Can diazepam be given to a newborn experiencing convulsions?

Diazepam Administration for Neonatal Convulsions

Yes, diazepam can be given to newborns experiencing convulsions, but it is not the preferred first-line agent—phenobarbital is recommended as first-line treatment for neonatal seizures, with lorazepam as an alternative if phenobarbital fails. 1

First-Line Treatment: Phenobarbital

• Phenobarbital is the preferred first-line anticonvulsant for neonatal seizures at a dose of 10 mg/kg IV. 1
• Neonates have unique pharmacokinetic considerations that make phenobarbital safer than other benzodiazepines or phenytoin due to decreased protein binding that increases free drug levels and toxicity risk with other agents. 1

When Diazepam May Be Used

If phenobarbital fails to control seizures, diazepam can be administered with the following critical parameters:

Dosing for Neonates

• IV diazepam: 0.1-0.3 mg/kg every 5-10 minutes (maximum 10 mg per dose), administered over approximately 2 minutes to avoid pain at the IV site. 2
• Rectal diazepam: 0.5 mg/kg up to 20 mg when IV access is unavailable, though absorption may be erratic. 2
• For continuous infusion in refractory cases: at least 1 mg/hour (approximately 0.3 mg/kg/hour) may be required, with doses up to 1.0-1.5 mg/hour typically needed to stop convulsions in term infants. 3
• Rectal administration achieves presumed anticonvulsive concentrations (150-300 ng/ml) within 5 minutes with doses of 0.5-1 mg/kg. 4

Critical Safety Monitoring

Respiratory depression is the most serious risk and occurs more frequently with diazepam than other benzodiazepines:

• There is an increased incidence of apnea when diazepam is given rapidly IV or combined with other sedative agents—continuous oxygen saturation monitoring and immediate respiratory support availability are mandatory. 2, 5
• Maintain an unobstructed airway, monitor vital signs continuously, and have artificial ventilation equipment immediately available. 1
• Diazepam causes respiratory depression in 21% of pediatric patients compared to 4% with lorazepam. 6

Important Limitations of Diazepam

• Diazepam is rapidly redistributed, and seizures often recur within 15-20 minutes, requiring immediate follow-up with a long-acting anticonvulsant such as phenytoin or phenobarbital. 2
• IM administration is NOT recommended due to risk of tissue necrosis. 2
• Accumulation of the depressive metabolite N-desmethyldiazepam occurs in all neonates, which must be considered with repeated dosing. 4

Preferred Alternative: Lorazepam

If phenobarbital fails, lorazepam is generally preferred over diazepam because it has a prolonged duration of anticonvulsant activity and lower risk of respiratory depression:

• Lorazepam 0.05 mg/kg IV, repeated up to a total dose of 0.15 mg/kg if necessary, achieves complete cessation of seizures within 3 minutes in 86% of neonates refractory to phenobarbital. 7
• Lorazepam causes respiratory depression in only 4% of patients versus 21% with diazepam. 6
• Six of seven neonates with refractory seizures responded to lorazepam without developing apnea or hypotension. 7

Common Pitfalls to Avoid

• Never administer diazepam rapidly—infuse over 2 minutes minimum to reduce pain and respiratory depression risk. 2, 5
• Do not rely on diazepam alone—always follow immediately with phenobarbital or phenytoin to prevent seizure recurrence. 2, 5
• Avoid IM route entirely due to tissue necrosis risk. 2
• Do not use flumazenil to reverse sedation in seizure patients, as it will counteract anticonvulsant effects and may precipitate seizures. 5, 8
• Flumazenil may only be considered for life-threatening respiratory depression, but this reverses seizure control. 2, 5

Treatment Algorithm for Neonatal Seizures

1. First-line: Phenobarbital 10 mg/kg IV 1
2. If seizures persist: Lorazepam 0.05 mg/kg IV (up to 0.15 mg/kg total) OR Diazepam 0.1-0.3 mg/kg IV 2, 7
3. Immediately follow with long-acting anticonvulsant (phenytoin or additional phenobarbital) 2, 5
4. For refractory status epilepticus: Consider continuous midazolam or pentobarbital infusion with ICU support 8