What is the recommended dosing of diazepam (Diazepam) for pediatric patients experiencing spasms?

Pediatric Diazepam Dosing for Spasms

For pediatric patients experiencing spasms, the recommended diazepam dosing is 0.1-0.3 mg/kg IV every 5-10 minutes (maximum 10 mg per dose) for acute management, or 0.5 mg/kg rectally (maximum 20 mg) when IV access is unavailable. 1

Intravenous (IV) Administration

• IV diazepam should be administered at 0.1-0.3 mg/kg every 5-10 minutes (maximum: 10 mg per dose) for status epilepticus in children 1
• Administration should occur over approximately 2 minutes to minimize pain at the IV site 1
• When administering IV diazepam, extreme care must be used particularly in very ill patients and those with limited pulmonary reserve due to the risk of apnea and/or cardiac arrest 2
• For pediatric patients, to reduce the risk of adverse effects such as apnea or prolonged somnolence, it is recommended to administer the drug slowly over a three-minute period in a dosage not exceeding 0.25 mg/kg 2
• After an interval of 15-30 minutes, the initial dosage can be safely repeated if needed 2

Rectal Administration

• When IV access is unavailable, rectal diazepam can be administered at 0.5 mg/kg (maximum: 20 mg) 1
• Rectal administration has been shown to be effective in 80% of cases for the acute treatment of convulsions 3
• The therapeutic effect is significantly correlated with the duration of convulsions before treatment; early treatment (convulsions ≤15 minutes) is effective in 96% of cases, while late treatment (convulsions >15 minutes) is effective in only 57% of cases 3

Oral Administration

• For oral administration in children with spasms, the FDA recommends 1 mg to 2.5 mg, 3 or 4 times daily initially, with gradual increases as needed and tolerated 4
• For sedation/anxiolysis, the recommended oral dose is 0.25-0.50 mg/kg (maximum: 20 mg) 1
• Children under 6 years old may require up to 1 mg/kg for effective treatment 1

Safety Considerations and Monitoring

• Resuscitative equipment, including that necessary to support respiration, should be readily available when administering diazepam 2
• There is an increased risk of apnea when diazepam is given rapidly IV or when combined with other sedative agents 1
• Monitor oxygen saturation and respiratory effort continuously during and after administration 1
• Flumazenil may be administered to reverse life-threatening respiratory depression caused by diazepam, but it will also counteract the anticonvulsant effects and may precipitate seizures 1
• Paradoxical agitation may occur, especially in younger children 1
• Diazepam should be followed immediately by a long-acting anticonvulsant due to its rapid redistribution and potential for seizure recurrence within 15-20 minutes 1

Alternative Benzodiazepines

• Lorazepam is an alternative option 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 5
• Midazolam can be administered IM at 0.2 mg/kg (maximum: 6 mg per dose) when IV access is unavailable 5

Treatment Algorithm for Pediatric Spasms

1. Ensure adequate airway and oxygenation
2. Establish vascular access if possible
3. Administer diazepam:
   • If IV access available: 0.1-0.3 mg/kg IV over 2-3 minutes (maximum 10 mg) 1
   • If IV access unavailable: 0.5 mg/kg rectally (maximum 20 mg) 1
4. If seizures continue after 5-10 minutes, repeat diazepam dose 1
5. If seizures persist after second dose, consider alternative anticonvulsants or consult with neurology 5
6. Monitor respiratory status continuously throughout treatment 1, 2