What is the safety and efficacy of administering lorazepam (Ativan) injectable orally to a 1-year-old patient experiencing seizures?

Oral Administration of Injectable Lorazepam for Seizures in a 1-Year-Old is NOT Recommended

Injectable lorazepam should never be given orally to a 1-year-old child experiencing seizures, as this route is contraindicated in the acute seizure setting due to aspiration risk and lack of efficacy data. 1

Why Oral Administration is Contraindicated

• Nothing should be given by mouth to a patient who has just had a seizure due to decreased responsiveness and high aspiration risk in the immediate postictal period 2, 1
• The American Academy of Pediatrics explicitly states that oral lorazepam is NOT used for acute post-seizure management—intravenous or intramuscular routes are the standard of care for seizure emergencies 1
• Oral administration has no established efficacy or safety data for acute seizure management in pediatric patients 1

Appropriate Routes for Lorazepam in a 1-Year-Old with Seizures

First-Line: Intravenous Administration

• Standard IV dose: 0.1 mg/kg (maximum 4 mg per dose) for status epilepticus 1, 3
• May be repeated every 10-15 minutes if seizures persist 1
• Intravenous lorazepam is established as efficacious for stopping seizures lasting at least 5 minutes in children (Level A evidence) 3

Alternative When IV Access Unavailable: Intramuscular Route

• IM dose: 0.2 mg/kg (maximum 6 mg per dose) when IV access is unavailable 1
• Can be repeated every 10-15 minutes 1
• Intramuscular midazolam has been shown superior to IV lorazepam when IV access is not established, though direct IM lorazepam data is more limited 3

Other Non-Oral Alternatives

• Intranasal lorazepam: 0.1 mg/kg has been shown non-inferior to IV lorazepam in children aged 6-14 years 4
• Buccal midazolam is probably effective (Level B evidence) and preferred over rectal routes due to ease of administration 3, 5
• Rectal diazepam is an acceptable alternative but has slower absorption 6, 3

Critical Safety Monitoring

• Respiratory support must be immediately available regardless of route, with continuous oxygen saturation monitoring 1
• Risk of apnea is increased, especially when combined with other sedatives 1
• Monitor for seizure recurrence for at least 2 hours after initial lorazepam administration 1

When to Activate Emergency Medical Services

Call EMS immediately for: 2, 1

• First-time seizure in any child
• Seizure lasting >5 minutes
• Multiple seizures without return to baseline between episodes
• Seizure in an infant <6 months of age
• Patient not returning to baseline within 5-10 minutes after seizure stops
• Seizure with traumatic injury, difficulty breathing, or occurring in water

Subsequent Management if Seizures Persist

• Lorazepam is rapidly redistributed and seizures often recur within 15-20 minutes, necessitating long-acting anticonvulsant coverage 1
• If seizures persist after lorazepam, immediately administer a long-acting anticonvulsant such as phenytoin (18 mg/kg IV over 20 minutes) or fosphenytoin (20 mg phenytoin equivalents/kg at ≤150 mg/min) 1
• If seizures continue after benzodiazepine and phenytoin/fosphenytoin, consider phenobarbital (15-20 mg/kg IV over 10 minutes) 1

Common Pitfalls to Avoid

• Never restrain the seizing child 2
• Never put anything in the mouth during or immediately after a seizure 2, 1
• Do not give food, liquids, or oral medicines to a person experiencing a seizure or with decreased responsiveness after a seizure 2, 1
• Do not use flumazenil to reverse sedation in seizure patients, as it will precipitate seizure recurrence 1