Lorazepam Administration in Newborns with Convulsions
Lorazepam can be given to newborns for seizures, but it is contraindicated in premature infants due to benzyl alcohol content in the formulation, and phenobarbital remains the preferred first-line anticonvulsant for neonatal seizures. 1, 2
Critical FDA Contraindication
- The FDA explicitly contraindicates lorazepam injection in premature infants because the formulation contains benzyl alcohol, which can cause fatal "gasping syndrome" in this population 2
- For full-term newborns, lorazepam can be used but only with extreme caution and appropriate monitoring 2
First-Line Treatment Hierarchy
- Phenobarbital (10 mg/kg IV) is the preferred first-line anticonvulsant for neonatal seizures, not lorazepam 1
- Lorazepam should be reserved for refractory seizures that fail to respond to phenobarbital 3, 4
- The American Academy of Pediatrics recommends that pharmacologic therapy for withdrawal-associated seizures is indicated, but other causes must be evaluated first 5
When Lorazepam May Be Used in Term Neonates
If phenobarbital fails (typically after 40 mg/kg), lorazepam 0.05 mg/kg IV may be administered, repeatable up to a total dose of 0.15 mg/kg 3
- In a prospective study of 7 neonates with refractory seizures, 6 of 7 (86%) achieved complete seizure cessation within 3 minutes of lorazepam administration after phenobarbital failure 3
- Another pilot study showed immediate cessation of seizure activity in all 7 neonatal patients within 5 minutes 4
- The standard pediatric dose of 0.05-0.10 mg/kg (maximum 4 mg) applies to older infants and children, but neonatal dosing is lower at 0.05 mg/kg per dose 6, 3
Mandatory Safety Precautions
Respiratory support equipment must be immediately available, with continuous oxygen saturation monitoring and unobstructed airway maintenance 1, 6
- Personnel skilled in airway management must be present before administration 1
- The risk of apnea increases significantly when lorazepam is combined with other sedatives (including phenobarbital) 1, 6, 7
- Close monitoring for myoclonus and paradoxical seizure activity is imperative in neonates 7
- Blood pressure monitoring is essential as hypotension can occur 7
Common Pitfalls to Avoid
- Never use lorazepam in premature infants under any circumstances due to benzyl alcohol toxicity 2
- Do not use lorazepam as first-line therapy—phenobarbital must be tried first 1, 3
- Lorazepam provides no analgesia; do not assume sedation equals pain control 7
- Seizures often recur within 12-16 hours after lorazepam; be prepared with long-acting anticonvulsants 3
- The oral route is never appropriate for acute seizure management in neonates 6