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Are We Underdosing Intranasal Midazolam in Pediatric Seizures?

April 20, 2021

Written by Cliff Freeman

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The use of intranasal midazolam at a dose of 0.1 mg/kg for treatment of pediatric seizures was not as effective as the same dose of midazolam when given by other routes including IM, IV and IO.

Why does this matter?
The first step in seizure management is to stop the seizure. While this is easier said than done, it is the priority in emergency management. First line treatment for seizure cessation is benzodiazepines. However, these treatments are only as good as the doses given. This study seems to support the need to “go big” when treating seizures in the prehospital environment, particularly when using intranasal administration in pediatric patients.

Maybe less is just less
This was a retrospective non-inferiority study including 2,034 non-trauma patients ≤14 years old being treated for seizures by 31 EMS agencies in the same city. The authors compared intranasal midazolam with all other routes of midazolam administration and measured the effectiveness by the need for repeat dosing of medications to achieve seizure cessation. The dosing for midazolam in this system was 0.1mg/kg regardless of route of administration. The risk difference for redosing after initial IN administration compared to alternate routes was 11.0% (95% CI 6.7 – 15.3%). This was an ineffective dose/route combination for the management of pediatric seizures.  A knee-jerk reaction to this study could be to exclude intranasal administration of benzodiazepines and go straight to intramuscular; however, this increases risk to providers, as it introduces sharps into a dynamic environment. The authors’ response was to increase intranasal dosing for midazolam in pediatric seizure to 0.2mg/kg, which seems like a reasonable option.

Editor’s Note: Since we routinely use intranasal midazolam 0.5mg/kg (max 10mg) for anxiolysis in the PED, this would also be a reasonable first dose for seizure patients. If we’re going to go big, let’s go big. ~Clay Smith

The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study. Prehosp Emerg Care. 2021 Mar 29:1-9. doi: 10.1080/10903127.2021.1897197. Epub ahead of print.

3 thoughts on “Are We Underdosing Intranasal Midazolam in Pediatric Seizures?

  • It’s also important to consider that the MAD device for IN contains approx. 0.1ml. That can mean a lot in PEDS. So add some air or put 0.1ml more in the siringe.

  • In Australia, there’s wide spread use of 0.3 mg/kg midazolam buccal or intranasal with 5mg/ml midazolam concentration.

What are your thoughts?