What is the recommended dose and administration of diazepam (Diazepam) for a pediatric patient experiencing an active seizure?

Diazepam Administration for Active Seizures in Pediatric Patients

For an actively seizing child, administer IV diazepam 0.2-0.5 mg/kg (maximum 5 mg for children under 5 years; maximum 10 mg for children 5 years and older) slowly over 2 minutes, repeating every 2-5 minutes as needed up to the maximum dose, followed immediately by a long-acting anticonvulsant to prevent seizure recurrence. 1, 2

When to Give Diazepam

Administer diazepam immediately for:

• Active tonic-clonic seizures (status epilepticus) lasting beyond 5 minutes 1
• Convulsive seizures that require urgent termination 2
• Severe recurrent convulsive seizures 2

The goal is to stop the seizure as quickly as possible to prevent progression to status epilepticus and minimize neurological morbidity. 1

Dosing by Age and Route

Intravenous Route (Preferred)

For infants over 30 days and children under 5 years:

• 0.2-0.5 mg/kg IV slowly every 2-5 minutes 2
• Maximum total dose: 5 mg 2
• Administer over approximately 2 minutes to avoid pain at the IV site 1

For children 5 years and older:

• 1 mg IV every 2-5 minutes 2
• Maximum total dose: 10 mg 2
• Can repeat in 2-4 hours if necessary, though residual metabolites may persist 2

Alternative dosing range (from guidelines):

• 0.1-0.3 mg/kg IV every 5-10 minutes (maximum 10 mg per dose) 1

Rectal Route (When IV Access Unavailable)

When IV access cannot be established:

• 0.5 mg/kg rectally, up to maximum 20 mg 1
• Use undiluted IV diazepam solution administered per rectum 3
• Absorption may be erratic compared to IV, with time to maximum concentration of 5-20 minutes in children 4
• Rectal diazepam is rapidly absorbed and represents an excellent alternative when IV access is difficult 3

Intramuscular Route

If neither IV nor rectal routes are feasible:

• 5-10 mg IM initially, then 5-10 mg in 3-4 hours if necessary (for older children) 2
• However, IM route is generally not preferred for acute seizure management 2

Critical Safety Considerations

Respiratory monitoring is mandatory:

• Monitor oxygen saturation continuously 1
• Have respiratory support immediately available 1, 2
• Increased risk of apnea when given rapidly IV or combined with other sedatives 1
• Hypotension may occur and should be monitored 2

Common pitfall: Diazepam redistributes rapidly, and seizures often recur within 15-20 minutes. 1 You must immediately follow diazepam with a long-acting anticonvulsant (phenytoin 18 mg/kg IV over 20 minutes, or fosphenytoin 20 mg phenytoin equivalents/kg) to prevent recurrence. 1

Administration Technique

For IV administration:

• Inject slowly over 2 minutes 1, 2
• If direct IV not feasible, inject slowly through infusion tubing as close as possible to vein insertion 2
• Titrate to desired response (cessation of seizure activity) 2

For rectal administration:

• Use undiluted IV diazepam solution 3
• Administer via rectal catheter or syringe without needle 3
• Expect absorption within 5-20 minutes 4

Subsequent Management

If seizures persist after maximum diazepam dose:

• Immediately administer long-acting anticonvulsant (phenytoin or fosphenytoin) 1
• If seizures continue after benzodiazepine and phenytoin, consider phenobarbital 15-20 mg/kg IV over 10 minutes 1
• Monitor for seizure recurrence for at least 2 hours after initial administration 5

Reversal agent considerations:

• Flumazenil may reverse life-threatening respiratory depression 1, 2
• However, flumazenil will also counteract anticonvulsant effects and may precipitate seizures 1, 2
• Never use flumazenil simply to reverse sedation in seizure patients 5

Important Contraindications to Long-Term Use

While diazepam is effective for acute seizure management, neither continuous nor intermittent anticonvulsant therapy with diazepam is recommended for long-term prevention of simple febrile seizures in children, as the potential toxicities outweigh the relatively minor risks. 6 This guideline applies only to prophylaxis, not acute seizure treatment.