Diazepam Dosing for Seizures in Children
For acute seizure management in children, administer diazepam 0.1-0.3 mg/kg IV (maximum 10 mg per dose) over approximately 2 minutes, or 0.5 mg/kg rectally (maximum 20 mg) when IV access is unavailable. 1, 2, 3
Intravenous Administration
The recommended IV dose is 0.1-0.3 mg/kg administered slowly over approximately 2 minutes to avoid pain at the injection site and reduce the risk of precipitating seizures with rapid administration. 1, 2, 3
Doses may be repeated every 5-10 minutes if seizures persist, up to a maximum total dose of 30 mg. 1, 3
Diazepam must be followed immediately by a long-acting anticonvulsant such as phenytoin or fosphenytoin because diazepam is rapidly redistributed and seizures often recur within 15-20 minutes. 1, 2
Age-Specific IV Dosing
Infants over 30 days and children under 5 years: 0.2-0.5 mg slowly every 2-5 minutes up to a maximum of 5 mg (IV preferred). 3
Children 5 years or older: 1 mg every 2-5 minutes up to a maximum of 10 mg (slow IV administration preferred). 3
Rectal Administration (When IV Access Unavailable)
The rectal dose is 0.5 mg/kg up to a maximum of 20 mg, using undiluted IV diazepam solution. 1, 2
Rectal diazepam is highly effective, stopping seizures in 81% of children after a single dose, though seizure recurrence before hospital arrival occurs in approximately 30% of cases. 4
Rectal administration is easier to perform than IV access in seizing children, equally efficacious, and associated with lower rates of respiratory depression compared to IV diazepam. 4
The WHO guidelines specifically recommend rectal diazepam when IV access is not available, advising against IM diazepam due to erratic absorption and risk of tissue necrosis. 1, 5, 3
Critical Safety Monitoring
Monitor oxygen saturation and respiratory effort continuously, as there is an increased incidence of apnea when diazepam is given rapidly IV or combined with other sedative agents. 1, 2
Be prepared to provide respiratory support with bag-valve-mask ventilation and have intubation equipment immediately available. 1, 2
Respiratory depression is less common with rectal administration (rare) compared to IV administration (occurred in 2 of 15 children in one study), but personnel must still be prepared for definitive respiratory support. 4
Flumazenil may reverse life-threatening respiratory depression but will also counteract anticonvulsant effects and may precipitate seizures, so use with extreme caution. 1, 2
Important Clinical Pitfalls to Avoid
Never administer diazepam intramuscularly—this route causes tissue necrosis and has erratic absorption. 1, 3
Avoid administering diazepam too rapidly IV, as this can precipitate seizures and cause severe pain at the injection site. 1, 2, 3
Do not rely on diazepam alone for seizure control—always follow with a long-acting anticonvulsant like phenytoin (20 mg/kg IV) or phenobarbital (15-20 mg/kg IV) to prevent seizure recurrence. 1, 6, 2
If diazepam is administered through an infusion line, inject slowly through the tubing as close as possible to the vein insertion to minimize precipitation. 3
Alternative First-Line Agent
Lorazepam may be preferred over diazepam because it has a prolonged duration of anticonvulsant activity (reducing recurrence rates) and may cause less respiratory depression. 1, 6, 2
Lorazepam dosing is 0.05-0.10 mg/kg IV/IM (maximum 4 mg per dose), repeated every 10-15 minutes if needed. 6, 2
In one comparative trial, only 4% of children receiving IV lorazepam experienced respiratory depression compared to 21% with IV diazepam, though this difference was not statistically significant. 7