm

1. Initial Management:

   • Ensure adequate airway and oxygenation 1
   • Check blood glucose immediately 1
   • Establish vascular or intraosseous access 1

2. First-Line Treatment:

   • Administer lorazepam 0.05-0.10 mg/kg IV/IO 1
   • If IV/IO access unavailable, consider rectal paraldehyde 0.4 mg/kg 1
   • May repeat lorazepam dose if seizures continue 1

3. Second-Line Treatment (if seizures persist after 2 doses of benzodiazepines):

   • Phenytoin 18-20 mg/kg IV/IO over 20 minutes 1
   • OR Phenobarbital 15-20 mg/kg IV/IO over 10 minutes 1

4. Refractory Status Epilepticus:

   • Call anesthesiologist for rapid sequence intubation 1
   • Consider continuous midazolam infusion 1

Important Considerations

• Benzodiazepines (lorazepam, diazepam, midazolam) have an increased risk of causing respiratory depression, especially when given rapidly IV or combined with other sedative agents 2, 3
• Network meta-analysis suggests midazolam has the highest probability of achieving seizure cessation, while lorazepam has the largest probability of reducing respiratory depression 4
• Flumazenil may be administered to reverse life-threatening respiratory depression caused by benzodiazepines but will also counteract the anticonvulsant effects and may precipitate seizures 1, 2
• Implementation of standardized protocols for status epilepticus treatment has been shown to decrease time to medication administration, particularly for second-line agents 5
• For neonatal seizures refractory to phenobarbital, lorazepam at 0.05 mg/kg IV (up to 0.15 mg/kg total) has shown efficacy without significant adverse effects 6

Pitfalls to Avoid

• Underdosing benzodiazepines is common and reduces efficacy 5
• Delayed administration of second-line agents can lead to prolonged seizures and worse outcomes 5
• Failure to monitor respiratory status during and after benzodiazepine administration 1, 2
• Using phenytoin with glucose-containing solutions can cause precipitation 1
• Administering benzodiazepines too rapidly can increase the risk of respiratory depression 2