From the Guidelines
For a 9 kg pediatric patient experiencing seizures, the recommended dose of midazolam (Versed) is 0.2 mg/kg, which translates to 1.8 mg per dose for this child, as per the most recent and highest quality study available 1.
Key Considerations
- Midazolam can be administered intramuscularly (IM) for seizures, with a maximum dose of 6 mg per dose, and may be repeated every 10–15 min if necessary.
- It is crucial to be prepared to provide respiratory support, as there is an increased incidence of apnea when midazolam is combined with other sedative agents.
- Monitoring oxygen saturation is essential, and flumazenil may be administered to reverse life-threatening respiratory depression caused by benzodiazepines such as midazolam, although it will also reverse the anticonvulsant effects and may precipitate seizures.
Administration and Monitoring
- For IV administration, midazolam should be given slowly over 2-3 minutes to avoid respiratory depression.
- The dose may be repeated once after 5-10 minutes if seizures persist, but it is essential to be vigilant for respiratory depression, especially after multiple doses or when combined with other sedatives.
- Always have resuscitation equipment ready, monitor vital signs closely, and be prepared to provide respiratory support if needed.
Mechanism of Action
- Midazolam works by enhancing the effect of the inhibitory neurotransmitter GABA in the brain, which increases chloride conductance through GABA-regulated channels, resulting in membrane hyperpolarization and seizure suppression.
Further Evaluation
- After acute management, further evaluation for the underlying cause of seizures is essential, as per the guidelines for pediatric emergencies 1.
From the FDA Drug Label
The safety and efficacy of midazolam for sedation/anxiolysis/amnesia following single dose intramuscular administration, intravenously by intermittent injections and continuous infusion have been established in pediatric and neonatal patients UNLIKE ADULT PATIENTS, PEDIATRIC PATIENTS GENERALLY RECEIVE INCREMENTS OF MIDAZOLAM ON A MG/KG BASIS. Younger (less than six years) pediatric patients may require higher dosages (mg/kg) than older pediatric patients, and may require closer monitoring.
For a pediatric patient weighing 9 kg with seizures, the dosage of midazolam should be calculated based on the patient's weight.
- The dosage for pediatric patients is generally higher than for adults on a mg/kg basis.
- Younger pediatric patients (less than 6 years) may require higher dosages and closer monitoring.
- The exact dosage cannot be determined without more specific information about the patient's condition and the desired level of sedation. 2
From the Research
Seizure Management in Pediatrics
- The management of seizures in pediatric patients, including those weighing 9 kg, involves the use of anticonvulsant medications such as benzodiazepines 3, 4, 5.
- Benzodiazepines, including midazolam, diazepam, and lorazepam, are considered first-line treatments for acute tonic-clonic convulsions and convulsive status epilepticus in children 3, 4, 5.
Midazolam Dosage and Administration
- The dosage of midazolam for pediatric patients can vary depending on the route of administration and the patient's weight 6.
- Intramuscular midazolam dosages can range from 0.1 to 0.2 mg/kg, while intranasal midazolam dosages can range from 0.1 to 0.2 mg/kg 6.
- Buccal midazolam has been shown to be effective in controlling seizures in pediatric patients, with a dosage of 0.5 mg/kg 3.
Comparison of Anticonvulsant Medications
- Intravenous lorazepam has been shown to be as effective as intravenous diazepam in the treatment of acute tonic-clonic convulsions, with fewer adverse events 3, 5.
- Buccal midazolam has been shown to be more effective than rectal diazepam in controlling seizures in pediatric patients 3, 5.
- Intranasal midazolam has been shown to be as effective as intravenous diazepam in the treatment of prolonged febrile convulsions 5.