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Benzodiazepine — Status Epilepticus (First-Line) / Procedural Sedation Pregnancy: Avoid — neonatal withdrawal; if essential for status epilepticus, use lowest effective dose

Midazolam (Paediatric)

Brand names: Epistatus (buccal), Buccolam, Hypnovel (IV)

Adult dose

Dose: Procedural sedation: 1–2.5 mg IV titrated; Status epilepticus: 10 mg buccal
Route: IV, buccal, IM, intranasal
Frequency: Single or titrated doses
Max: 10 mg per episode (seizure)
Adult reference — see paediatric dose section

Paediatric dose

Dose: Buccal (status epilepticus): 3 months–1 year: 2.5 mg; 1–5 years: 5 mg; 5–10 years: 7.5 mg; >10 years: 10 mg. IV bolus (procedural sedation): 0.05–0.1 mg/kg slowly. IV status epilepticus: 0.1–0.2 mg/kg. mg/kg
Route: Buccal (first-line community/ward), IV (hospital), intranasal, IM
Frequency: Single dose for seizure; may repeat once after 10 minutes
Max: 10 mg buccal; 10 mg IV per episode
BNFc: Buccolam (licensed buccal solution — age-banded pre-filled syringes) or Epistatus (unlicensed special). Buccal midazolam is APLS first-line for seizures — administer between gum and cheek, divide dose between both sides. IV intranasal (0.2 mg/kg) effective alternative when IV access unavailable. Antidote: flumazenil.

Dose adjustments

Renal

No dose adjustment required for single doses

Hepatic

Use with caution — prolonged sedation in hepatic impairment

Paediatric weight-based calculator

BNFc: Buccolam (licensed buccal solution — age-banded pre-filled syringes) or Epistatus (unlicensed special). Buccal midazolam is APLS first-line for seizures — administer between gum and cheek, divide dose between both sides. IV intranasal (0.2 mg/kg) effective alternative when IV access unavailable. Antidote: flumazenil.

Clinical pearls

  • APLS UK 2021 algorithm: buccal midazolam → lorazepam IV/IO → levetiracetam/phenytoin/phenobarbital IV — midazolam is step 1 regardless of IV access (buccal route); superior to rectal diazepam in convenience and equivalent efficacy
  • Intranasal midazolam: 0.2 mg/kg via MAD (mucosal atomiser device) — useful when IV access not yet established; rapid CNS penetration via olfactory mucosa
  • Flumazenil antidote: reverses benzodiazepine effect — 10 mcg/kg IV (max 200 mcg); short half-life (1 hour) vs midazolam (2–6 hours) — watch for re-sedation
  • Procedural sedation: midazolam alone not an analgesic — combine with analgesia (intranasal fentanyl, oral sucrose in neonates) for painful procedures

Contraindications

  • Respiratory depression without ventilatory support
  • Acute narrow-angle glaucoma
  • Myasthenia gravis

Side effects

  • Respiratory depression (dose-dependent — most serious)
  • Apnoea (especially IV rapid bolus)
  • Hypotension
  • Hiccups
  • Paradoxical excitation
  • Amnesia

Interactions

  • Opioids — additive respiratory depression (MHRA warning)
  • CYP3A4 inhibitors (fluconazole, clarithromycin, erythromycin) — increase midazolam levels significantly
  • CNS depressants — additive

Monitoring

  • SpO2 and respiratory rate (continuous)
  • HR and BP
  • Sedation level (COMFORT-B scale)
  • Seizure duration and response time
  • Flumazenil availability

Reference: BNF for Children; APLS UK 2021 Algorithm; Buccolam SPC; Scott et al. Lancet 1999 (Buccal Midazolam vs Rectal Diazepam). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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