What are the recommended lorazepam doses for children aged six months and older for anxiety, acute seizures, and procedural sedation?

Lorazepam Pediatric Dosing

For children aged 6 months and older, lorazepam dosing is 0.05-0.1 mg/kg IV/IM (maximum 4 mg per dose) for status epilepticus, repeatable every 10-15 minutes; 0.05-0.1 mg/kg PO/IM/IV for anxiety and procedural sedation in prepubertal children (ages 6-12 years); and 0.5-1 mg for adolescents, repeatable every 30-60 minutes. 1

Status Epilepticus and Acute Seizure Management

First-Line Dosing

• Administer 0.1 mg/kg IV (maximum 4 mg per dose) for status epilepticus, which may be repeated every 10-15 minutes if seizures persist. 2
• An alternative dosing range of 0.05-0.1 mg/kg IV (maximum 4 mg) is also recommended by the American Academy of Pediatrics. 2, 3, 1
• For convulsive status epilepticus specifically, 0.1 mg/kg IV (maximum 2 mg) may be repeated after at least 1 minute, with a maximum of 2 doses. 2

Alternative Routes When IV Access Unavailable

• IM administration: 0.2 mg/kg (maximum 6 mg per dose), repeatable every 10-15 minutes. 2, 3
• Rectal administration (0.5 mg/kg up to 20 mg) has erratic absorption and is not recommended as first-line. 2
• Never give oral lorazepam for acute post-seizure management due to decreased responsiveness and aspiration risk in the immediate postictal period. 2, 1

Non-Convulsive Status Epilepticus

• Use 0.05 mg/kg (maximum 1 mg) IV, repeating every 5 minutes up to 4 doses. 2

Anxiety and Procedural Sedation

Prepubertal Children (Ages 6-12 Years)

• Standard dosing: 0.05-0.1 mg/kg PO/IM/IV. 1
• Lorazepam has advantages including no extrapyramidal symptoms, low addiction potential, and high therapeutic index. 1

Adolescents

• Dosing: 0.5-1 mg, may repeat every 30-60 minutes. 1

Critical Safety Considerations

Respiratory Monitoring

• Respiratory support must be immediately available regardless of route, with continuous oxygen saturation monitoring. 2, 3, 1
• There is an increased incidence of apnea when lorazepam is combined with other sedative agents, particularly in neonates and young children. 2, 3, 1
• Monitor for respiratory depression continuously during and after administration. 3

Paradoxical Reactions

• Paradoxical behavioral disinhibition from benzodiazepines is especially common in younger children and those with developmental disabilities. 1
• Monitor for paradoxical excitation in addition to expected sedation. 1

Flumazenil Precautions

• Avoid flumazenil to reverse sedation in seizure patients, as it will precipitate seizure recurrence by counteracting anticonvulsant effects. 2, 3, 1
• Flumazenil may only be administered to reverse life-threatening respiratory depression, but recognize it will also eliminate seizure control. 2, 3

Post-Administration Management

Monitoring Duration

• Continue monitoring for seizure recurrence for at least 2 hours after initial lorazepam administration. 2, 1
• Lorazepam is rapidly redistributed and seizures often recur within 15-20 minutes, necessitating long-acting anticonvulsant coverage. 2

Refractory Seizures

• 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). 2
• If seizures continue after benzodiazepine and phenytoin/fosphenytoin, consider phenobarbital (15-20 mg/kg IV over 10 minutes). 2

Pharmacokinetic Considerations

Expected Therapeutic Levels

• A 0.1 mg/kg dose achieves concentrations of approximately 100 ng/mL and maintains concentrations >30-50 ng/mL for 6-12 hours. 4
• A second dose of 0.05 mg/kg would achieve desired therapeutic serum levels for approximately 12 hours without excessive sedation. 4
• Uniform pediatric dosing (0.1 mg/kg, to a maximum of 4 mg) can be used to achieve concentrations of 50-100 ng/mL, which have been previously associated with effective seizure control. 5

Age-Related Differences

• Age-dependent dosing is not necessary beyond using a maximum initial dose of 4 mg. 4
• Younger age is associated with slightly higher weight-normalized clearance. 5
• Mean lorazepam systemic clearance in children is 1.3 ± 0.4 mL/min/kg, with a terminal half-life of 10.5 ± 2.9 hours. 6

Common Pitfalls to Avoid

• Administering benzodiazepines too rapidly IV increases the risk of respiratory depression. 3
• Failure to monitor respiratory status during and after benzodiazepine administration can lead to adverse outcomes. 3
• Using lorazepam orally in the immediate postictal period risks aspiration. 2, 1
• Combining lorazepam with other sedatives without adequate respiratory monitoring increases apnea risk. 2, 3, 1