IV Midazolam Dosing for Convulsions in Children
For acute convulsive seizures or status epilepticus in children, administer IV midazolam 0.1 mg/kg (maximum 5 mg per dose) slowly over 2-3 minutes, and repeat every 10-15 minutes if seizures persist, escalating to a loading dose of 0.15-0.20 mg/kg followed by continuous infusion starting at 1 μg/kg/min (0.06 mg/kg/hr) for refractory cases. 1, 2
Initial Bolus Dosing
- Standard IV dose: 0.05-0.10 mg/kg administered slowly over 2-3 minutes, with a maximum single dose of 5 mg 1, 2
- Peak effect occurs at 3-5 minutes after administration, so wait this interval before redosing to avoid oversedation 1, 2
- Repeat dosing: May be repeated every 10-15 minutes if seizures continue 1, 2
- Most seizures (91%) respond within 3 bolus doses, with minimal chance of response beyond that point 3
The American Academy of Pediatrics guidelines emphasize that lower doses are ineffective for seizure control, making the 0.1 mg/kg dose the practical starting point rather than 0.05 mg/kg 1. Research confirms that seizures typically stop within 1 minute of administration when adequate dosing is used 4.
Escalation for Refractory Status Epilepticus
If seizures persist despite repeated bolus doses:
- Loading dose: 0.15-0.20 mg/kg IV 1, 2, 5
- Continuous infusion: Start at 1 μg/kg/min (0.06 mg/kg/hr) 1, 2, 5
- Titration: Increase by increments of 1 μg/kg/min every 15 minutes 1, 2
- Maximum infusion rate: 5 μg/kg/min (0.3 mg/kg/hr) until seizures stop 1, 2
Studies demonstrate that continuous midazolam infusion achieves complete seizure control in 96% of refractory cases at a mean infusion rate of 3.1 μg/kg/min within 65 minutes 6. The protocol-based approach combining bolus and infusion successfully manages 89% of refractory cases 7.
Special Population: Neonates and Infants <1 Month
The provided guidelines do not specify different dosing for neonates under 1 month of age. In the absence of specific neonatal guidance, use extreme caution with dose reduction to the lower end of the pediatric range (0.05 mg/kg) and extend the administration time beyond 2-3 minutes due to increased risk of apnea and cardiovascular instability in this age group 1.
Critical Safety Monitoring
- Respiratory depression risk is highest when midazolam is combined with other sedatives or opioids 1, 2
- Monitor oxygen saturation continuously and be prepared to provide respiratory support regardless of route 1, 2, 5
- Respiratory depression can occur up to 30 minutes after administration, requiring extended monitoring 8
- Flumazenil must be immediately available to reverse life-threatening respiratory depression, though this will also reverse anticonvulsant effects and may precipitate seizures 1, 2
- Assisted ventilation was required in only 3% of cases when treating impending status epilepticus with the bolus protocol 3
Common Pitfalls to Avoid
- Inadequate time between doses: Wait the full 3-5 minutes for peak effect before redosing to prevent cumulative oversedation 1, 2
- Rapid IV administration: Administer slowly over 2-3 minutes to avoid hypotension and oversedation 1, 2
- Paradoxical agitation: Occurs in approximately 6% of younger children; consider alternative agents if this develops 1, 8
- Failure to escalate appropriately: If 3 bolus doses fail, proceed directly to loading dose and continuous infusion rather than continuing intermittent boluses 3
- Combining with other CNS depressants: Reduce midazolam dose by 30-50% when used with opioids or other sedatives 2