What is the recommended dose of benzodiazepines (BZDs), such as lorazepam (Ativan) or midazolam (Versed), for pediatric patients?

Benzodiazepine Dosing in Pediatric Patients

For pediatric sedation and anxiolysis, midazolam should be dosed at 0.05-0.1 mg/kg IV (maximum 5 mg) given slowly over 2-3 minutes, with lorazepam dosed at 0.05-0.1 mg/kg IV/IM as an alternative. 1, 2

Route-Specific Dosing Algorithms

Intravenous/Intraosseous Administration

For procedural sedation/anxiolysis:

• Age <6 months: 0.05-0.1 mg/kg IV over 2-3 minutes (use extreme caution due to high risk of airway obstruction) 3
• Age 6 months-5 years: Initial 0.05-0.1 mg/kg; may titrate up to total 0.6 mg/kg (usually not exceeding 6 mg) 3, 4
• Age 6-12 years: Initial 0.025-0.05 mg/kg; may titrate up to total 0.4 mg/kg (usually not exceeding 10 mg) 3, 4
• Age 12-16 years: Dose as adults; total usually does not exceed 10 mg 3

For rapid sequence intubation:

• Midazolam: 0.2-0.4 mg/kg IV/IO (maximum 20 mg) 1
• Lorazepam: 0.1 mg/kg IV/IM 1

Intramuscular Administration

• Midazolam: 0.1-0.15 mg/kg IM for routine sedation; up to 0.5 mg/kg for highly anxious patients (total usually not exceeding 10 mg) 3
• Lorazepam: 0.05-0.1 mg/kg IM 1

Intranasal Administration

• Midazolam: 0.2-0.3 mg/kg intranasal for anxiolysis and mild sedation 2
• Critical limitation: Intranasal midazolam at 0.5 mg/kg showed only 54% physician satisfaction for laceration repair versus 88% with IV ketamine/midazolam, indicating this route is inadequate for painful procedures 2

Oral Administration

• Midazolam: 0.25-0.5 mg/kg PO (maximum 20 mg); children <6 years may require up to 1 mg/kg 3, 4

Continuous Infusion (Critical Care Settings)

Non-neonatal patients:

• Loading dose: 0.05-0.2 mg/kg IV over 2-3 minutes in intubated patients 3
• Maintenance infusion: 0.06-0.12 mg/kg/hr (1-2 mcg/kg/min), titrate by 25% increments as needed 5, 3

Neonatal patients (<32 weeks):

• Infusion rate: 0.03 mg/kg/hr (0.5 mcg/kg/min) 3

Critical Safety Considerations

Respiratory Depression Risk

The combination of benzodiazepines with opioids dramatically increases apnea risk and requires immediate availability of respiratory support equipment. 1, 2

• Continuous oxygen saturation monitoring is mandatory 2
• Respiratory depression occurs in 11.6% of pediatric patients receiving midazolam for procedural sedation 2
• Fentanyl combined with benzodiazepines causes synergistic respiratory depression even at low doses 1

Titration Requirements

Wait 2-3 minutes between doses to assess peak effect before administering additional medication. 3

• Midazolam takes approximately three times longer than diazepam to achieve peak EEG effects due to water solubility 3
• Failure to wait for peak effect is a common cause of oversedation 3

Flumazenil Reversal

Flumazenil must be immediately available at 0.01-0.02 mg/kg IV (maximum 0.2 mg per dose) to reverse life-threatening respiratory depression. 1, 5

• Repeat at 1-minute intervals to maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower 1
• Critical warning: Flumazenil reverses anticonvulsant effects and may precipitate seizures if benzodiazepine was used for seizure control 1, 2
• Contraindicated in tricyclic antidepressant overdose (may induce seizures or arrhythmias) 1
• Duration of flumazenil is shorter than most benzodiazepines; observe continuously for at least 2 hours after last dose 1

Status Epilepticus Dosing

For seizure management, nonintravenous midazolam and IV lorazepam are superior to diazepam formulations. 6

• Network meta-analysis shows midazolam has highest probability (SUCRA = 0.792) of achieving seizure cessation 6
• Lorazepam has best safety profile for respiratory depression (SUCRA = 0.4346) 6
• Common error: 43.4% of EMS-provided initial benzodiazepine doses are inappropriately low, leading to need for multiple doses 7

Age-Specific Vulnerabilities

Infants <6 Months

This population is particularly vulnerable to airway obstruction and hypoventilation; use smallest increments with meticulous monitoring. 3

• Physiology transition from neonatal to pediatric is uncertain, making dosing recommendations unclear 3
• Titrate with extreme caution to clinical effect 3

Young Children (1-5 Years)

Paradoxical agitation occurs more frequently in this age group and should be anticipated. 2, 3

• Seven of seven patients experiencing resedation after flumazenil were in the 1-5 year age range 8
• Monitor for at least 1-2 hours after flumazenil administration due to resedation risk 8

Comparative Agent Selection

Midazolam vs. Lorazepam

Midazolam has faster onset but shorter duration; lorazepam provides longer seizure control. 9

• Midazolam duration: 3-4 hours 9
• Lorazepam duration: up to 72 hours 9
• Use of lorazepam or diazepam (versus midazolam) is associated with need for multiple benzodiazepine doses in prehospital setting 7

Chemical Restraint in Agitated Patients

For acute agitation, lorazepam or midazolam at 0.05-0.1 mg/kg IV/IM can be combined with antipsychotics. 1

• Combinations of haloperidol with lorazepam or midazolam may be more effective than either alone 1
• Can be administered in same syringe 1

Common Pitfalls to Avoid

1. Do not use intranasal midazolam as sole agent for painful procedures—consider ketamine or IV route instead 2

2. Do not combine with opioids without appropriate airway management capabilities present 1, 2

3. Do not administer rapid IV bolus—always give over 2-3 minutes to prevent hypotension and respiratory depression 3

4. Do not assume adult dosing applies to adolescents—always calculate mg/kg doses 4

5. Do not use flumazenil routinely—most benzodiazepine oversedation can be managed with supportive care alone 1